Applied behavioral analysis (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 to describe 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 and the MCG Health Behavioral Healthcare 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
Confidentiality requirements and regulations
The Health Insurance Portability and Accountability Act (HIPAA) plays a crucial role in the context of ABA treatment plans by ensuring the confidentiality, security, and proper handling of individuals’ medical records and personal health information. HIPAA compliance is paramount when developing and implementing these treatment plans, as they typically contain sensitive information regarding the individual’s health status, behavioral assessments, and personal data. By adhering to HIPAA regulations, healthcare providers and ABA practitioners protect the privacy of their patients while fostering a trustworthy environment. This legal framework ensures that all discussions, documents, and records related to the treatment plan are only accessible to authorized personnel and the patient’s guardians, thereby safeguarding the medical necessity and personal details contained within ABA treatment plans.
ABA treatment plan goals and examples
ABA treatment plans are designed to guide the personal and social development of autistic individuals in an effort to enhance the quality of their everyday lives. The aim is twofold: to encourage more positive behaviors and to reduce those that might be problematic or interfere with learning. These plans are customized, focusing on teaching essential skills such as effective communication, improving social interactions, and fostering independence in daily routines. Crafted with the individual’s specific needs and areas of concern in mind, each plan sets out to measure tangible progress in behavior, bridging the gap between where they are and where they aspire to be. There are 10 components of an ABA treatment plan, all of which must be included to form a comprehensive, effective treatment plan.
An ABA treatment plan example might be for a child who struggles with social interactions, particularly in group settings, such as the classroom. The plan would start with an assessment of the child’s current social skills to identify specific areas for improvement, such as initiating conversations, maintaining eye contact, or understanding social cues. Following this assessment, specific goals would be set; these could include the child initiating a conversation with a peer at least once during each school day.
The ABA techniques employed might include role-playing scenarios with the child to practice conversations, using positive reinforcement to encourage eye contact during these interactions, and social stories to help the child understand various social cues and appropriate responses. Progress toward the goals would be continuously monitored and evaluated, with adjustments made to the plan as needed based on the child’s development. This example illustrates how an ABA treatment plan is not only about identifying and working on areas of improvement but also about setting measurable goals and using evidence-based methods to achieve these goals in a structured manner.
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 of 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.
Contact us to learn more about our ABA billing and complete revenue cycle services.