Providing Applied Behavioral Analysis Treatment to Group Health Members With Autism Spectrum Disorder


Group Health provides coverage for applied behavioral analysis (ABA) treatment to individuals with autism spectrum disorder (ASD). The intent of this document is to provide guidance to providers on the process for accessing the benefit, what type of documentation is needed, and what is the scope of ABA services.

Coverage and Referral

Not all Group Health plans cover ABA treatment. Coverage can be verified by having individuals and/or families contact Group Health Customer Service toll-free at 1-888-901-4636. ABA treatment requires a diagnosis of autism spectrum disorder of ASD (DSM-V code) and there must be a referral for ABA treatment from a licensed health, mental health, or allied health provider (e.g., physician, psychologist, or speech-language pathologist).

Authorization Process

Requests for ABA treatment need to be reviewed to determine whether they meet Group Health Clinical Review Criteria (PDF). Prior authorization is needed for development of initial treatment plan and ongoing ABA treatment. ABA treatment can only be delivered by providers who are contracted with Group Health and/or meet Group Health Credentialing Criteria.

The authorization process is as follows:

  • There is an initial review of a referral to determine whether the individual meets eligibility criteria for ABA treatments (i.e. diagnosis, coverage, presence of autistic behaviors that are having clinically significant impact on functioning in home, school, and and/or community).
  • If individual meets criteria for ABA services, then initial authorization is for development of an individualized treatment plan (ITP).
  • Once the ITP is completed, it is reviewed and if it meets Group Health Clinical Review Criteria, authorization is typically given for six months of ABA therapy.
  • After six months, a progress report needs to be submitted to determine whether the member continues to meet criteria for ABA therapy and if so, an additional six months of ABA therapy is authorized.
  • Initial Treatment and Progress Plans (Word) should be sent to:
    Group Health
    Review Services
    12400 East Marginal Way S.
    Seattle, WA 98168-2559
    Fax: 1-800-377-8853

Completing the ITP

Note: Specific Group Health clinical criteria are in bold.

The ITP must be based on a diagnostic assessment within no more than 12 months of initiating treatment.

A diagnostic assessment is an individual's performance on standardized developmental assessment, checklists, or rating scales. Example assessments include:

  • Self-help skills: Vineland Adaptive Behavior Scales
  • Communication skills: Preschool Language Scale-5 (PLS-5), Clinical Evaluation of Language Fundamentals-5 (CELF-5)
  • Social skills: Social Skills Rating Scales (SSRS), Assessment of Basic Language and Learning Skills (ABBLS), Achenbach System of Empirically Based Assessment (ASEBA)
  • Behavior rating scales: ASEBA, Behavior Assessment System for Children Second Edition (BASC-2)

Group Health recommends that ITP goals be based upon where there is the most significant developmental and/or standardized gap in the diagnostic assessment.

The ITP should address autistic symptoms in one or more of the following areas:

  • Communication
  • Social interaction
  • Behavior (to include restricted, repetitive, and/or stereotypical patterns of behavior, interests, and/or activities)

Coverage of ABA treatment is for behaviors and/or symptoms related to the core symptoms of autism as noted above.

ABA treatment is not covered for symptoms and/or behaviors that are not part of core symptoms of autism (i.e. impulsivity due to ADHD, reading difficulty due to learning disability, excessive worry due to anxiety disorder).

If academic or adaptive deficits are included in the ITP, then the focus should be on addressing autistic symptoms that are impeding these deficits in the home environment (i.e. reduce frequency of self-stimulatory behavior to allow child to be able to complete mathematics sorting task and/or following through on toilet training instruction), rather than on the academic and/or adaptive skill targets (i.e. child will read paragraph level information at grade level or be able to dress self independently).

  • 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.

Functional, objective, and measurable goals should be established. As noted above each goal should include baseline performance, desired performance (imitate, label, list); quality of performance (with assistance, independently); criteria for meeting objective (frequency, duration, accuracy, speed, and intensity) and conditions of performance (location, prompts, audience). Again, goals should be related to areas of deficit/delay identified in developmental assessment. Group Health will cover for assessment of baseline performance in targeted goals. Target for goals should be what child is expected to achieve within six months.

Example ITP Goal

Target area: Improve receptive language as noted by standard score of 75 which is greater than 1.5 standard deviations form mean on receptive factor of preschool language scale.
Target behavior: Individual's performance indicates they are unable to follow two-step directions.
Baseline: Twenty percent accuracy following two-step directions.
Goal: In order to improve receptive language skills due to a diagnosis of autism spectrum disorder, patient will follow simple two-step directions when provided with gesture cues across 80 percent of opportunities when presented with age appropriate instructional material across three treatment sessions.

  • Strategies for generalized learning skills; and
  • A description of parental education, goals, training, and support services.

Strategies for generalization of learning skills (for example having the individual respond to 2-step direction given by parents) should also have specific measurable goals and objectives.

Parent education should include the following:

  1. Role of parent for each target established in the ITP.
  2. How the parent will integrate goals to promote generalization in home and other environments.
  3. Parent training goals need to be functional, objective, measurable, and specific.

Example ITP Goal

Target behavior: Improve receptive language.
Parent goal: In order to promote generalization of receptive language skills, parents will provide simple two-step directions, with gesture cue during structured homework activities.
Target: Patient is able to follow two-step directions with gesture cue with 80 percent accuracy across one week.

Strategies for coordinating ABA treatment with school-based special education programs and other treatment programs.

Targets should be developed in coordination with other services (SLP, BHS, IEP team). There should be awareness of what specific goals is being worked by a speech and language pathologist and the school (i.e. IEP) with treatment goals identified that can help facilitate generalization of skills learned in school based and/or therapy services to the home environment. While Group Health only covers ABA services provided in the home or clinic, Group Health will cover:

  • Time needed to review IEP and/or other specialty service goals to incorporate these goals into the ITP ,and/or
  • Meeting with school and/or other treatment providers to both coordinate care and to facilitate incorporation of school and/or treatment provider goals into the ITP.

Measurable discharge criteria and a discharge plan.

As part of the ITP, there should be description of what needs to occur in order for the individual to be able to be discharged from ABA treatment. Typically individuals' no longer need ABA services if:

  • Their behaviors and/or symptoms do not prevent them from adequately participating in home, school, or community activities and/or no longer present a safety risk to self or others.
  • Their behaviors and/or symptoms can be adequately addressed through alternative methods (i.e. school, developmental disability services, parent training), or
  • 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.

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.
  • A description of how care is being coordinated with school and/or health care providers.
  • If the individual 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 individual 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.

When describing progress towards goals, describe goal and current performance using specific measurable performance as compared to baseline performance. (For example: A goal for percentage of time the individual follows two-step directions during instructional sessions was 80 percent. Baseline performance was 10 percent. Current performance is 60 percent.)

For parent/caregiver goals, give brief summary of progress (focus with parents was on how to address individual's disruptive behaviors during meal time. Parents have been successful in ignoring verbal outbursts and rewarding appropriate meal time behavior).

Include in the progress report what was done during past six months to coordinate treatment with school and/or health care providers (i.e. phone call was made to speech therapist to make sure there is common picture communication system).

As previously noted, it is expected that goals identified on the ITP should be achieved within six months. It is recognized that there needs to be some experience in working with an individual to determine rate of progress and thus there will be some individuals where a number of goals identified in the ITP are not met after six months. If the goals are not met, it is important to develop a functional analysis to determine the reason for lack of progress (i.e. individual continuing to have difficulty maintaining eye contact, individual continues to engage in self-stimulatory behaviors that prevent follow through with discrete learning) as well as then how intervention will be modified to address lack of progress.

If an individual is unable to demonstrate progress towards meeting the majority of goals after two six month periods of ABA treatment, then consideration will be made as to whether there is a reasonable expectation that child is capable of making progress with ABA therapy. If so, then the individual no longer meets criteria for continued ABA therapy.

Revised 7/29/2014

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 doesn’t 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.