Applied Behavioral Analysis (ABA) Billing Guide

1 Washington apple Health (Medicaid). Applied Behavioral Analysis (ABA). Program Billing Guide (For clients age 20 and younger). December 1, 2020. 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 December 1, 2020, and supersedes earlier Billing guides to this program. Unless otherwise specified, the program(s) in this Guide are governed by the rules found in WAC 182-531A-0100. 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 2019 American Medical Association.

3 2 | Applied BEHAVIOR Analysis (ABA) PROGRAM Billing Guide . Copyright disclosure Current Procedural Terminology (CPT) copyright 2019 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 Entire Guide Revised format of To comply with entire Guide . accessibility standards. Replaced parent Clarification training with caregiver training . What is the Purpose of Added information Clarification the ABA Program? describing when ABA. is considered medically necessary apple Health Changes Removed apple This section is for January 1, 2020 Health Changes unnecessary, as it is section outdated.

4 All regions are fully integrated managed care. Clients who are not Added information Clarification enrolled in an HCA- regarding payment for contracted managed ABA and Behavioral care plan for physical health services health services Integrated managed Removed listing of This section is care regions regions and their unnecessary, as it is integration dates outdated. All regions are fully integrated managed care. What are the Added information Clarification qualifications for a COE? about qualifications and removed redundant requirements CPT codes and descriptions only are copyright 2019 American Medical Association. 3 | Applied BEHAVIOR Analysis (ABA) PROGRAM Billing Guide . Subject Change Reason for Change How does a provider Added a hyperlink for Clarification become recognized as a COE training COE? Community-based Removed section This section is redundant program services with the ABA delivery methods and settings . section ABA services Created new heading Clarification for this section What is the early Added exception to Clarification made to intensive Behavioral rule request for align with WAC 182-501- intervention day extenuating 0169.

5 Treatment program (day circumstances treatment program)? Added the maximum Clarification ages allowed for treatment and for completion of the program Requirements for the Revised and added Clarification day treatment program bullets with more details about: Care coordination and discharge planning; and Staffing ratios and planning Day treatment program Revised to add more Clarification model detail Telemedicine and Added a hyperlink for Clarification COVID-19 COVID-19 information What services are not Updated hyperlink Correction paid for under from ABA fee schedule telemedicine? to Physician-Related Services/Professional Health Care Services fee schedule CPT codes and descriptions only are copyright 2019 American Medical Association. 4 | Applied BEHAVIOR Analysis (ABA) PROGRAM Billing Guide . Subject Change Reason for Change What procedure codes Removed this section This section is no longer do I use to bill for home needed, as the codes and community-based have been in place for services?

6 Two years. Requesting prior Revised information Clarification authorization (PA) about ways to request PA. Individual Treatment Revised descriptions Revised to reflect short Codes for procedure codes descriptions 97153 and 0373T. CPT codes and descriptions only are copyright 2019 American Medical Association. 5 | Applied BEHAVIOR Analysis (ABA) PROGRAM Billing Guide . Table of Contents Resources Available .. 9. Definitions .. 10. Program Overview .. 11. Who should read this Guide ?.. 11. What is ABA? .. 11. What is the purpose of the ABA program? .. 11. Client Eligibility .. 12. How do I verify a client's eligibility? .. 12. Verifying eligibility is a two-step process: .. 12. Are clients enrolled in an HCA-contracted managed care organization (MCO). eligible? .. 13. Managed care enrollment .. 13. Clients who are not enrolled in an HCA-contracted managed care plan for physical health services .. 14. Integrated managed care .. 14. Integrated apple Health Foster Care (AHFC) .. 15.

7 Fee-for-service apple Health Foster Care .. 16. What if a client has third-party liability (TPL)? .. 16. Provider 17. Who may provide services under the Applied behavior Analysis (ABA). program? .. 17. What is a Center of excellence (COE)? .. 17. What are the qualifications for a COE?.. 17. How does a provider become recognized as a COE? .. 18. Will HCA accept an evaluation that was not completed by a COE?.. 18. Who can apply to provide ABA services? .. 19. Who can enroll with HCA as a lead behavior Analysis therapist (LBAT)? .. 19. Additional requirements for LBAT enrollment .. 19. How do providers enroll with HCA as a certified behavior technician (CBT)?20. Additional requirements for CBT enrollment .. 20. Becoming a facility-based day treatment program .. 20. Accessing ABA 21. What is the Applied behavior Analysis (ABA) pathway to care? .. 21. Stage one of the pathway to care .. 21. Referral .. 21. What does the COE do?.. 21. CPT codes and descriptions only are copyright 2019 American Medical Association.

8 6 | Applied BEHAVIOR Analysis (ABA) PROGRAM Billing Guide . Required 22. The comprehensive diagnostic evaluation .. 22. Stage two of the pathway to care .. 23. Selecting an ABA provider .. 23. Caregiver training only while the child is on a waitlist for individual ABA. services .. 24. The ABA assessment and treatment 24. Stage three of the pathway to care .. 26. LBAT responsibilities .. 26. CBT responsibilities .. 26. ABA delivery methods and settings .. 27. ABA services: .. 27. What is the early intensive Behavioral intervention day treatment program (day treatment program)? .. 28. Purpose of the day treatment program .. 28. Providers in the day treatment program .. 29. Requirements for the day treatment program .. 29. Day Treatment Program Model .. 31. What client files and records does HCA require? .. 31. Telemedicine and COVID-19 .. 34. What is telemedicine? .. 34. Originating site .. 34. Distant site .. 34. Which services may be provided via telemedicine?.. 34. What services are not paid for under telemedicine?

9 35. Authorization .. 36. What is prior authorization (PA)? .. 36. When is PA required? .. 36. Requesting prior authorization (PA) .. 37. Online direct data entry into ProviderOne .. 37. Written or Fax .. 37. Does PA for ABA services expire? .. 37. What if additional units of service are needed to continue providing ABA. services? .. 38. What are the requirements for recertification of ABA services? .. 38. Additional requirements for recertification of ABA services .. 39. Why might HCA deny recertification of ABA services? .. 39. CPT codes and descriptions only are copyright 2019 American Medical Association. 7 | Applied BEHAVIOR Analysis (ABA) PROGRAM Billing Guide . What is a limitation extension (LE)? .. 39. How do I obtain an LE?.. 40. Coverage .. 41. What is covered? .. 41. ABA treatment home and community-based settings .. 41. Functional Assessment and Analysis /Treatment Plan 41. Telemedicine .. 41. Team 41. Individual Treatment Codes .. 42. Caregiver Treatment Codes.

10 42. ABA Group Home and Community-Based Treatment .. 42. ABA Intensive Day Treatment .. 42. ABA treatment group settings .. 43. Caregiver Training in a Group Setting* .. 43. ABA Group Treatment in Home and Community-Based Settings* .. 43. What modifiers do providers bill with? .. 44. What about services covered under other HCA programs? .. 44. Which services are not covered? .. 45. Billing .. 46. What are the general Billing requirements? .. 46. What codes do day treatment programs use to bill HCA? .. 46. How do I bill claims electronically? .. 46. Rendering and individual provider taxonomy numbers .. 47. CPT codes and descriptions only are copyright 2019 American Medical Association. 8 | 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.