These services may or may not be covered by your HealthPartners plan. Please see your plan documents for your specific coverage information. If there is a difference between this general information and your plan documents, your plan will be used to determine your coverage.
Prior authorization is required for early intensive intervention services (EIIS) to treat autism as follows:
- For members whose coverage includes the mandated Autism benefit, this treatment requires prior authorization by the Behavioral Health Department when intensive behavioral health services.
The following services are outside of the scope of this policy. They may require prior authorization within the scope of another policy. Please see the related policies section.
- sensory integration
- occupational therapy
- speech therapy
- physical therapy
- rehabilitative services
- habilitative services
Coverage criteria described in this policy apply to large group fully insured benefit plans that are subject to the Minnesota statutes Section 62A.3094. It may apply to select self-insured plans per the direction of the plan sponsor.
These services are generally not covered for small group or individual plans
Early intensive intervention for a child with an autism spectrum disorder diagnosis is covered as described below in Indications that are covered. This includes coverage for the diagnosis, evaluation, multidisciplinary assessment, and medically necessary care of children under 18 with autism spectrum disorders.
Indications that are covered
- Coverage for the diagnosis, evaluation, multidisciplinary assessment, and medically necessary care of children under 18 with autism spectrum disorders, including but not limited to the following:
- early intensive behavioral and developmental therapy based in behavioral and developmental science, including, but not limited to, all types of applied behavior analysis, intensive early intervention behavior therapy, and intensive behavior intervention;
- neurodevelopmental and behavioral health treatments and management;
- speech therapy;
- occupational therapy;
- physical therapy; and
- The diagnosis, evaluation, and assessment must include an assessment of the child's developmental skills, functional behavior, needs, and capacities.
- The coverage required under this subdivision must include treatment that is in accordance with an individualized treatment plan prescribed by the enrollee's treating physician or mental health professional.
- A health carrier may request an updated treatment plan only once every six months, unless the health carrier and the treating physician or mental health professional agree that a more frequent review is necessary due to emerging circumstances.
- An independent progress evaluation conducted by a mental health professional with expertise and training in autism spectrum disorder and child development must be completed to determine if progress toward function and generalizable gains, as determined in the treatment plan, is being made.
Note: A child’s treatment shall continue during the progress evaluation and/or the appeal process.
Indications that are not covered
Child - means a person under the age of 18
Autism spectrum disorders - means the conditions as determined by criteria set forth in the most recent edition of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.
Medically necessary care - means health care services appropriate, in terms of type, frequency, level, setting, and duration, to the enrollee's condition, and diagnostic testing and preventative services. Medically necessary care must be consistent with generally accepted practice parameters as determined by physicians and licensed psychologists who typically manage patients who have autism spectrum disorders.
Mental health professional - means a mental health professional as defined in Minnesota State Statutes section 245.4871, subdivision 27, clause (1), (2), (3), (4), or (6), who has training and expertise in autism spectrum disorder and child development.
If available, codes are listed below for informational purposes only, and do not guarantee member coverage or provider reimbursement. The list may not be all-inclusive
Skills training and development, per 15 minutes
Therapeutic behavioral services, per 15 minutes
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This information is for most, but not all, HealthPartners plans. Please read your plan documents to see if your plan has limits or will not cover some items. If there is a difference between this general information and your plan documents, your plan documents will be used to determine your coverage. These coverage criteria may not apply to Medicare Products if Medicare requires different coverage. For more information regarding Medicare coverage criteria or for a copy of a Medicare coverage policy, contact Member Services at 952-883-7979 or 1-800-233-9645.
- 12/23/2013 - Date of origin
- 01/01/2017 - Effective date