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Provider Notice Issued 09/30/2021

Date:    September 30, 2021

To:       All Medical Assistance Program Providers

Re:      Update to Coverage of Adaptive Behavior Support Services for Children with Autism Spectrum Disorder

_______________________________________________________________________________________________________________________________________________________ 

This notice informs providers of updates to the Department's coverage of services for children (age 0 through 20) with Autism Spectrum Disorder (ASD) under both Medicaid fee-for-service and Medicaid managed care plans.

By Informational Notice dated October 30, 2020, the Department announced coverage for Applied Behavior Analysis (ABA) services for children with a diagnosis of ASD when ordered by a physician licensed to practice medicine in all its branches. The Department detailed the fee schedule and Fee for Service prior authorization process for ABA services in the Informational Notice dated January 19th 2021. 

Effective October 1, 2021, the Department is broadening its coverage of services for children with ASD to be inclusive of Adaptive Behavior Support (ABS) services.  ABS services expand the service delivery framework for children with ASD to include additional clinically effective interventions, inclusive of but not limited to the clinical treatment modality of ABA.

The information and guidance in this notice provides additional information regarding this change and supersedes the prior informational notices listed above.

Covered ABS Services

1. 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 ABS Services. The information gathered through the BATP service must be consolidated into a behavioral assessment and treatment plan that must be:

  • Completed, reviewed, and updated as needed, minimally once every 180 days; 
  • Reviewed, approved, and signed by the developing BCBA and:
    • For BCBAs providing ABS under the clinical supervision of an Licensed Clinical Psychologists (LCP) or Licensed Clinical Social Worker (LCSW), the supervising LCP or LCSW must sign the BATP; or
    • For BCBAs employed by a Behavioral Health Clinic (BHC) enrolled to provide ABS, the BHC's Licensed Practitioner of the Healing Arts (LPHA) must sign the BATP; and,
       
  • Signed by, and a copy provided to, the individual, or the individual's parent or guardian, upon completion or revision.

2. Behavioral Analytic Intervention (BAI).  BAI consist of services identified on the individual's BATP for the maximum reduction of mental disability through the use of behavioral stimuli and consequences, to produce socially significant improvement in behavior, and includes the use of direct observation, measurement, and functional analysis of the relationships between an individual's environment and behavior. BAI may be provided in an individual or group modality. BAI services are to be delivered in one of the following delivery modes:

 

  • Comprehensive BAI.  Comprehensive BAI services identify deficits and build skills in young individuals as developmentally appropriate. Comprehensive BAI services are intended for individuals under the age of seven who have a diagnosis of Autism Spectrum Disorder (ASD) and exhibit adaptive skill deficits including but not limited to impairments in social, communication and/ or rate of skill acquisition. Individuals may also engage in behavior that significantly interferes with home or community activities (examples include, but are not limited to, aggression, self-injury, elopement).

     
  • Focused BAI.  Focused BAI services are intended for school-aged individuals and work in tandem with other behavioral health (e.g., behavioral therapy, counseling, case management, social/emotional skills building) and therapeutic (occupational, speech, physical) services to address a child's needs. Focused BAI Services are intended for individuals age seven through 20 who engage in behavior that significantly interferes with home or community activities (examples include, but are not limited to, aggression, self-injury, elopement). 

Provider Qualifications

ABS services must be delivered by individuals meeting the qualifications of a Board-Certified Behavior Analyst (BCBA) or a Registered Behavior Technician (RBT).  

Board Certified Behavior Analyst (BCBA). A BCBA is:

 1. An unlicensed individual who is credentialed by the Behavior Analyst Certification Board (BACB) as a BCBA and is providing ABS under the clinical supervision of an HFS-enrolled LCSW or LCP, pursuant to a written collaborative agreement detailing the supervisory arrangement on file with and approved by the Department;

 2. An unlicensed individual who is credentialed by the BACB as a BCBA and is employed by a Behavior Health Clinic (BHC) enrolled with the Department to provide ABS services;


 3. A clinical psychologist who is credentialed by the BACB as a BCBA, holds a valid license in the state of practice and is legally authorized under state law or rule to practice as a clinical psychologist, so long as that practice is not in conflict with the Clinical Psychologist Licensing Act [225 ILCS 15] and implementing rules (68 Ill. Adm. Code 1400); or

 4. A clinical social worker possessing a master's or doctoral degree who is credentialed by the BACB as a BCBA, holds a valid license in the state of practice and is legally authorized under state law or rule to practice as a social worker, so long as that practice is not in conflict with the Clinical Social Work and Social Work Practice Act [225 ILCS 20] and implementing rules (68 Ill. Adm. Code 1470) .

 
Registered Behavior Technician (RBT).  An individual who has been credentialed as an RBT by the Behavior Analyst Certification Board (BACB), is 21 years of age or older, has a high school diploma or GED, and:

1. Works as an employee of a BHC enrolled with the Department to provide ABS services; or

 

2. Provides ABS under the clinical supervision of an HFS-enrolled LCSW or LCP pursuant to a written collaborative agreement detailing the supervisory arrangement on file with and approved by the Department.  

Written Collaborative Agreement. When ABS is provided outside of a BHC, unlicensed BCBAs and RBTs are required to have a written collaborative agreement with an LCSW or LCP offering clinical supervision. The written collaborative agreement must be executed between the LCSW or LCP offering clinical supervision and the BCBA or RBT providing ABS, and the agreement shall describe:

  • The professional relationship between the LCSW or LCP offering clinical supervision and the BCBA or RBT (e.g., employee, contracted employee, etc.);

 

  • The services and treatment that the BCBA or RBT may provide; and

 

  • The direction provided by the BCBA to the RBT, when both are providing services to an individual under the clinical supervision of the LCSW or LCP.

 
BCBA Case Leadership. RBTs must receive Case Leadership from a BCBA, in addition to receiving clinical supervision. The BCBA must be present with the RBT to provide Case Leadership through observation, modeling, guidance, and case oversight for the services on an individual's BATP that are provided by the RBT. RBTs are expected to receive Case Leadership for 5%, or more, of all direct services provided to the individual. 

1. Case Leadership activities include, at a minimum, two face-to-face, real-time contacts per month in the form of the following activities:Observing, providing behavioral skills training, and delivering performance feedback to the RBT;

2.  Modeling clinical, technical, and professional skills and behavior;

3.  Guiding the development of problem-solving and decision-making with the RBT;

4.  Reviewing clinical documentation (e.g., daily progress notes, data sheets) with the RBT; and

5. Overseeing and evaluating the effects of behavior analytic service delivery. 

Provider Enrollment
Providers seeking reimbursement for services must be enrolled for participation in the Department's Medical Programs via the web-based system known as Illinois Medicaid Program Advanced Cloud Technology (IMPACT). ABS services are reimbursable to providers enrolled in the IMPACT system as:

1. A Behavioral Health Clinic (BHC) with a Specialty of ABS;

2. A Licensed Clinical Psychologist (LCP) or a Licensed Clinical Social Worker (LCSW) with a Subspecialty of BCBA;

3. A Board-Certified Behavior Analyst (BCBA); or,

4. A Registered Behavioral Technician (RBT).

 
LCP and LCSW Enrollment

  • LCSWs and LCPs seeking to enroll with the Department to provide clinical supervision to qualified BCBAs or RBTs, need to complete an IMPACT application and receive notice from the Department that they are approved to participate in Illinois' Medical Assistance Program pursuant to the Informational Notice dated December 28, 2016. 
  • LCPs and LCSWs who are BACB credentialed as BCBA, may  seek to modify their IMPACT record to add the Subspecialty of: Board Certified Behavior Analyst. 
  • The information found in Table 1 is provided to assist LCPs and LCSWs in determining the most appropriate IMPACT enrollment options. 


Table 1. LCP and LCSW Enrollment Options

Enrollment TypeApplicant TypeProvider
Type
SpecialtySubspecialtyClaim Type
Individual/
Sole Proprietor

Regular Individual/ Sole Proprietor

OR

Rendering/ Servicing Provider

PsychologistLicensed Clinical PsychologistNo Subspecialty837P
Primary Specialty
Board Certified Behavior Analysts
Behavioral Health ServicesLicensed Clinical Social Worker (LCSW)No Subspecialty
Primary Specialty
Board Certified Behavior Analysts
 *Only those providers who have a certified W-9 through the Illinois Comptroller's office may select the Applicant Type of Individual/Sole Proprietor

 
Behavioral Health Clinic (BHC) Enrollment

Entities seeking to enroll as a BHC, pursuant to 89 Ill. Admin. Code 140.499 and 89 Ill. Admin. Code 140.TABLE O, may receive reimbursement for ABS services detailed in the ABS Fee Schedule when services are rendered by a BCBA or RBT employed by the BHC and the BHC is enrolled to provide ABS services. 

To enroll with the Department as a BHC (legacy Provider Type 027), providers must complete and submit a Facility, Agency, Organization (FAO) enrollment application through the IMPACT system, selecting all necessary Specialty/Subspecialty combinations based upon the services the provider intends to provide. 

In addition, entities currently enrolled as a BHC with an BHC Outpatient Specialty may add ABS to their service array by modifying their IMPACT enrollment and adding the ABS Specialty to their record.
BHCs seeking  reimbursement  for ABS services must minimally:

  1. Select the Specialty of 'Adaptive Behavior Support (ABS);'
  2. Enter a pseudo license number of 'BHC99999ABS' under 'Step 4: Add Licenses/ Certifications/ Other;' and 
  3. Enter taxonomy 261QM0855X under 'Step 10: Taxonomy Details.'  

The information found in Table 2 is provided to assist BHCs in determining the most appropriate IMPACT enrollment options.


                                                                                                   Table 2. BHC Enrollment Options

Enrollment TypeProvider
Type
SpecialtySubspecialtyServicesProgram ApprovalClaim Type
Facility, Agency, Organization (FAO)Behavioral Health ClinicBHC OutpatientNone
  • IATP
  • Crisis Intervention
  • Therapy/Counseling
  • Community Support
  • Med. Admin.
  • Med. Monitoring
  • Med. Training
  • Case Management
  • Develop. Screening
  • Develop. Testing
  • MH Risk Assessment
  • Prenatal Care At-Risk Assess.
N/A837P

BHC Day TreatmentIntensive Outpatient
  • Intensive Outpatient
IOP
BHC Team Based ServicesCommunity Support Team
  • Community Support Team
CST
BHC Crisis ResponseMobile Crisis Response
  • Mobile Crisis Response
MCR

Crisis Stabilization
  • Crisis Stabilization
STA

 
BCBA and RBT Enrollment:

BCBAs and RBTs who are not LCSWs or LCPs and want to provide ABS services must enroll as a Rendering/ Servicing provider within IMPACT and attribute to an enrolled LCP/LCSW or BHC. 

BCBAs and RBTs attributing to enrolled LCPs/LCSWs will be asked to provide a copy of their Written Collaborative Agreement prior to Department approval of their IMPACT application. 

The information found in Table 3 is provided to assist BCBAs and RBTs who are not LCSWs or LCPs in determining the most appropriate IMPACT enrollment options.

Table 3. Unlicensed BCBA and RBT Enrollment Options

Enrollment TypeApplicant TypeProvider
Type
SpecialtySubspecialtyClaim Type
Individual/
Sole Proprietor
Rendering/ Servicing ProviderAdaptive Behavior Support ServicesBCBANo Subspecialty837P

RBTNo Subspecialty837P

 

 ABS Services
 
Prior Approval for ABS Services
The prior approval information in this section applies to customers served in fee-for-service. Please contact the appropriate HealthChoice Illinois MCO for information regarding ABS prior approval requirements and processes for managed care enrolled customers.

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 ABS Services form and submit it, along with all required clinical documentation, to HFS.ABS@Illinois.gov.

Prior Authorization Clinical Documentation.  The following attachments may be required to obtain approval for ABS services.

1. Physician Order. The physician order and referral for ABS service delivery is required with the first submission for prior authorization of ABS services and is valid for one year.  The order must contain the following information:

       1. The physician's National Provider Identifier (NPI); 

       2. Individual's name and date of birth;

       3. Individual's Primary Diagnosis;

       4. Physician's treatment recommendation; and

       5. Signature and Date of the ordering provider.

2.  Comprehensive Diagnostic Evaluation (CDE). The individual's completed CDE, performed by a physician or a clinical psychologist, must be submitted with the first submission for prior authorization for ABS 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 individual; 
    • Assessment of the individual outlining behaviors consistent with ASD per DSM-V criteria, resulting in one of the following completed assessments:
      • Autism Diagnostic Observation Schedule (ADOS);
      • Gilliam Autism Rating Scale (GARS);
      • Autism Diagnostic Interview (ADI); or
      • 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 individual'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 individual's BATP. 

     5. Behavioral Assessment and Treatment Plan (BATP). Requests for BAI services must be accompanied by the individual BATP, completed within 30 days prior to the 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. If the notice of disposition is not sent within the applicable time limit, prior approval will be granted automatically pursuant to 89 Ill. Admin. Code Section 140.40.

Review Outcomes. The provider (electronically) and the individual (via US postal service) will be notified of outcomes of the prior authorization review consistent with  89 Ill. Admin. Code Section 102.70, including the right to appeal. Service approvals will be remitted electronically to the requesting provider. ABS service approvals are not transferable, as they are specific to an individual, provider, and service allotment (i.e., dates of services, procedure codes and units of service for each code).

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 the missing or additional information from the provider. All requests for missing or additional information must be remedied by the provider within 2 business days. Following the re-submission of materials by the provider (remedy of missing or incomplete documentation), the 30-day time limit for prior authorization review starts anew.
 
ABS Fee Schedule
The Department is issuing an updated fee schedule for all providers seeking reimbursement for ABS services. The Department's ABS Fee Schedule is on the Department's Reimbursements webpage.

Claims Submission
The BHC, LCP or LCSW must submit claims on behalf of the BCBA and RBT with the BCBA or RBT's name and NPI reported in the Rendering/Servicing segment of the claim. Claims that identify an RBT as the Rendering/Servicing Provider must also include the Supervising BCBA's name and NPI in the Loop 2310D, segment NM1, Supervising Provider field.
 
Provision of Multiple Units of Service
Providers seeking to submit multiple units of the same procedure code/modifier combination rendered to the same individual on the same date of service (DOS) are required to "roll up," or combine these units, into a single service line of a claim to avoid triggering the Department's duplicate check logic edit. As a reminder, the 'Daily Max Quantity' listed for a given procedure code on the ABS fee schedule is the maximum number of units reimbursable for an individual on a single date of service. 
 
Technical Assistance and Support
For inquiries regarding this notice and program see below:

  • Billing questions, Bureau of Professional and Ancillary Services: 877-782-5565.

 
Questions regarding ABS service coverage, prior authorization, and billing requirements for managed care enrolled customers should be directed to the appropriate HealthChoice Illinois MCO.

 
Kelly Cunningham, Administrator
Division of Medical Programs

 

 

 

 

 

 

 

 

 



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