Applied Behavioral Analysis Provider Information

Background

Kaiser Permanente provides coverage for applied behavioral analysis (ABA) treatment to individuals with autism spectrum disorder (ASD) or developmental disability for which there is evidence that ABA therapy is effective. The intent of this document is to provide guidance to providers on the process for accessing the benefit, what type of documentation is needed, and what is the scope of ABA services.

Coverage and referral

Not all Kaiser Permanente plans cover ABA treatment. Coverage can be verified by having individuals and/or families contact Kaiser Permanente of Washington Member Services toll-free at 1-888-901-4636. ABA treatment requires a diagnosis of autism spectrum disorder or developmental disability for which there is evidence that ABA therapy is effective and there must be a referral for ABA treatment from a licensed health, mental health, or allied health provider (e.g., physician, psychologist, or speech-language pathologist).

Authorization process

Requests for ABA treatment need to be reviewed to determine whether they meet Kaiser Permanente clinical review criteria (PDF). Preauthorization is needed for ABA treatment, regardless of patient insurance plan. Requests for ABA services need to be reviewed to determine whether they meet Clinical Review Criteria. ABA services are delivered by facilities and providers who are contracted with Kaiser Permanente. If contracted facilities and providers are not accessible, treatment can be delivered by non-contracted facility or provider who meet all state regulatory and licensure requirements laid out in the clinical criteria. The authorization process is as follows:

Preauthorization Process

• When a Kaiser Permanente member receives a referral for ABA services a preauthorization request is generated to pre-approve an ABA assessment.
• A pre-approval of services is given after the member meets clinical criteria (linked above).
• There is an initial review of a referral to determine whether an enrollee meets eligibility criteria for ABA services (i.e., diagnosis, coverage, presence of autistic behaviors that are having clinically significant impact on functioning, in home, school, and and/or community).
• If the enrollee meets criteria for ABA services, an ABA assessment preauthorization is approved.
• Preauthorization requests can come from the members medical provider (primary care physician, pediatrician, psychologist, etc.)
• If the member already has an ASD diagnosis and has the formal documentation, the ABA provider can submit a preauthorization request with the diagnosis documents.
• The letter of approval for preauthorization of services will contain the CPT code.
• ABA assessments varies among patients; Kaiser Permanente does not issue a set number of hours for the initial assessment.
• Nevertheless, the hours used for initial assessments can range from 6-10 hours.
• Any request that exceeded 10 hours will need to provide an additional clinical justification and hours utilization breakdown using the Kaiser Permanente ABA PreAuthorization Request template (Word).

Initial ABA authorizations

The ABA provider submits the initial individualized treatment plan (ITP) to Kaiser Permanente for clinical review (reference clinical criteria and report templates for tips on completing ITP). The ITP must use the Kaiser Permanente ABA Initial Assessment Template (Word), to ensure all information needed is received.

• If additional information is needed (i.e., clinical justification for hours, assessment dates, etc.), the clinical review team will send the ABA provider a “records request” letter delineating the items requested as well as a due date.
• Records requests have a 3/5-day-calendar timeline from the day they are sent out (including weekends and holidays).
• It is imperative that all items requested be submitted to the clinical review department no later than the due date. Failure to comply with the deadline may result in a denial of services.
• ITPs that meet clinical criteria will be approved, and the patient and provider will receive an approval letter.
• The approval letter will list all the CPT codes approved as well as the number of hours approved for each code.

Continued ABA treatment

• After six months, a progress report needs to be submitted by the ABA provider to determine whether enrollee continues to meet criteria for ABA therapy. The treatment plan will be reviewed by Kaiser Permanente and if approved, an additional six months of ABA therapy is authorized.
• Progress reports need to be submitted 15-days before the end of the current authorization period.
• Progress Reports submitted after the 15-day due date, may not be eligible for retro pay on claims that fall on days with no current authorizations.
• To account for any extenuating circumstances that prevented the ITP to be submitted on time, the ABA provider must include a detailed explanation with the report.
• Initial Treatment and Progress Plans are to be submitted to review services via affiliate link and fax.
• The Kaiser Permanente report templates are to be used for initial and continued care reports. Failure to use these templates may results in submission of incomplete information which would delay the authorization process.
  Kaiser Permanente ABA Progress Report Template (Word)

Termination of Services

• An individualized treatment plan is warranted when ABA services end. Use the Kaiser Permanente ABA Termination Report Template (Word).
• Explain why the patient is discharging for the ABA provider’s care.
• Ensure to report on all progress the patient made and how the goals should be maintained after discharge.
• Explain what type of treatment the patient is stepping down to (i.e., counseling, school management, medication, etc.)

Additional Information

Addendums to current authorizations

There are times when issues arise in the middle of a six-month authorization that require a change in treatment hours. For any requested to increase or change approved ABA services, the ABA provider must submit an addendum. Please use the Kaiser Permanente ABA Addendum Request Template (Word).

Appeals

• If a decision is rendered that is not an approval of services (e.g., decline of ABA services, partial approvals of requested hours, etc.,) and the member is not in agreement, an appeal can be made.
• Appeals can only be initiated by the Kaiser Permanente member.
• The ABA provider can act on the members behalf with a written authorization.
• The appeal decision is made by a reviewer who is totally independent of the initial reviewer, and the decision is issued on a specified timeline.

Find more details on the appeal process.

Contact information

Authorization Requests can be submitted via fax and Affiliate Link (preferred method)

Fax: 844-660-0717
Attention: ABA Clinical Review - Elizabeth Silva-Kaplan, ABA Program Manager

Affiliate Link – manual entry and job aid available
Once you set up your profile the authorization letter will be sent out to the in-basket.

Clinical Review Department
For status updates and issues with referrals
1-800-289-1363, option 2, option 4

Provider Assistance Unit
For issues with claims and patient healthcare plan questions
1-888-767-4670

Further assistance with claims:
Escalation form link

For any additional information and clinical questions please contact the ABA department.

Medical offices

• Medical center hours and locations
• Holiday closures and hours