Applied Behavioral Analysis (ABA) Program Billing Guide

Washington Apple Health (Medicaid)

Applied Behavioral Analysis (ABA) Program Billing Guide

(For clients age 20 and younger)

July 1, 2019

Every effort has been made to ensure this guide's accuracy. If an actual or apparent conflict between this document and an agency rule arises, the agency rules apply.

About this guide

Applied Behavior Analysis (ABA) Program for Clients Age 20 and Younger

This publication takes effect July 1, 2019, and supersedes earlier guides to this program.

HCA is committed to providing equal access to our services. If you need an accommodation or require documents in another format, please call 1-800-562-3022. 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 stateonly funded health care programs. Washington Apple Health is administered by the Washington State Health Care Authority.

What has changed?

Subject Behavioral Health Organization (BHO)

Integrated managed care regions

ABA Treatment Codes for Service after December 31, 2018

Change Removed the North Sound region

Effective July 1, 2019, a new integrated managed care region, called North Sound, will be implemented. North Sound region includes Island, San Juan, Skagit, Snohomish, and Whatcom counties. Revised units and assessment allowed for Procedure Code 97151

Reason for Change Effective July 1, 2019, behavioral health services in the North Sound region will be provided under integrated managed care New integrated managed care region

Billing clarification

Removed analysis limitation for Procedure Code 0362T

This publication is a billing instruction. 2

Applied Behavior Analysis (ABA) Program for Clients Age 20 and Younger

How can I get agency provider documents?

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

Where can I download agency forms?

To download an agency provider form, go to HCA's Billers and providers webpage, select Forms & publications. Type the HCA form number into the Search box as shown below (Example: 13-835).

Copyright disclosure

Current Procedural Terminology (CPT) copyright 2018 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association (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.

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Table of Contents

Applied Behavior Analysis (ABA) Program for Clients Age 20 and Younger

Resources Available ...................................................................................................................... 7

Definitions...................................................................................................................................... 8

Program Overview........................................................................................................................ 9

Who should read this guide?..................................................................................................... 9 What is ABA? ........................................................................................................................... 9 What is the purpose of the ABA program?............................................................................... 9

Client Eligibility .......................................................................................................................... 10

Who is eligible? ...................................................................................................................... 10 Verifying a client's eligibility................................................................................................. 10

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

eligible?............................................................................................................................. 11 Managed care enrollment.................................................................................................. 12 Behavioral Health Organization (BHO) ........................................................................... 12 Apple Health ? Changes for July 1, 2019 ......................................................................... 12 Integrated managed care ................................................................................................... 13 Integrated Apple Health Foster Care (AHFC) .................................................................. 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? ....................................................... 18 Will the agency accept an evaluation that was not completed by a COE? ....................... 18 Who can apply to provide ABA services? .............................................................................. 18 Who can enroll with the agency as a lead behavior analysis therapist (LBAT)? ................... 19 Additional requirements for LBAT enrollment ................................................................ 19 How do providers enroll with the agency as a certified behavior technician (CBT)? ............ 19 Additional requirements for CBT enrollment................................................................... 20 Becoming a facility-based day treatment program ........................................................... 20

Accessing ABA Services ............................................................................................................. 21

What is the applied behavior analysis (ABA) pathway to care? ............................................ 21 Stage one of the pathway to care ............................................................................................ 21

Referral ............................................................................................................................. 21 What does the COE do? .................................................................................................... 22 Required documentation ................................................................................................... 22 The comprehensive diagnostic evaluation ........................................................................ 22 Stage two of the pathway to care ............................................................................................ 24 Selecting an ABA provider ............................................................................................... 24 Parent training only while the child is on a waitlist for individual ABA services............ 24 Alert! This Table of Contents is automated. Click on a page number to go directly to the page.

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Applied Behavior Analysis (ABA) Program for Clients Age 20 and Younger

The ABA assessment and treatment plan ......................................................................... 25 Stage three of the pathway to care .......................................................................................... 26

LBAT responsibilities ....................................................................................................... 27 CBT responsibilities.......................................................................................................... 27 ABA delivery methods and settings ................................................................................. 28 Community-based program services................................................................................. 28 Home and community services:........................................................................................ 28 What is the early intensive behavioral intervention day treatment program (day treatment program)?.......................................................................................................... 29 Purpose of the day treatment program .............................................................................. 29 Providers in the day treatment program............................................................................ 30 Requirements for the day treatment program ................................................................... 30 Day Treatment Program Model ........................................................................................ 32 What client files and records does the agency require? .......................................................... 33

Telemedicine ................................................................................................................................ 35

What is telemedicine? ............................................................................................................. 35 Originating site.................................................................................................................. 35 Distant site ........................................................................................................................ 35

Which services may be provided via telemedicine? ............................................................... 35 What services are not paid for under telemedicine? ............................................................... 36

Authorization............................................................................................................................... 37

What is prior authorization (PA)?........................................................................................... 37 When is PA required? ............................................................................................................. 37 What forms and documents are required for PA for fee-for-service clients? ......................... 38 Does PA for ABA services expire? ........................................................................................ 39 What if additional units of service are needed to continue providing ABA services? ........... 39 What are the requirements for recertification of ABA services?............................................ 40

Additional requirements for recertification of ABA services........................................... 40 Why might the agency deny recertification of ABA services?............................................... 40 What is a limitation extension (LE)? ...................................................................................... 41 How do I obtain an LE? .......................................................................................................... 41

Coverage ...................................................................................................................................... 42

What is covered?..................................................................................................................... 42 ABA treatment ? home and community-based settings ................................................... 42 ABA treatment ? group settings ....................................................................................... 43

What modifiers do providers bill with? .................................................................................. 44 What about services covered under other agency programs? ................................................. 44 Which services are not covered?............................................................................................. 45

Billing ........................................................................................................................................... 46

What are the general billing requirements? ............................................................................ 46 What procedure codes do I use to bill for home and community-based services? ................. 46 What codes do day treatment programs use to bill the agency? ............................................. 46

Alert! This Table of Contents is automated. Click on a page number to go directly to the page. 5

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