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New Preauthorization Requirement for Applied Behavioral Analysis

September 28, 2016

Effective Jan. 1, 2017, there will be a requirement for a preauthorization for Applied Behavior Analysis (ABA) for the treatment of Autism Spectrum Disorder for eligible Blue Cross and Blue Shield of Oklahoma (BCBSOK) members. Preauthorization for these services is processed through Behavioral Health Medical Management Review, by calling the number on the member's ID card.

Continue to watch the Provider website and the Blue Review provider newsletter for additional information regarding the following preauthorization forms:

  • Diagnostic Physician/Specialist Evaluation
  • Provider Credentials Verification
  • Assessment Info and Initial Treatment Plan

Reminders:

  • The member must have an Autism Spectrum Disorder diagnosis from a qualified diagnostician.
  • The ABA service provider must have the credentials necessary to conduct ABA services.
  • An initial functional assessment, including a treatment plan that identifies any deficient skills and the appropriate interventions, must be completed.
  • After the first authorization for ABA services, additional authorizations may require concurrent review to ensure the member continues to meet the medical necessity guidelines.
  • iExchange® is not available for ABA preauthorization or behavioral health at this time, therefore please call the number on the back of the member’s ID card for ABA preauthorization requests.

Please be aware that not all benefit plans within a particular network provide coverage for ABA for the treatment of Autism Spectrum Disorder. Member eligibility and benefits should be checked before every scheduled appointment. Eligibility and benefit quotes include membership status, coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts. It is strongly recommended that providers ask to see the member's ID card for current information and a photo ID to guard against medical identity theft. When services may not be covered, members should be notified that they may be billed directly.

Keep in mind that BCBSOK will deny claims for ABA services that do not meet medical necessity criteria and that you perform without preauthorization.

If you have any questions, please contact your BCBSOK Provider Network Representative Lore Holtsberg at 405-316-7199 or Lore_Holtsberg@bcbsok.com.


Please note: The fact that a service or treatment has been preauthorized or predetermined for benefits is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member's eligibility and the terms of the member's certificate of coverage applicable on the date services were rendered. "Coverage" means the determination of whether or not the particular service or treatment is a covered benefit under the terms of the particular member's benefit plan. A coverage determination is based upon plan documents and (when applicable) a review of clinical information to determine whether clinical guidelines/criteria for coverage are met. Regardless of any benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.