Applied Behavioral Analysis (ABA) Billing Guide

1 Washington Apple health (Medicaid). Applied Behavioral Analysis (ABA). Program Billing Guide March 1, 2021. Disclaimer Every effort has been made to ensure this Guide 's accuracy. If an actual or apparent conflict between this document and a health Care Authority (HCA) rule arises, the rule applies. Billing guides are updated on a regular basis. Due to the nature of content change on the internet, we do not fix broken links in past guides. If you find a broken link, please check the most recent version of the Guide . If this is the most recent Guide , please notify us at About this Guide *. This publication takes effect March 1, 2021, and supersedes earlier Billing guides to this program. Unless otherwise specified, the program(s) in this Guide are governed by the rules found in Chapter 182-531A WAC. HCA is committed to providing equal access to our services. If you need an accommodation or require documents in another format, please call 1-800-562- 3022.

2 People who have hearing or speech disabilities, please call 711 for relay services. Washington Apple health means the public health insurance programs for eligible Washington residents. Washington Apple health is the name used in Washington State for Medicaid, the children's health insurance program (CHIP), and state-only funded health care programs. Washington Apple health is administered by HCA. Refer also to HCA's ProviderOne Billing and resource Guide for valuable information to help you conduct business with HCA. How can I get HCA Apple health provider documents? To access provider alerts, go to HCA's provider alerts webpage. To access provider documents, go to HCA's provider Billing guides and fee schedules webpage. Where can I download HCA forms? To download an HCA form, see HCA's Forms & Publications webpage. Type only the form number into the Search box (Example: 13-835). *. This publication is a Billing instruction. CPT codes and descriptions only are copyright 2020 American Medical Association.

3 2 | Applied BEHAVIOR Analysis (ABA) PROGRAM Billing Guide . Copyright disclosure Current Procedural Terminology (CPT) copyright 2020 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein. What has changed? Subject Change Reason for Change What is the early Added childhood to To accurately describe intensive Behavioral the title of the for whom the program is intervention day program. clinically beneficial. This treatment program (day change is retroactive to Corrected wording treatment program) dates on and after from client back to February 1, 2021. child or children . under the day treatment program.

4 CPT codes and descriptions only are copyright 2020 American Medical Association. 3 | Applied BEHAVIOR Analysis (ABA) PROGRAM Billing Guide . Table of Contents Resources 7. Definitions .. 8. Program Overview .. 9. Who should read this Guide ? .. 9. What is ABA?.. 9. What is the purpose of the ABA program?.. 9. Client 10. How do I verify a client's eligibility? .. 10. Verifying eligibility is a two-step process: .. 10. Are clients enrolled in an HCA-contracted managed care organization (MCO). eligible? .. 11. Managed care enrollment .. 11. Clients who are not enrolled in an HCA-contracted managed care plan for physical health services .. 12. Integrated managed care .. 12. Integrated Apple health Foster Care (AHFC) .. 13. Fee-for-service Apple health Foster Care .. 14. What if a client has third-party liability (TPL)? .. 14. provider Eligibility .. 15. Who may provide services under the Applied behavior Analysis (ABA). program? .. 15. What is a Center of Excellence (COE)?

5 15. What are the qualifications for a COE? .. 15. How does a provider become recognized as a COE? .. 16. Will HCA accept an evaluation that was not completed by a COE? .. 16. Who can apply to provide ABA services? .. 17. Who can enroll with HCA as a lead behavior Analysis therapist (LBAT)? .. 17. Additional requirements for LBAT enrollment .. 17. How do providers enroll with HCA as a certified behavior technician (CBT)?18. Additional requirements for CBT enrollment .. 18. Becoming a facility-based day treatment program .. 18. Accessing ABA Services .. 19. What is the Applied behavior Analysis (ABA) pathway to care? .. 19. Stage one of the pathway to care .. 19. Referral .. 19. What does the COE do? .. 19. CPT codes and descriptions only are copyright 2020 American Medical Association. 4 | Applied BEHAVIOR Analysis (ABA) PROGRAM Billing Guide . Required 20. The comprehensive diagnostic evaluation .. 20. Stage two of the pathway to care .. 21. Selecting an ABA provider .

6 21. Caregiver training only while the client is on a waitlist for individual ABA. 22. The ABA assessment and treatment plan .. 22. Stage three of the pathway to care .. 24. LBAT 24. CBT responsibilities .. 24. ABA delivery methods and settings .. 25. ABA services: .. 25. What is the early childhood intensive Behavioral intervention day treatment program (day treatment program)?.. 26. Purpose of the day treatment 26. Providers in the day treatment program .. 26. Requirements for the day treatment program .. 27. Day Treatment Program 29. What client files and records does HCA require? .. 29. Telemedicine and 32. What is telemedicine?.. 32. Originating site .. 32. Distant site .. 32. Which services may be provided via telemedicine? .. 32. What services are not paid for under telemedicine? .. 33. Authorization .. 34. What is prior authorization (PA)? .. 34. When is PA required?.. 34. Requesting prior authorization (PA) .. 35. Online direct data entry into ProviderOne.

7 35. Written or Fax .. 35. Does PA for ABA services expire? .. 35. What if additional units of service are needed to continue providing ABA. services? .. 36. What are the requirements for recertification of ABA services? .. 36. Additional requirements for recertification of ABA services .. 37. Why might HCA deny recertification of ABA services? .. 37. CPT codes and descriptions only are copyright 2020 American Medical Association. 5 | Applied BEHAVIOR Analysis (ABA) PROGRAM Billing Guide . What is a limitation extension (LE)? .. 37. How do I obtain an LE? .. 38. Coverage .. 39. What is covered? .. 39. ABA treatment home and community-based settings .. 39. Functional Assessment and Analysis /Treatment Plan Development .. 39. Telemedicine .. 39. Team Conference .. 39. Individual Treatment Codes .. 40. Caregiver Treatment Codes .. 40. ABA Group Home and Community-Based Treatment .. 40. ABA Intensive Day Treatment .. 40. ABA treatment group settings .. 41.

8 Caregiver Training in a Group Setting* .. 41. ABA Group Treatment in Home and Community-Based Settings* .. 41. What modifiers do providers bill with? .. 42. What about services covered under other HCA programs?.. 42. Which services are not covered? .. 43. Billing .. 44. What are the general Billing requirements? .. 44. What codes do day treatment programs use to bill HCA? .. 44. How do I bill claims electronically? .. 44. Rendering and individual provider taxonomy numbers .. 45. CPT codes and descriptions only are copyright 2020 American Medical Association. 6 | Applied BEHAVIOR Analysis (ABA) PROGRAM Billing Guide . Resources Available Topic Resource Prior Authorization (PA) or For all requests for PA or LE, the following documentation is Limitation Extension (LE) required: A completed, TYPED, General Information for Authorization form, HCA 13-835. This request form MUST be the initial page when you submit your request. A completed Applied Behavior Analysis Services request form, HCA 12-411, for initial PA requests and recertification.

9 A completed Assessment and Behavior Change Plan form, HCA 13-400, for PA requests and recertification. For information about downloading HCA forms, see Where can I download HCA forms? Becoming a provider or submitting See HCA's ProviderOne Resources webpage a change of address or ownership Contacting provider Enrollment See HCA's ProviderOne Resources webpage Finding out about payments, See HCA's ProviderOne Resources webpage denials, claims processing, or HCA. managed care organizations Electronic Billing See HCA's ProviderOne Resources webpage Finding HCA documents ( , See HCA's ProviderOne Resources webpage Billing guides, fee schedules). Private insurance or third-party See HCA's ProviderOne Resources webpage liability, other than HCA-contracted managed care Access E-learning tools See HCA's ProviderOne Resources webpage More information See HCA's Autism and Applied Behavior Analysis (ABA). therapy webpage CPT codes and descriptions only are copyright 2020 American Medical Association.

10 7 | Applied BEHAVIOR Analysis (ABA) PROGRAM Billing Guide . Definitions This list defines terms and abbreviations, including acronyms, used in this Billing Guide . Refer to Chapter 182-500 WAC for a complete list of definitions for Washington Apple health . Autism diagnostic tool - A tool used to establish the presence (or absence) of autism and to make a definitive diagnosis, which will be the basis for treatment decisions and the development of a treatment plan. Examples of autism diagnostic tools include: Autism diagnosis interview (ADI). Autism diagnostic observation schedule (ADOS). Autism screening tool - A tool used by a primary care provider to detect indicators or risk factors for autism and may indicate a suspicion of the condition, which would then require confirmation, which would then require a referral to a Center of Excellence for confirmation. Examples of screening tools include: Ages and stages questionnaire (ASQ). Communication and symbolic behavior scales (CSBS).