Prescription Fulfillment
Prescription fulfillment refers to the amount of hours for services implemented in relation to the amount of services authorized. Also known as utilization of hours as approved.
Importance Of Prescription Fulfillment
- Helps assess member achievements and identify potential barriers to response to treatment.
- Allows for evaluation of outcomes based on dosage.
- Lack of prescription fulfillment (e.g., lower-intensity treatment, delays in commencing treatment, and interruptions in treatment) may result in regression or lack of treatment outcomes.
ABA Treatment Hour Considerations
- Additional services member accesses including school-based interventions, occupational therapy, speech therapy, physical therapy, play-based therapies and how many hours the member can realistically attend and manage for ABA.
- If there is discrepancy between hours requested and member’s availability for services, please provide rationale and a coordination of services plan.
- Frequency, duration, and location of services recommended are consistent with the member’s diagnoses, skill deficits, behavioral excesses, and treatment goals.
- Progress toward goals is commensurate with level of care.
- Barriers to achieving desired level of care and how these barriers can be addressed.
- ABA recommendation may differ from ABA request.
- ABA recommendation should refer to treatment hours requested if no barriers are present.
- ABA request refers to treatment hours that are able to be completed based on member’s needs and caregiver agreement taking into account member and provider availability and other factors that may act as barriers to treatment.
- If there is a difference between these two dosages, providers should document barriers to member receiving full ABA recommended hours.
*Please note, providers may submit addendum to their approved authorization at any time. if additional units or codes need to be requested.
Assessing Fulfillment
- Assessing fulfillment and/or barriers to fulfillment can be done on a monthly basis, and long-term fulfillment can be reviewed during the reassessment period.
- Potential barriers that prevent members from accessing services may include:
- Socioeconomic factors
- Transportation needs
- Conflicting schedules
- Lack of childcare
- Absence of ABA knowledge
- Our plan may have benefits that are able to assist with addressing some of these barriers.