UPDATED: Effective February 1, 2022: New Medicaid Benefit for Applied Behavior Analysis Services - Prior Authorization Required
Date: 01/25/22
Effective February 1, 2022, Texas Health and Human Services (HHS) is adding a new Medicaid benefit for Applied Behavior Analysis (ABA) services for individuals under 21 years of age* with Autism Spectrum Disorder (ASD). This new Medicaid benefit will be available for the following Superior programs:
- STAR
- STAR Health
- STAR Kids
- *STAR+PLUS Medicaid for Breast and Cervical Cancer (MBCC) Program
Superior requires prior authorization be obtained for all ABA services prior to the delivery of service. Utilization review for prior authorization requests will be managed by Magellan Healthcare. Prior authorization requests, for dates of services on or after February 1, 2022, can be submitted to Magellan Healthcare by fax 1-888-656-0368 or by calling 1-800-424-4812.
The Texas Medicaid Provider Procedures Manual (TMPPM) clinical policy contains the medical necessity criteria for the new ABA benefit. Providers should include the valid prior authorization number received for the provision of ABA services on the claim form. Information on the prior authorization procedures and requirements can be found on Superior’s Prior Authorization Requirements webpage.
The procedure codes for the new ABA benefit include the following procedure codes:
97151 | 97153 | 97154 | 97155 | 97156 | 97158 | 99366 |
Claim billing requirements are documented in Superior’s STAR, STAR+PLUS, STAR Health and STAR Kids Provider Manual, found on Superior’s Provider Training and Manuals webpage.
Below is a table outlining the ABA benefit procedural codes and descriptions, service limitations, modifiers and additional key information. Superior will adhere to the limits below; however, the limitations listed may be exceeded with evidence of medical necessity.
PROCEDURE CODE | DESCRIPTION | PROVIDER LICENSURE /SPECIALTY | REQUIRED BILLING MODIFIER | LIMITATIONS | ADDITIONAL INFORMATION |
|---|---|---|---|---|---|
97151 | ABA initial evaluation
| Master’s Level / Licensed Behavior Analyst (LBA) | HO only | Limited to 6 hours (24 units) for initial evaluation | Authorized only for a 30-day period |
97151
| ABA re-evaluation
| Master’s Level / Licensed Behavior Analyst (LBA) | HO only | Limited to 6 hours (24 units) | Authorized only for a 30-day period |
97153 | ABA individual treatment | Master’s Level / Licensed Behavior Analyst (LBA)
| HO only | Direct treatment for the child/youth is limited to a total of 8 hours per day, inclusive of procedure codes 97153, 97154, 97155, 97158. | n/a |
97154 | ABA group treatment | Master’s Level / Licensed Behavior Analyst (LBA)
| HO
| Direct treatment for the child/youth is limited to a total of 8 hours per day, inclusive of procedure codes 97153, 97154, 97155, 97158. | n/a |
97155 | ABA individual treatment | Master’s Level / Licensed Behavior Analyst (LBA) Bachelor’s degree level /Licensed Assistant Behavior Analyst (LaBA)
| HO or HN | Direct treatment for the child/youth is limited to a total of 8 hours per day, inclusive of procedure codes 97153, 97154, 97155, 97158. | n/a |
97156 | ABA parent/caregiver/family education and training | Master’s Level / Licensed Behavior Analyst (LBA) Bachelor’s degree level /Licensed Assistant Behavior Analyst (LaBA)
| HO or HN | n/a | n/a |
97158 | ABA group treatment | Master’s Level / Licensed Behavior Analyst (LBA) Bachelor’s degree level /Licensed Assistant Behavior Analyst (LaBA)
| HO or HN | Direct treatment for the child/youth is limited to a total of 8 hours per day, inclusive of procedure codes 97153, 97154, 97155, 97158. | n/a |
99366 | Interdisciplinary team meeting | Not specified | No modifier required | Limited to diagnosis code F840-Austism and is contingent upon prior authorization of ABA evaluation, re-evaluation, or treatment team. | May be reimbursed for interdisciplinary team meetings attended by qualified non-physician healthcare providers |
Provision of service/billing and reimbursement limitations services are listed below:
- Concurrent Provider Billing: Superior will not reimburse multiple ABA providers during one ABA session with a child/youth when more than one ABA provider is present (concurrent billing). Concurrent billing is excluded except when the family and the child/youth with ASD are receiving separate services and the child/youth is not present in the family session.
- Billing for Administrative Time Prohibited: Superior will not reimburse for ABA treatment services when the child/youth and/or family is not present or is not engaged in a therapeutic relationship with the provider.
- Reimbursement: Covered ABA procedure codes are reimbursed for the direct service time. Pre and post work for the session are not reimbursed separately. Separate reimbursement for treatment planning, note documentation, report writing, or updating of charts and data sheet is prohibited (other than what is allowable under procedure code 97151).
- Telehealth ABA Services: Some service delivery to children/youth and/or parents/caregivers may be delivered remotely. It is the provider’s responsibility to ensure that remotely delivered telehealth services are within scope of practice, not contraindicated for the child/youth, family, or particular situation, are clinically appropriate and effective, and in compliance with Texas licensure and standards for telehealth.
ABA evaluation and treatment services may only be delivered via telehealth using synchronous audio-visual technology or a similar technology. Procedure codes 97151, 97155, 97156, 97158 and 99366 may be delivered via telehealth and require Modifier 95 to designate remote delivery.
DESCRIPTION | MODIFIER |
|---|---|
Telehealth | 95 |
For any questions, or if you are interested in providing services for this new benefit, please contact Superior’s Account Management department.