Washington Apple Health (Medicaid). Applied Behavioral. Analysis (ABA). Program Billing. Guide. March 1, 2021
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CPT® codes and descriptions only are copyright 2020 American Medical Association. 2 | APPLIED BEHAVIOR ANALYSIS (ABA) PROGRAM BILLING GUIDE Disclaimer Every effort has been made to ensure this guide™s accuracy. If an actual or apparent conflict between this document and a Health Care Authority (HCA) rule arises, the rule appl ies . Billing guides are updated on a regular basis. Due to the nature of content change on the internet, we do not fix broken links in past guides. If you find a broken link, please check the most recent version of the guide. If this is the most recent guide, please notify us at firstname.lastname@example.org . About this guide * This publication takes effect March 1 , 2021 , and supersedes earlier billing guides to this program. Unless otherwise specified, the program(s) in this guide are governed by the rules found in Chapter 182 -531A WAC . HCA is committed t o 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 state -only funded health care programs. Washington Apple Hea lth is administered by HCA . Refer also to HCA™s ProviderOne billing and resource guide for valuable information to help you conduct business with HCA. How can I get HCA Apple Health provider documents? To acc ess provider alerts, go to HCA™s provider alerts webpage . To access provider documents, go to HCA™s provider billing guides and fee schedules webpage . Where can I download HCA forms? To download an HCA form, see HCA™s Forms & Publications webpage. Type only the form number into the Search box (Example: 13 -835). * This publication is a billing instruction.
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CPT® codes and descriptions only are copyright 2020 American Medical Association. 3 | APPLIED BEHAVIOR ANALYSIS (ABA) PROGRAM BILLING GUIDE Copyright disclosure Cur rent Procedural Terminology (CPT) copyright 2020 American Medical Association (AMA). All rights reserved. CPT is a registered trademark of the AMA. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AM A, 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. What has changed? Subject Ch ange Reason for Change What is the early intensive behavioral intervention day treatment program (day treatment program) Added ﬁchildhood ﬂ to the title of the program . Corrected wording from ﬁclient ﬂ back to ﬁchildﬂ or ﬁ children ﬂ under the day treatment program . To accurately describe for whom the program is clinically beneficial . This change is retroactive to dates on and after February 1, 2021.
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CPT® codes and descriptions only are copyright 2020 American Medical Association. 4 | APPLIED BEHAVIOR ANALYSIS (ABA) PROGRAM BILLING GUIDE Table of Contents Resources Available .. 7 Definitions .. 8 Program Overview . 9 Who should read th is guide? .. 9 What is ABA? .. 9 What is the purpose of the ABA program? .. 9 Client Eligibility .. 10 How do I verify a client™s eligibility? 10 Verifying eligibility is a two -step process: .. 10 Are clients enrolled in an HCA -contracted managed care organization (MCO) eligible? 11 Managed care enrollment . 11 Clients who are not enrolled in an HCA -contracted managed care plan for physical health services 12 Integrated managed care .. 12 Integrated Apple Health Foster Care (AHFC) .. 13 Fee -for -service Apple Health Foster Care 14 What if a client has third -party liability (TPL)? . 14 Provider Eligibility .. 15 Who may provide services under the applied behavior analysis (ABA) program? 15 What is a Center of Excellence (COE)? .. 15 What are the qualifications for a COE? . 15 How does a provider become recognized as a COE? 16 Will HCA accept an evaluation that was not completed by a COE? . 16 Who can apply to provide ABA services? .. 17 Who can enroll with HCA as a lead behavior analysis therapist (LBAT)? 17 Additional requirements for LBAT enrollment . 17 How do providers enroll with HCA as a certified behavior technician (CBT)? 18 Additional requirements for CBT enrollment 18 Becoming a facility -based day treatment program 18 Accessing ABA Services 19 What is the applied behavior analysis (ABA) pathway to care? 19 Stage one of the pathway to care .. 19 Referral .. 19 What does the COE do? .. 19
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CPT® codes and descriptions only are copyright 2020 American Medical Association. 5 | APPLIED BEHAVIOR ANALYSIS (ABA) PROGRAM BILLING GUIDE Required documentation 20 The comprehensive diagnostic evaluation . 20 Stage two of the pathway to care .. 21 Selecting an ABA provider 21 Caregiver training only while the client is on a waitlist for individual ABA services 22 The ABA assessment and treatment plan 22 Stage three of the pathway to care .. 24 LBAT responsibilities 24 CBT responsibilities .. 24 ABA delivery methods and settings .. 25 ABA services: 25 What is the early childhood intens ive behavioral intervention day treatment program (day treatment program)? . 26 Purpose of the day treatment program . 26 Providers in the day treatment program . 26 Requirements for the day treatment program .. 27 Day Treatment Program Model .. 29 What client files and records does HCA require? . 29 Telemedicine and COVID -19 32 What is telemedicine? .. 32 Originating site . 32 Distant site . 32 Which services may be provided via telemedicine? .. 32 What services are not paid for under telemedicine? . 33 Authorization .. 34 What is prior authorization (PA)? 34 When is PA required? 34 Requesting prior authorization (PA) 35 Online direct data entry into ProviderOne . 35 Written or Fax . 35 Does PA for ABA services expire? .. 35 What if additional units of service are needed to continue providing ABA services? .. 36 What are the requirements for recertification of ABA services? .. 36 Additional requi rements for recertification of ABA services . 37 Why might HCA deny recertification of ABA services? .. 37
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CPT® codes and descriptions only are copyright 2020 American Medical Association. 6 | APPLIED BEHAVIOR ANALYSIS (ABA) PROGRAM BILLING GUIDE What is a limitation extension (LE)? . 37 How do I obtain an LE? .. 38 Coverage .. 39 What is covered? 39 ABA treatment Œ home and community -based settings .. 39 Functional Assessment and Analysis/Treatment Plan Development 39 Telemedicine 39 Team Conference 39 Individual Treatment Codes 40 Caregiver Treatment Codes . 40 ABA Group Home and Community -Based Treatment .. 40 ABA Intensive Day Treatment .. 40 ABA treatment Œ group settings .. 41 Caregiver Training in a Group Setting* .. 41 ABA Group Treatment in Home and Community -Based Settings* . 41 What modifiers do providers bill with? 42 What about services covered under other HCA programs? .. 42 Which services are not covered? . 43 Billing 44 What are the general billing requirements? 44 What codes do day treatment programs use to bill HCA? . 44 How do I bill claims electronically? .. 44 Rendering and individual provider taxonomy numbers . 45
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CPT® codes and descriptions only are copyright 2020 American Medical Association. 8 | APPLIED BEHAVIOR ANALYSIS (ABA) PROGRAM BILLING GUIDE Definitions This list defines terms and abbreviations, including acronyms, used in this billing guide. Refer to Chapter 182 -500 WAC for a complete list of definitions for Washington Apple Health. Autism diagnostic tool – A tool used to establish the presence (or absence) of autism and to make a definitive diagnosis, which will be the basis for treatment decision s and the development of a treatment plan. Examples of autism diagnostic tools include: Autism diagnosis interview (ADI). Autism diagnostic observation schedule (ADOS). Autism screening tool – A tool used by a primary care provider to detect indicators or risk factors for autism and may indicate a suspicion of the condition, which would then require confirmation, which would then require a referral to a Center of Excellence for confirmation. Examples of screening tools include: Ages and stages questionnaire (ASQ). Communication and symbolic behavior scales (CSBS). Parent’s evaluation and developmental status (PEDS). Modified checklist for autism in toddlers (MCHAT). Screening tools for autism in toddlers and young children (STAT). Comprehensive treatment model Œ A model that meets a client™s individual needs in addressing core symptom areas of autism and related disorders, disrupts challenging behaviors, and builds a foundation for learning -readiness across multiple domains of functioning. Diagnostic and Statistical Manual of Mental Disorders (DSM -5) – The manual published under this title by the American Psychiatric Association that provides a common language and standard criteria f or the classification of mental disorders. Managed care organization (MCO) Œ See WAC 182 -538-050. National Provider Identifier (NPI) Œ See WAC 182 -500 -0075 .
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CPT® codes and descriptions only are copyright 2020 American Medical Association. 9 | APPLIED BEHAVIOR ANALYSIS (ABA) PROGRAM BILLING GUIDE Program Overview Who should read this guide? This guide contains instructions for: Centers of Excellence (COEs) who conduct the clinical diagnostic evaluation, and Applied behavior analysis (ABA) providers o ffering ABA services. This guide may also be helpful to primary care providers who want to assist clients and their families in accessing ABA services and navigating the pathway to care. What is ABA? ABA is an approach to improve behavior and skills rela ted to core impairments associated with autism and a number of other developmental disabilities. ABA therapy involves application of validated principles of human behavior to change inappropriate behaviors. Providers monitor and measure how well therapy is working using validated methods. ABA therapy also focuses on social significance, which promotes a family -centered, whole -life approach. What is the purpose of the ABA program? Apple Health includes coverage for ABA services to address the core symptoms associated with autism spectrum disorders or other developmental disabilities. ABA services support learning and assist with the development of social, behavioral, adaptive, motor, vocational, and cognitive skills. ABA services are considered medi cally necessary when other less intensive treatment has been unsuccessful , and the client™s condition is known to be responsive to ABA based on current research .
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CPT® codes and descriptions only are copyright 2020 American Medical Association. 10 | APPLIED BEHAVIOR ANALYSIS (ABA) PROGRAM BILLING GUIDE Client Eligibility Most Apple Health clients are enrolled in an HCA -contracted managed care organization (MCO). This means that Apple Health pays a monthly premium to an MCO for providing preventative, primary, specialty, and other health services to Apple Health clients. Clients in managed care must see only providers who are in their MCO™s pro vider network, unless prior authorized or to treat urgent or emergent care. See HCA™s Apple Health managed care page for further details. It is important to always check a client™s eligibility prior to provid ing any services because it affects who will pay for the services. How do I verify a client™s eligibility? Check the client™s services card or follow the two -step process below to verify that a client has Apple Health coverage for the date of service and t hat the client™s benefit package covers the applicable service. This helps prevent delivering a service HCA will not pay for. Verifying eligibility is a two -step process: Step 1. Verify the patient™s eligibility for Apple Health . For detailed instructions on veri fying a patient™s eligibility for Apple Health, see the Client Eligibility, Benefit Packages, and Coverage Limits section in HCA™s ProviderOne Billing and Resource Guide . If the patient is eligible for Apple Health, proceed to Step 2 . If the patient is not eligible, see the note box below. Step 2. Verify service coverage under the Apple Health client™s benefit package . To determine if the requested service is a covered benefit under the Apple Health client™s benefit package, see HCA™s Program Benefit Packages and Scope of Services webpage. Note : Patients who are not Apple Health clients may submit an application for health care coverage in one of the following ways: 1. By visiting the Washington Healthplanfinder™s website . 2. By calling the Customer Support Center toll -free at: 855 -WAFINDER (855 -923-4633) or 855 -627-9604 (TTY) 3. By mailing the application to: Washington Healthplanfinder PO Box 946 Olympia, WA 98507
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CPT® codes and descriptions only are copyright 2020 American Medical Association. 11 | APPLIED BEHAVIOR ANALYSIS (ABA) PROGRAM BILLING GUIDE In-person application assistance is also available. To get information about in -person application assistance available in their area, people may visit the Washington Healthplanfinder™s website or call the Customer Support Center. Are clients enrolled in an HCA -contracted managed care organization (MCO) eligible? Yes . Most Apple Health (Medicaid) clients are enrolled in one of HCA™s contracted managed care organizations (MCOs). For these clients, managed care enrollment is displayed on the client benefit inquiry screen in ProviderOne. All medical services covered unde r an HCA -contracted MCO must be obtained through the MCO™s contracted network. The MCO is responsible for: Payment of covered services Payment of services referred by a provider participating with the plan to an outside provider Note : A client™s enrollmen t can change monthly. Providers who are not contracted with the MCO must receive approval from both the MCO and the client™s primary care provider (PCP) prior to serving a managed care client. Send claims to the client™s MCO for payment . Call the client™s MCO to discuss payment prior to providing the service. Providers may bill clients only in very limited situations as described in WAC 182 -502-0160 Managed care enrollment Most Apple Health (Medicaid) clients are enrolled in HCA -contracted MCO the same month they are determined eligible for managed care as a new or renewing client. Some clients may still start their first month of eligibility in the FFS program because their qualificat ion for MC enrollment is not established until the month following their Medicaid eligibility determination. Providers must check eligibility to determine enrollment for the month of service. New clients are those initially applying for benefits or those w ith changes in their existing eligibility program that consequently make them eligible for Apple Health managed care. Checking eligibility Providers must check eligibility and know when a client is enrolled and with which MCO. For help with enrolling, cli ents can refer to the Washington Healthplanfinder™s Get Help Enrolling page. MCOs have retroactive authorization and notification policies in place. The provider must know the MCO™s requirements and be compliant with the MCO™s policies.
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