Applied Behavioral Analysis (ABA) Therapy for Group Health Members
Only certain Group Health members have coverage of ABA therapy. That coverage may be set forth in the enrollee's coverage agreement or a rider to the agreement. Members should contact Group Health Customer Service to find out if their plan provides coverage of ABA therapy.
ABA therapy requires diagnosis of an Autism Spectrum Disorder (DSM-IV-TR 299.0, 299.10, 299.80) by a neurologist; pediatric neurologist, developmental pediatrician, psychologist or psychiatrist experienced in the diagnosis and treatment of autism.
Members must have a referral for ABA therapy from a licensed health, mental health, or allied health provider (e.g., physician, psychologist, or speech-language pathologist).
Preauthorization for initial and continued ABA therapy must be medically necessary and meet Group Health Clinical Review Criteria.
In order for a member to be authorized for therapy, an individualized treatment plan (ITP) must be completed by the lead behavioral therapist. The ITP must be submitted to Group Health, Review Services, 12400 East Marginal Way S. AMB-2 Seattle, WA 98168-2559 FAX: 1-800-377-8853. The ITP must include all of the following:
- Identification and detailed description of targeted behaviors; and
- Symptoms in one or more of the following areas:
- Social interaction
- Behavior (to include restricted, repetitive, and/or stereotypical patterns of behavior, interests, and/or activities)
- Objective, baseline measurement levels for each target behavior/symptoms in terms of frequency, intensity and duration, including use of standardized autism measures; and
- A comprehensive description of treatment interventions and techniques specific to each of the targeted behaviors/symptoms, including documentation of the number of service hours, in terms of frequency and duration for each intervention; and
- Establishment of treatment goals and objective measures of progress for each intervention specified; and
- Strategies for generalized learning skills; and
- A description of parental education, goals, training, and support services; and
- Strategies for coordinating treatment with school-based special education programs; and
- Plans for transition through a continuum of treatments, services, and settings; and
- Measurable discharge criteria and a discharge plan.
- The ITP must be based on a diagnostic assessment within no more than 12 months of initiating treatment.
- The ITP should be multidisciplinary in nature, member-centered, family focused, community based, culturally competent and least intrusive.
- Treatment plans that are templates or generic to a particular program are not acceptable.
- The ITP must address behaviors and symptoms that prevent the member from adequately participating in home, school, or community activities and/or present a safety risk to self or others and should focus on parent training.
For continued ABA coverage, at least every six months, providers need to submit a progress report that documents the following:
- Progress towards goals identified in the ITP.
- A description of parent/caregiver goals and participation in implementing the ITP.
- If the member has reached the previously defined goals, the re-evaluation should identify new goals toward progress or transition the member to less intensive interventions.
- If the member has not achieved the defined goals, there should be a re-evaluation that identifies the reasons for not meeting the goals and a revised ITP that addresses revised interventions to help the member meet defined goals.
- If functional and measurable progress toward treatment goals is not occurring and there is no reasonable expectation of further progress, then continued ABA services are not considered medically necessary.
Lead Behavioral Therapists are responsible for development of the ITP and clinical supervision of the treatment program. Such supervision must include:
- Bimonthly (once every 60 days) approval and review of the ITP and case review of every member receiving clinical health services; and
- At least one hour of on-site supervision, with on-site observation for at least one hour for every 40 hours of service to the member.
Lead Behavioral Therapists must satisfy all Group Health Credentialing requirements. These requirements include but are not limited to the following:
- Demonstrating that she/he is a board certified behavior analyst (BCBA) or that she/he has at least 240 hours of coursework related to behavior analysis and/or 750 hours of supervised experience or comprehensive behavioral analytic therapies for children with autism; and
Either individually satisfy the following requirements:
- Be a licensed health provider under Title 18, Revised Code of Washington, including but not limited to: Speech therapist, occupational therapist, psychologist, pediatrician, neurologist, psychiatrist, mental health counselor, social worker; and
- Be licensed to practice independently; and
- Be credentialed and contracted by the Plan; or
- Be employed by a Healthcare Delivery Organization that meets the following requirements:
- Be a hospital, mental health facility, home health agency, or in-home agency licensed to provide home health services or other mental health agency licensed by the Washington Department of Health; or community mental health agency or home health agency licensed by the Washing ton Department of Social and Health Services; and
- Be credentialed and contracted by the Plan.
- Unlicensed providers delivering ABA services must meet the following requirements:
- Be employed by a lead behavioral therapist or Healthcare Delivery Organization that meets the above requirements.
Non-medical, ancillary activities such as travel, telephone calls, team meetings, and development of ABA program materials, are not medically necessary services and will not be covered by Group Health.
Providers shall cooperate with Group Health in care management activities, quality assurance programs, health care information audits, review of records, and other activities deemed appropriate by Group Health for ensuring quality of care and patient satisfaction.
The Provider Manual is not intended for any use by any party other than as a resource for Group Health Cooperative's contracted providers in fulfilling their obligations under provider contracts. Group Health intends for the manual to be accurate for its intended purpose but doesnt guarantee accuracy. Providers should comply with the terms of their provider contracts and any legal requirements in the event of an inconsistency between the manual and a requirement in their provider contracts or the law.