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

By informationalnotice dated October 30, 2020, the Department announced coveragefor ABA services for children with a diagnosis of autism spectrum disorder whenordered by a physician licensed to practice medicine in all its branches. Thatnotice also identified provider qualifications and summarized the stepsinvolved for enrollment of LCPs, LCSWs, and Registered Behavioral Technicians(RBTs) specifically for ABA services.

Properly enrolledLCPs and LCSWs may request prior approval and provide approved services asoutlined below.

ABA Service Description

Behavioral Assessment and Treatment Planning (BATP).  BATP is the formal process of informationgathering and service planning to: 1) evaluate current maladaptive ordisruptive behaviors, skills and needs; and 2) identify individualizedtreatment goals, objectives and recommendations for the delivery of ABAServices. The BATP is expected to be completed, or updated:

·        Once every 180 days;

·        Be reviewed, approved, and signed bya BCBA; and

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

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

·        At all service locations andsettings deemed appropriate for reimbursement, consistent with Departmentpolicy; 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 associatedreimbursement rate is available on the HFS website as a component of the LicensedClinical Psychologists and Licensed Clinical Social Workers Fee Schedule.

Prior Approval for ABA Services

BATP services exceeding six hours (24 units) per a 180-dayperiod and all BAI services require prior authorization. Providers mustcomplete the PriorAuthorization for Applied Behavioral Analysis (ABA) Servicesform and submit all required documentation to HFS.ABA@Illinois.gov.

ABA Prior Authorization ClinicalDocumentation

The following attachments may be required to obtain approvalfor ABA services.

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

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

ACDE is an assessment, evaluation, or test that is required to establish adiagnosis of ASD. The CDE must include:

·        Direct interaction and assessment ofthe participant;

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

o AutismDiagnostic Observation Schedule (ADOS);

o GilliamAutism Rating Scale (GARS);

o AutismDiagnostic Interview (ADI); or

o ChildhoodAutism Rating Scale (CARS)

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

·        Current functional ability in bothverbal and nonverbal areas; and

·        A primary caregiver interview.

TheCDE may also include a review of standardized cognitive and developmentaltesting; neurological testing; hearing screening; vision screening; genetictesting; and other non-specified medical testing required to rule out otherdisorders and conditions.

3.   Documentation of FunctionalImpairment. If the participant’s CDE was completed more than 24 months prior tothe date of request for prior authorization, current individualizeddocumentation of functional impairment by a physician or a clinicalpsychologist is required.

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

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

 Prior Authorization Review Timelinesand Decisions

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

             ·        Review Outcomes. The provider andthe participant will be notified of the outcome of the prior authorizationreview and the right to appeal, if applicable, consistent with  89Ill. Admin. Code Section 102.70. ABA service approvals are nottransferable, as they are specific to a participant, provider, and serviceallotment.

             ·        Missing or Incomplete Documentation.If a prior authorization request is incomplete, or requires additional clinicaldocumentation to be properly considered, the Department will suspend the priorauthorization review process, stopping the 30-day time limit for priorauthorization review, and request additional clinical information from the provider.All requests for additional clinical information must be remedied by theprovider in order to re-start the prior authorization review process with a new30-day review window. 

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

Kelly Cunningham, Administrator

Division of Medical Programs​​