Prior Authorization Processes for Applied Behavior Analysis
AKA pre-certification, or pre-cert, or pre-auth.
First, some insurance background
When a child is diagnosed with autism, many families seek out Applied Behavior Analysis programs to address their child’s individual needs. Given the intensity and long-term nature of ABA, most families opt to utilize their health insurance to pay for these medically-necessary services. While in the past, insurance companies denied coverage for these therapies, over the years, all 50 states have passed legislative action to mandate insurance coverage for ABA and other Autism services. These laws vary wildly from state to state though, so it is crucial you understand the mandate that affects you. Visit this link to learn more about your state’s mandate.
It should also be pointed out that just because all states have mandates for insurance coverage, not all insurance plans will cover ABA. These mandates are going to really just apply to state-regulated fully-funded plans. Federally regulated plans like self-funded (ERISA) plans are not subject to state laws and may choose to exclude coverage for ABA. Your state Medicaid plan(s) may also not cover ABA, and short-term, limited-duration plans are also known to exclude certain services like ABA.
So first we need to determine that you have an insurance plan that covers ABA, then it’s time to start booking appointments, right? Unfortunately, it’s not that simple.
Enter the prior authorization process.
Unless you have one of those rare plans that doesn’t require one (lucky you), your insurance plan is going to insist that your child have prior authorization for ABA services.
So… what is it, anyway?
A prior authorization is just an indication of the level of care your insurance plan is willing to cover for a certain treatment, and that you meet their medical-necessity criteria to receive that treatment. For an ABA program, the general criteria they want is that your child be of a certain age (state mandates again) and have an official diagnosis of an Autism Spectrum Disorder. The prior authorization process can be time-consuming and for ABA, is comprised of two-steps.
At each step, your provider will need to determine your insurance’s specific authorization process and submit their requests accordingly.
The Authorization Process
Step 1: Assessment Authorization
Supporting documentation: Autism Diagnosis Report, possibly an ABA “prescription” or referral
In order to develop a treatment plan and recommendations, a BCBA first needs to conduct an assessment. This is not the same as the evaluation used to diagnose your child with Autism, rather it is a more in-depth look at your child’s skills and behaviors to determine where the gaps are and how an ABA program can address those needs. After the assessment is completed, the BCBA will make a recommendation for how many hours of treatment your child needs and write the individualized treatment plan.
Step 2: Ongoing Services Authorization
Supporting documentation: Treatment Plan and ASD Diagnostic Report
To obtain an authorization for ongoing ABA services, your provider will send the treatment plan to your insurance company along with a request for how many hours of treatment they are recommending for your child. Once approved, the insurance company will typically* authorize treatment for six months at a time. In these instances, around 5 months into treatment your BCBA will re-conduct those assessments again, update the treatment plan and recommendations as necessary, and re-submit everything back to the insurance company for another authorization for the next 6 months. That process then repeats itself for the duration of your child’s treatment.
*Some insurance companies authorize for shorter time periods , ex: 3 months. Shorter authorizations may mean the insurance company wants to see more supporting documentation or a re-evaluation for ASD.
Potential Barriers during the authorization process
No process comes without some barriers, especially when working with health insurance. Your ABA provider will be able to navigate these potential issues with you, but these things can cause delays to gaining that authorization.
During the ongoing services authorization stage, the insurance company may request a “peer review/utilization review” during which your BCBA and a medical professional from the insurance company will go over the treatment recommendations. In this discussion, the peer reviewer may determine your child needs fewer hours than your BCBA is recommending, thus effecting the treatment your child receives.
Diagnostic Report Issues
In recent years, insurance companies have become more rigid in their diagnostic requirements for ABA. Their medical guidelines may require a specific assessment your child has not received, or if your child received their diagnosis many years ago, they may require a re-evaluations be completed.
Other Insurance Policy Restrictions
Depending on your type of insurance and your state’s autism mandates, you may run into policy roadblocks at your insurance company. These can include the previously listed diagnostic issues, age restrictions, locations where the treatment can occur, etc. Also remember self-funded, Medicaid, and short-term plans may not cover ABA at all!
You got the authorization!
Once you have put in the time working with both your BCBA and Insurance company, you will have earned your authorization for ABA services. Be aware that this is a process that can take weeks, but don’t be discouraged. All that time and patience is worth it, as now you can begin scheduling appointments and your child can begin their ABA journey. So, don’t give up and remember, we are with you every step of the way!