Applied behavioral analysis or ABA therapy is considered medically necessary by most, but certainly not all, insurance companies or plans. Payers require that services they approve and reimburse are medically necessary, and providers must have documentation to justify these services. Payers may require providers to present this information in advance of treatment with prior authorization or require a post-service review by requesting medical documentation after services have been provided in a standard review or during an audit.
What is medical necessity?
Medical necessity is a term used by health insurance companies. It describes all the coverage that is offered by the benefit plan. For example, ABA treatment plans for autism coverage will differ based on how a health insurance company decides what it is willing to pay for. The policy will clearly state what it deems medically necessary.
How is medical necessity determined?
Each payer has unique medical necessity standards using a combination of external guidelines, and local and federal laws. Some commonly used external guidelines are Interqual Behavioral Health Medical Necessity Criteria or the MCG Health Behavioral Health Care Guidelines (formerly Milliman). Providers need to be knowledgeable about each payer’s requirements for documentation.
Before you write your ABA treatment plan, verify that the insurance policy covers the member, diagnosis, and service. Even a perfectly-written medical necessity document will likely still be denied if these are not covered.
In addition, although ABA is frequently covered, academic/educational, vocational, or recreational activities are not considered medically necessary. You will need to justify that these programs for ABA therapy are medically necessary. Therefore, careful documentation of ABA treatment plan goals and intervention is critical, particularly when ABA therapy is recommended to take place in a school or community setting.
Here are some ABA treatment plan examples of documentation that most payers want to be included:
- Client Demographics
- Diagnostic Evaluation specific to autism, most require standardized autism testing
- Adaptive Behavior Evaluation
- Relevant medical history and prior/current treatment
- Biopsychosocial information
- Recommended treatment “dosage” with frequency and duration of service, including detail on direct therapy, case supervision, and caregiver training
- Individualized treatment plan with detailed treatment goals for each type of service recommended, ongoing progress and mastery, and discharge criteria
- Explanation as to why the ABA treatment plan goals could not be mastered or effective at a lower level of care
- Detailed credentials, contact information, and signature for the provider rendering provider
Get quality assistance with ABA authorizations and documentation at Missing Piece
Struggling to get your authorizations approved or documentation correct?
At Missing Piece, we pride ourselves on being knowledgeable about the medical necessity requirements for each payer. We arm our providers with the necessary clinical and treatment plan guidelines for documentation, and our authorization team facilitates submitting requests for approval. On the rare occasion that something is not approved as requested, the Authorization Specialist can submit appeals on your behalf and work to ensure that the patient is approved for all medically-necessary services.
To learn more about our ABA billing and complete revenue cycle services, contact us for the best information available.