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Outpatient Behavioral Health (BH) – ABA Treatment Request ...

BHVH. Outpatient Behavioral Health (BH) . ABA Treatment Request : Required Information for Precertification About this form Do not use for Maryland and Massachusetts You can't use this form to initiate a precertification Request . To initiate a Request , you have to call the number on the member's card. Or you can submit your Request electronically. Effective, March 1, 2018, this form replaces all other Applied Behavioral Health Analysis (ABA). precertification information Request documents and forms. This form will help you supply the right information with your precertification Request . You don't have to use the form. But it will help us adjudicate your Request more quickly. How to fill out this form As the patient's attending physician, you must complete all sections of the form. You can use this form with all aetna Health plans, except aetna 's Medicare Advantage plans.

Health benefits and health insurance plans offered, underwritten and/or administered by the following: Allina Health and Aetna Health Insurance Company (Allina Health | Aetna)

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Transcription of Outpatient Behavioral Health (BH) – ABA Treatment Request ...

1 BHVH. Outpatient Behavioral Health (BH) . ABA Treatment Request : Required Information for Precertification About this form Do not use for Maryland and Massachusetts You can't use this form to initiate a precertification Request . To initiate a Request , you have to call the number on the member's card. Or you can submit your Request electronically. Effective, March 1, 2018, this form replaces all other Applied Behavioral Health Analysis (ABA). precertification information Request documents and forms. This form will help you supply the right information with your precertification Request . You don't have to use the form. But it will help us adjudicate your Request more quickly. How to fill out this form As the patient's attending physician, you must complete all sections of the form. You can use this form with all aetna Health plans, except aetna 's Medicare Advantage plans.

2 You can also use this form with Health plans for which aetna provides certain management services. This includes Innovation Health Plan, Inc. and Innovation Health Insurance Company. You can't use the form with Traditional Choice/Indemnity plans. When you're done Once you've filled out the form, submit it and all requested supportive documentation to our Autism Care Team. You can send it via confidential fax to 1-860-607-7406. What happens next? Once we receive the requested documentation, we will perform a clinical review. Then we'll make a coverage determination and let you know our decision. Your administrative reference number will be on the electronic precertification response. How we make coverage determinations We encourage you to review Clinical Policy Bulletin #648: Autism Spectrum Disorders, and Applied Behavior Analysis Medical Necessity Guide, before you complete this form.

3 You can find the policy by visiting the website on the back of the member's ID card. The Applied Behavior Analysis Medical Necessity Guide can be found by visiting: professionals/documents- Questions? If you have any questions about how to fill out the form or our precertification process, call us at 1-800-424-4047. aetna is the brand name used for products and services provided by one or more of the aetna group of subsidiary companies, including aetna Life Insurance Company and its affiliates ( aetna ). Innovation Health is the brand name used for products and services provided by Innovation Health Insurance Company and Innovation Health Plan, Inc. aetna and its affiliates provide certain management services for its affiliates, including Innovation Health . GR-69017-3 (2-18) EDI Page 1 of 3. Outpatient Behavioral Health (BH) . ABA Treatment Request : Required Information for Precertification Fax to Fax number Autism Care Team 1-860-607-7406.

4 Section 1 Provide the following general information Member name Administrative reference number (if available). Member telephone number Member ID Member date of birth / /. Facility, Physician, Provider or Vendor name Facility, Physician, Provider or Vendor TIN or PIN number, and Billing State: State: TIN number: PIN number: Facility, Physician, Provider or Vendor fax Facility, Physician, Provider or Vendor status number Participating Non-participating 1- - - Facility, Physician, Provider or Vendor telephone number Name and telephone number of Contact person (if not the provider). Planned start date of procedure or service / /. Current diagnosis code(s): Select the CPT/HCPCS codes which best describe the service(s) you will provide: Applied Behavioral Analysis (ABA) Pennsylvania Act 62/Wrap Around Services How many hours are being requested for ABA H0032 BSC hours per week: assessment inclusive of 0359T, 0360T, 0361T, H2019 MT hours per week: 0362T, 0363T?

5 How many hours are being requested per week for H2021 TSS hours per week: ABA therapy inclusive of 0364T, 0365T, 0366T, 0367T, 0368T, 0369T, 0370T, 0371T, 0372T, 0373T, 0374T? GR-69017-3 (2-18) EDI Page 2 of 3. Outpatient Behavioral Health (BH) . ABA Treatment Request : Required Information for Precertification Section 2 Provide the following patient-specific information 1. Referral Provider for ABA service Credentials 2. Who will be directly providing the service (working with the child)? Credential/Certification 3. Check box to ensure the following essential elements are met Diagnosis on the Autism Spectrum Time limited, individualized Treatment plan There are identifiable target behaviors Involvement of community resources Parents/Guardians involved in Treatment Service providers are appropriately licensed/certified 4. The patient displays impairment in the following areas (attach supporting data that demonstrates current status) select all that apply: Self-injurious behavior Socialization skills Destructive behavior Poor general development skills (ex: imitation, identifying objects, sharing skills).

6 Aggressive behavior Self-stimulatory behavior Elopement Verbal outbursts Communication skills Tantrum behavior/verbal outbursts 5. Please include the following supporting documentation with your Request , where applicable How was the diagnosis of Autism made? What is the member's IQ? Current medications? Documentation that Essential Elements are met A functional Behavioral assessment is planned to be completed within the first 60 days where specific target behaviors are clearly defined. Re evaluation has been performed (every 6 months) to assess the need for ongoing ABA; OR, validated assessments (such as IQ, communication level, an autism scale). have been done every 12 months Treatment plan, when applicable, includes the frequency, rate, symptom intensity or duration, or other objective measure of baseline levels of each target behavior, along with quantifiable criteria for progress established.

7 Specific type, duration and frequency of interventions are tied to the function served by the specific target behaviors. Treatment plan documents a gradual tapering of higher intensities of intervention and a shifting to supports from other sources (schools as an example) as progress occurs. Collaboration with any other Treatment providers should be documented. Supporting data that demonstrates the level/severity of impairment that justifies the number of hours requested Documentation that supports parent(s) or guardian(s) are/will be trained and required to provide specific additional interventions. Any additional details to be considered for this Request Section 3 Read this important information Any person who knowingly files a Request for authorization of coverage of a medical procedure or service with the intent to injure, defraud or deceive any insurance company by providing materially false information or conceals material information for the purpose of misleading, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.

8 Section 4 Sign the form Just remember: You can't use this form to initiate a precertification Request . To initiate a Request , call the number on the member's card. Or you can submit your Request electronically. Form completed by Title GR-69017-3 (2-18) EDI Page 3 of 3.


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