According to medicare.gov, medically necessary is defined as “Health care services or supplies needed to diagnose or treat an illness, injury, condition, disease, or its symptoms and that meet accepted standards of medicine.”
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 are provided in a standard review or during an audit.
Each payer has unique medical necessity standards using a combination of external guidelines, 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 begin writing your documentation, verify the insurance policy covers the member, diagnosis, and service. If these are not covered, even a perfectly written medical necessity document will likely still be denied.
In addition, although ABA is frequently covered, academic/educational, vocational, or recreational activities are not considered medically necessary. Therefore, careful documentation of goals and intervention is critical, particularly when ABA therapy is recommended to take place in a school or community setting.
Here are some components most payers want 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 services recommended, ongoing progress and mastery, and discharge criteria
- Explanation as to why goals could not be mastered or effective by a lower level of care
- Detailed credentials, contact information, and signature for the provider rendering provider
Struggling to get your authorizations approved or documentation correct?
Missing Piece Billing and Consulting is 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 the patient is approved for all medically necessary services.
To learn more about our ABA billing and complete revenue cycle services, please contact us at 765-628-7400 or by email at firstname.lastname@example.org.