Use of ABA therapy for autism has helped many young people improve various skills. An ABA treatment plan, for example, can improve language, communication, social skills, and various other behaviors. This has led to many therapists adopting the use of ABA treatment plans to try and address the challenges faced by those with autism.
When it comes to what is expected of an ABA treatment plan by health insurance organizations, each insurance company has policies on clinical documentation, treatment plans, and progress notes. The list below is adapted from Optum and offers a comprehensive overview of required treatment plan components. Please refer to your specific insurance company’s contracts or provider manuals for more details.
The components of an ABA treatment plan
Missing Piece has found the following elements are key to surviving a medical necessity review or an audit. Each treatment request must include all 10 components listed below:
1) Biopsychosocial Information including, but not limited to:
- Current family structure
- Medications, including dosage and prescribing physician
- Medical history
- School placement
- Time in academic activities
- History of ABA services
- Other mental health services, including any mental health hospitalizations
- Other services the child is receiving such as ST, OT, or PT
- Any major life changes
2) Why ABA services are needed and how ABA addresses the current areas of need:
- Why ABA is the preferred treatment over other mental health services
3) Goals should relate to the core deficits of an Autism Spectrum Disorder (communication, relationship development, social behaviors, and problem behaviors):
- Should be derived from the functional assessment and/or skills-based assessments that occur before initiating treatment
- Should not be academic in nature, unless the child is under school age(s)
- Should not be related to vocational skills
- Must have established baseline levels for the behavior or skill
- Must have target dates for when the goal will be mastered
- Must have a date of introduction
- Should be broken into short-term and long-term, if needed
- Should include graphs, if available
- Must be ready to discuss when/why a member has made slow or no progress in the acquisition, maintenance, and generalization of target skills
- Should include a behavior support/maintenance plan noting changes based on ongoing assessments. Functional behavior assessments or skills-based assessments should be completed as needed to work with member’s behavioral/skill challenges
- Observe the member’s behavior to determine the effectiveness of the behavior support/maintenance plan, and if not effective, note changes to the plan
4) Behavior Intervention Plan:
- Include definition of the behavior, antecedents, consequences, prevention, baseline, and any de-escalation procedures
- Include individualized steps for the prevention and/or resolution of crisis (i.e., identification of antecedents and consequences)
5) Coordination with other behavioral health and medical providers, including but not limited to:
- Psychologists
- Individualized Education Plan/Services
- Psychiatrist
- Speech Therapist
- Anyone who is concurrently providing services
- Coordination of care
6) Parent/Guardian involvement:
- Parents/guardians need to understand and agree to comply with the requirements of treatment
- The treatment plan should address how the parents/guardians will be trained in management skills that can be generalized to the home
- There should include demonstration and maintenance of management skills by parents/guardians
- Address how barriers to parent involvement are being addressed
- Whether the parent is addressing the treatment goals when treatment professionals are not present and note their overall skill abilities
- Parents’ training and time involvement and any materials or meetings that occur with the parent on a routine basis
7) Transition Plan:
- May include the level of support a child needs to be successful when moving from one intensity of care to another. The skills the child is currently being taught to facilitate the transition, and the level of communication between the supervising clinician and any other related allied professionals such as the child’s teacher, speech therapist, occupational therapist, social worker, etc.
- Transition plans may include several additional components depending on the child’s situation:
- A transition plan would be appropriate when a child is moving from a home-based program to mainstream education, when changing grade levels, aging out of services, or moving out of public education
- The transition plan should address how the child will move from the current level of service to lower levels (hours) of service through discharge; this should be directly related to how the child is meeting objectives
- If the member is an older child or adolescent, the treatment plan should reflect a plan to transition the member into adult services
8) Discharge Criteria:
- Discharge criteria, including estimated length of treatment, should be developed when services are initiated. The discharge plan should include:
- Date of discharge
- Post-discharge level of care and recommended forms and frequency of treatment
- Names of the provider who will deliver treatment
- Resources to assist the member with overcoming barriers to care (e.g., lack of transportation, lack of childcare, or lack of self-help and community support services)
- The discharge criteria should include information about what the member should do in the event of a crisis before the first appointment at the lower level of care
- It must also include requirements for:
- Discharge
- Next level of care (e.g., outpatient mental health services, medication management, a mainstream school, etc.)
- Linkages with other services
- How the parents can contact the provider for additional assistance
- Community resources, if applicable
- Discharge criteria should be measurable and directly related to the attainment and maintenance of the goal
9) Crisis plan:
- Include steps for prevention and de-escalation of the crisis. It should address the following types of situations:
- Emergency situations, such as a weather or medical emergency (i.e. seizures), including who should be contacted, which includes appropriate supervisors or emergency personnel
- Names and phone numbers of contacts that can assist the member in resolving the crisis, such as other treatment providers who may assist in the prevention or de-escalation of behaviors, even for those clients who do not currently display aberrant behavior
10) Recommendations:
- List hours/units being requested and codes
- May include a daily schedule
As part of the onboarding and implementation process, Missing Piece educates each provider on treatment plan writing and the specific requirements for each payer. The Authorization team continually provides training and feedback to providers to ensure authorization request submissions comply with payer requirements to minimize rejections, reductions, or denials. If authorization is reduced or denied, which is rare, Missing Piece will assist you in submitting authorization appeals to support your patient in receiving the necessary medical services.
Find out more about Missing Piece and how we can help behavioral health services providers
To learn more about Missing Piece’s prior authorization support and ABA therapy billing services, reach out to us to schedule your free consultation. You can also contact us to find out more about the other ways our services can assist you.