Insurance Authorization

Reassessment

Unit Calculation

All ABA CPT codes use 15-minute units. Apply the 8-minute rule:

• 8–22 minutes = 1 unit
• 23–37 minutes = 2 units
• 38–52 minutes = 3 units
• 53–67 minutes = 4 units

Modifier Codes

• HM: Less than bachelor's degree level (RBT).
• HN: Bachelor's degree level.
• HO: Master's degree level (BCBA).
• HP: Doctoral level (BCBA-D).
• 95: Synchronous telehealth.
• GT: Telehealth (some payers still use this).
• XE, XP, XS, XU: Distinct procedural service modifiers to allow same-day billing of same code by different providers.

ICD-10 Diagnostic Codes

Primary Autism Spectrum Diagnoses

Severity Specifiers (DSM-5)

Payers may require severity level documentation:

• Level 1: Requiring support
• Level 2: Requiring substantial support
• Level 3: Requiring very substantial support

Common Comorbid Codes

• F90.0–F90.9: ADHD
• F80.1–F80.2: Language disorders
• F88: Global developmental delay
• F70–F79: Intellectual disabilities
• R62.50: Failure to thrive (feeding concerns)

Authorization Request Components

Initial Authorization

1. Client demographics: Name, DOB, member ID, diagnosis with ICD-10 codes.
2. Diagnostic confirmation: Copy of diagnostic report from a qualified evaluator.
3. Assessment summary: Standardized assessment results (VB-MAPP, ABLLS-R, Vineland-3), FBA findings, skills assessment.
4. Treatment plan: Measurable goals, interventions, and service recommendations.
5. Medical necessity statement: Clear justification linking assessment findings to requested services.
6. Recommended services and hours: Specific CPT codes, units per week, and duration of authorization.
7. Provider credentials: BCBA certification, state license, NPI numbers.

Reauthorization

1. Progress data: Graphs showing data trends for each goal.
2. Updated goals: New, modified, or discontinued goals with rationale.
3. Treatment summary: Narrative describing progress, barriers, and clinical decisions.
4. Updated assessment: Reassessment results if available.
5. Continued medical necessity: Why ongoing services are still needed.

Common Denial Reasons and Responses

Appeals Process

Internal Appeals (Level 1)

• File within the payer's timeline (typically 30–60 days from denial).
• Submit a detailed letter addressing the specific denial reason.
• Include supporting documentation: assessment data, progress graphs, peer-reviewed research.
• Request a peer-to-peer review with the payer's clinical reviewer.

External Appeals (Level 2)

• If internal appeal is denied, request an independent external review.
• Most states mandate external review rights.
• An independent reviewer evaluates the clinical documentation.
• External review decisions are typically binding on the payer.

Peer-to-Peer Review Tips

• Prepare talking points organized around the denial reason.
• Have all assessment data, treatment plans, and progress data immediately accessible.
• Be specific about medical necessity—cite the client's individual needs, not generic justifications.
• Reference payer-specific clinical guidelines to show compliance.
• Document the call: date, time, reviewer name, outcome.

State Mandates

• As of 2024, all 50 US states plus DC have some form of autism insurance mandate.
• Coverage requirements vary significantly: age limits, dollar caps, hour limits, diagnosis requirements.
• Some states mandate coverage of ABA specifically; others use broader language.
• Federal parity laws (MHPAEA) also apply to ABA services under behavioral health.
• Stay current with your state's specific mandate through the state BACB chapter or autism advocacy organizations.

Documentation Best Practices

• Keep clinical notes contemporaneous—document on the same day as service.
• Use objective, behavioral language in all documentation.
• Ensure session notes reflect the specific CPT code billed.
• For 97155: document what was observed, what data were reviewed, what modifications were made, and the clinical rationale.
• For 97156: document the caregiver skill trained, the training method used (BST components), caregiver performance, and next steps.
• Maintain a clear audit trail linking assessment → goals → interventions → data → clinical decisions.

Key References

• American Medical Association. (2019). CPT Professional Edition.
• Council for Autism Service Providers. (2020). Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers (2nd ed.).
• Behavior Analyst Certification Board. (2020). Ethics Code for Behavior Analysts.