Applied Behavioral Analysis (ABA) Billing Guide

Washington Apple Health (Medicaid)

Applied Behavioral Analysis (ABA) Program Billing Guide

February 1, 2021

Disclaimer

Every effort has been made to ensure this guide's accuracy. If an actual or apparent conflict between this document and a Health Care Authority (HCA) rule arises, the rule applies. Billing guides are updated on a regular basis. Due to the nature of content change on the internet, we do not fix broken links in past guides. If you find a broken link, please check the most recent version of the guide. If this is the most recent guide, please notify us at askmedicaid@hca..

About this guide*

This publication takes effect February 1, 2021, and supersedes earlier billing guides to this program. Unless otherwise specified, the program(s) in this guide are governed by the rules found in Chapter 182-531A WAC. HCA is committed to providing equal access to our services. If you need an accommodation or require documents in another format, please call 1-800-5623022. People who have hearing or speech disabilities, please call 711 for relay services.

Washington Apple Health means the public health insurance programs for eligible Washington residents. Washington Apple Health is the name used in Washington State for Medicaid, the children's health insurance program (CHIP), and state-only funded health care programs. Washington Apple Health is administered by HCA.

Refer also to HCA's ProviderOne billing and resource guide for valuable information to help you conduct business with HCA.

How can I get HCA Apple Health provider documents?

To access provider alerts, go to HCA's provider alerts webpage. To access provider documents, go to HCA's provider billing guides and fee schedules webpage.

Where can I download HCA forms?

To download an HCA form, see HCA's Forms & Publications webpage. Type only the form number into the Search box (Example: 13-835).

* This publication is a billing instruction. CPT? codes and descriptions only are copyright 2020 American Medical Association.

2 | APPLIED BEHAVIOR ANALYSIS (ABA) PROGRAM BILLING GUIDE

Copyright disclosure

Current Procedural Terminology (CPT) copyright 2020 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA.

Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

What has changed?

Subject

Change

Reason for Change

Entire guide

Changed language throughout guide from "child" or "children" to "client."

To align with policy changes filed under emergency rules in WSR 21-04-111, effective 2/1/2021. The age limit for ABA is removed.

Title page

Removed language "for clients age 20 and younger."

To align with policy changes filed under emergency rules in WSR 21-04-111, effective 2/1/2021. The age limit for ABA is removed.

What is the purpose of the ABA program

Removed language "for children age 20 and younger."

To align with policy changes filed under emergency rules in WSR 21-04-111, effective 2/1/2021. The age limit for ABA is removed.

What is the early intensive behavioral intervention day treatment program (day treatment program)

Removed age limitations for the day treatment program

To align with policy changes filed under emergency rules in WSR 21-04-111, effective 2/1/2021. The age limit for ABA is removed.

Coverage

Updated short descriptions

To align with the current 2021 CPT? and HCPC short description

CPT? codes and descriptions only are copyright 2020 American Medical Association. 3 | APPLIED BEHAVIOR ANALYSIS (ABA) PROGRAM BILLING GUIDE

Subject

Coverage ? ABA Group Home and CommunityBased Treatment

Change

Reason for Change

Added "Yes" to the prior authorization (PA) column for CPT? code 97158

PA is required for CPT? code 97158; to align with current ABA fee schedule

CPT? codes and descriptions only are copyright 2020 American Medical Association. 4 | APPLIED BEHAVIOR ANALYSIS (ABA) PROGRAM BILLING GUIDE

Table of Contents

Resources Available..........................................................................................................................8 Definitions ............................................................................................................................................9 Program Overview ......................................................................................................................... 10

Who should read this guide? ............................................................................................... 10 What is ABA?................................................................................................................................ 10 What is the purpose of the ABA program?.................................................................... 10 Client Eligibility................................................................................................................................ 11 How do I verify a client's eligibility? ................................................................................. 11

Verifying eligibility is a two-step process:................................................................. 11 Are clients enrolled in an HCA-contracted managed care organization (MCO) eligible? .......................................................................................................................................... 12

Managed care enrollment................................................................................................. 12 Clients who are not enrolled in an HCA-contracted managed care plan for physical health services ...................................................................................................... 13 Integrated managed care .................................................................................................. 13 Integrated Apple Health Foster Care (AHFC) ........................................................... 14 Fee-for-service Apple Health Foster Care.................................................................. 15 What if a client has third-party liability (TPL)?............................................................. 15 Provider Eligibility .......................................................................................................................... 16 Who may provide services under the applied behavior analysis (ABA) program? ....................................................................................................................................... 16 What is a Center of Excellence (COE)? ............................................................................. 16 What are the qualifications for a COE?............................................................................ 16 How does a provider become recognized as a COE?................................................ 17 Will HCA accept an evaluation that was not completed by a COE? ................... 17 Who can apply to provide ABA services? ....................................................................... 18 Who can enroll with HCA as a lead behavior analysis therapist (LBAT)? ......... 18 Additional requirements for LBAT enrollment............................................................. 18 How do providers enroll with HCA as a certified behavior technician (CBT)?19 Additional requirements for CBT enrollment ............................................................... 19 Becoming a facility-based day treatment program ................................................... 19 Accessing ABA Services ............................................................................................................... 20 What is the applied behavior analysis (ABA) pathway to care? ........................... 20 Stage one of the pathway to care ...................................................................................... 20 Referral ...................................................................................................................................... 20 What does the COE do? ..................................................................................................... 20 CPT? codes and descriptions only are copyright 2020 American Medical Association.

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