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Provider Notice Issued 01/19/2021

Date:    January 19, 2021

 

To:       All Medical Assistance Program Providers

 

Re:      Coverage for Applied Behavioral Analysis (ABA) Services for Children 0 through 20 Years – Prior Approval

 

 

This notice outlines the process for licensed clinical psychologists (LCPs) and licensed clinical social workers (LCSWs) enrolled to provide applied behavioral analysis (ABA) services to request prior approval. The prior approval process described in this notice is specific to children covered under Medicaid fee-for-service. For children covered under a Medicaid managed care plan, please contact the plan for guidance on their approval requirements.

 

By informational notice dated October 30, 2020, the Department announced coverage for ABA services for children with a diagnosis of autism spectrum disorder when ordered by a physician licensed to practice medicine in all its branches. That notice also identified provider qualifications and summarized the steps involved for enrollment of LCPs, LCSWs, and Registered Behavioral Technicians (RBTs) specifically for ABA services.

 

Properly enrolled LCPs and LCSWs may request prior approval and provide approved services as outlined below.

 

ABA Service Description

Behavioral Assessment and Treatment Planning (BATP).  BATP is the formal process of information gathering and service planning to: 1) evaluate current maladaptive or disruptive behaviors, skills and needs; and 2) identify individualized treatment goals, objectives and recommendations for the delivery of ABA Services. The BATP is expected to be completed, or updated:

·         Once every 180 days;

·         Be reviewed, approved, and signed by a BCBA; and

·         Be signed, and a copy provided to the participant, or the participant’s parent or guardian, upon completion or revision.

 

Behavioral Analytic Intervention (BAI). BAI consist of services identified on the participant’s BATP for the maximum reduction of mental disability through the use of behavioral stimuli and consequences, to produce socially significant improvement in behavior, including the use of direct observation, measurement, and functional analysis of the relationships between environment and behavior. BAI may be provided:

·         At all service locations and settings deemed appropriate for reimbursement, consistent with Department policy; and

·         In an individual or group modality, as defined by the service code.

 


ABA Fee-for-Service Fee Schedule

HFS approved ABA Service codes and their associated reimbursement rate is available on the HFS website as a component of the Licensed Clinical Psychologists and Licensed Clinical Social Workers Fee Schedule.

 

Prior Approval for ABA Services

BATP services exceeding six hours (24 units) per a 180-day period and all BAI services require prior authorization. Providers must complete the Prior Authorization for Applied Behavioral Analysis (ABA) Services form and submit all required documentation to HFS.ABA@Illinois.gov.

 

ABA Prior Authorization Clinical Documentation

The following attachments may be required to obtain approval for ABA services.

 

1.    Physician Order. The physician order and referral for ABA service delivery is required with the first submission for ABA services and is valid for one year.

 

2.    Comprehensive Diagnostic Evaluation (CDE). The participant’s completed CDE, performed by a physician or a clinical psychologist, must be submitted with the first submission for ABA services, and upon request for all subsequent submissions. 

 

A CDE is an assessment, evaluation, or test that is required to establish a diagnosis of ASD. The CDE must include:

·         Direct interaction and assessment of the participant;

·         Assessment of the individual outlining behaviors consistent with ASD per DSM-V criteria, resulting in one of the following completed assessments:

o Autism Diagnostic Observation Schedule (ADOS);

o Gilliam Autism Rating Scale (GARS);

o Autism Diagnostic Interview (ADI); or

o Childhood Autism Rating Scale (CARS)

·         A review of the individual’s developmental and psychosocial history (milestones);

·         Current functional ability in both verbal and nonverbal areas; and

·         A primary caregiver interview.

 

The CDE may also include a review of standardized cognitive and developmental testing; neurological testing; hearing screening; vision screening; genetic testing; and other non-specified medical testing required to rule out other disorders and conditions.

 

3.    Documentation of Functional Impairment. If the participant’s CDE was completed more than 24 months prior to the date of request for prior authorization, current individualized documentation of functional impairment by a physician or a clinical psychologist is required.

 

4.    Clinical Narrative. Requests for BATP services exceeding six (6) hours per 180-day period should be accompanied by a clinical narrative detailing why more than six (6) hours of assessment and treatment planning are needed to complete the participant’s BATP.

 

5.    Behavioral Assessment and Treatment Plan (BATP). Requests for BAI services must be accompanied by the participant’s BATP, completed within 30 days of request date for prior authorization of BAI services.



 Prior Authorization Review Timelines and Decisions

Pursuant to 89 Ill. Admin. Code 140.Table E, Item 26, prior authorization determinations shall be made within 30 days of submission.

 

             ·         Review Outcomes. The provider and the participant will be notified of the outcome of the prior authorization review and the right to appeal, if applicable, consistent with  89 Ill. Admin. Code Section 102.70. ABA service approvals are not transferable, as they are specific to a participant, provider, and service allotment.

 

             ·         Missing or Incomplete Documentation. If a prior authorization request is incomplete, or requires additional clinical documentation to be properly considered, the Department will suspend the prior authorization review process, stopping the 30-day time limit for prior authorization review, and request additional clinical information from the provider. All requests for additional clinical information must be remedied by the provider in order to re-start the prior authorization review process with a new 30-day review window. 

 

Questions regarding the prior approval process for ABA services may be directed to  HFS.ABA@illinois.gov.

 

 

Kelly Cunningham, Administrator

Division of Medical Programs​


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