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Coverage criteria policies

Autism – applied behavior analysis for treatment of autism spectrum disorders – South Dakota - effective 7/1/2019

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 documents will be used to determine your coverage.

Administrative Process

Prior authorization is required for Applied Behavior Analysis (ABA) for treatment of autism spectrum disorders.

  • For members whose coverage includes the mandated Applied Behavior Analysis (ABA) benefit, this treatment requires prior authorization by the Behavioral Health Department when Applied Behavior Analysis services are requested.

Coverage

Applied Behavior Analysis for treatment for a child with an autism spectrum disorder diagnosis is covered subject to the indications listed below and per your plan documents. This includes coverage for the diagnosis, evaluation, multidisciplinary assessment, and medically necessary care of children through age18 with autism spectrum disorders.

Indications that are covered

  1. A health carrier or plan provider subject to §§ 58-17-154 to 58-17-162, inclusive, shall have the right to request a review of the treatment that a person is receiving not more than once every three months unless the insurer and the person's licensed physician or licensed psychologist execute an agreement that a more frequent review is necessary. Any agreement regarding the right to review a treatment plan more frequently applies only to a particular person receiving applied behavior analysis and may not apply to all persons receiving applied behavior analysis by a licensed physician, licensed psychologist, or licensed behavior analyst. The cost of obtaining a review under this section shall be paid by the health carrier or plan.
  2. The coverage for applied behavior analysis shall provide an annual maximum benefit that may not be less than the following:
    1. Through age 6 $36,000
    2. Age 7 through age 13 $25,000
    3. Age 14 through age 18 $12,500
  3. Meets Behavioral Health Care MCG Applied Behavioral Analysis coverage criteria (22nd edition).

    Please contact the Behavioral Health Department at 952-883-7501 for a copy.

Indications that are not covered

  1. Recipient is 19 or older
  2. Care that is not medically necessary
  3. Care that is beyond the annual maximum for each age group as defined above or in the recipient’s benefit contract.

Definitions

Applied behavior analysis- the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationship between environment and behavior;

Autism spectrum disorder-a complex neurodevelopmental medical disorder characterized by social impairment, communication difficulties, and restricted, repetitive, and stereotyped patterns of behavior;

Behavioral health treatment-evidence-based interventions that:

  1. Achieve specific improvements in functional capacity of a person; and
  2. Are provided or supervised by a licensed practitioner as provided in § 58-17-159;

Treatment-evidence-based care which is prescribed or ordered for a person diagnosed with an autism spectrum disorder by a licensed physician or psychologist, including: Behavioral health treatment; Pharmacy care; and Therapeutic care.

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.

The services associated with these codes require prior authorization:

Codes

Description

H2014

Skills training and development, per 15 minutes

H2019

Therapeutic behavioral services, per 15 minutes

97151

Comprehensive Multidisciplinary Disciplinary Evaluation - Behavioral identification assessment, administered by a physician or other Qualified Health Professional, each 15 mins.

99366

Coordinated care conference - Medical team conference with interdisciplinary team of health care professionals, face-to-face with patient and/or family, 30 mins or more,

97153

Adaptive behavior treatment by protocol, administered by tech under the direction of a physician or other qualified health care professional, face-to-face with one patient; each 15 mins.

97154

Group adaptive behavior treatment by protocol, administered by technician under direction of a physician or other qualified healthcare professional, face-to-face with two or more patients, each 15 mins.

97155

Intervention - Observation and Direction: Adaptive behavior treatment with protocol modification.

97156

Family/caregiver training and counseling: Individual Family adaptive behavioral treatment guidance, each 15 mins.

97157

Family/caregiver training and counseling: Group: Multiple-family group adaptive behavior treatment guidance, each 15 mins.

CPT Copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Products

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.

References

  1. South Dakota Codified Law Statute 36-38-2
  2. South Dakota Codified Law Statute 58-17-154
  3. South Dakota Codified Law Statute 58-17-157
  4. South Dakota Codified Law Statute 58-17-158
  5. South Dakota Codified Law Statute 58-17-159
  6. South Dakota Codified Law Statute 58-17-160

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Policy activity

  • 02/21/2019 - Date of origin
  • 07/01/2019 - Effective date

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