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Applied Behavioral Analysis Outpatient Treatment Request Checklist

Including the following clinical information will aid in the timely processing of the request.

For initial treatment requests

  • Comprehensive diagnostic evaluation (typically within 0-5 years) indicating diagnosis eligible for ABA treatment and recommendation for ABA from a qualified provider, if required
  • Social, developmental, and medical history, including current medication(s) and comorbid diagnoses
  • Information regarding prior and current services received (e.g., Early Steps, IEP, OT, PT, ST, ABA, BHOP, etc.)
  • Requested codes and dates of service
    • If request exceeds the market standard of 8-10 hours for assessment/reassessment, please include rationale specific to the member’s needs.
  • Proposed treatment schedule, including ABA services, other therapies, school schedule, and naps
    • If there is discrepancy between hours requested and member’s availability for services, please provide rationale and coordination plan with other providers.
  • Assessment tool data (e.g., VB-MAPP, ABLLS-R, AFLS, EFL, etc.) that is appropriate for member based on chronological age and developmental level, along with description of current communication status (e.g., vocal, utilizes AAC device, etc.)
    • Please note: some portions of assessment tools may not meet the coverage criteria. Each case is reviewed on an individual basis and additional rationale may be requested.
  • Clinically significant treatment goals that include core deficit(s) or excesses targeted, start date, measurable objective with mastery criteria, anticipated end date, and ABA techniques to be utilized
  • Operational definition for behavior(s) targeted for reduction, data collection method, and baseline rates
    • If treatment plan contains behaviors targeted for reduction, include an FBA and BIP, or indicate when these will be completed.
  • Specific and measurable goals to be targeted within caregiver training relevant to member and familial stressors
  • Crisis Plan
  • Generalization Plan
  • Transition Plan that includes:
    • Specific and measurable goals that are individualized to member that outline skills needed to be achieved to allow member to be successful in lower level of care
    • Updated progress toward attainment of transition goals achieved over authorization period
    • Details indicating how hours are projected to be titrated based on achievement of transition plan goals
      • If member is school-aged but is not able to participate due to attending full time ABA, please supply transition planning to school (including communication with school system, IEP status)
  • Evidence of caregiver participation in the development of the plan and their understanding of treatment plan (i.e., parent signature)
  • Provider signature, per within health plan requirements

For ongoing treatment requests

  • Additional and/or updated diagnostic testing, if previously requested
  • Updated social, developmental and medical history, including current medication(s) and comorbid diagnoses
  • Information regarding prior and current services received (e.g., Early Steps, IEP, OT, PT, ST, ABA, BHOP, etc.)
  • Requested units by code and start date of new service request
    • If there is an increase or decrease in hours requested, include a description explaining why the hours are being modified.
    • If requesting units greater than treatment standard of 8-10 hours for assessment/reassessment, please include detailed rationale specific to member.
  • Proposed treatment schedule, including ABA services, other therapies, school schedule, and naps
    • If there is discrepancy between hours requested and member’s availability for services, please provide rationale.
  • Updated assessment tool data, that is appropriate for member based on chronological age and developmental level, along with historical scores, and description of current communication status
    • Please note: some portions of assessment tools may not meet the coverage criteria. Each case is reviewed on an individual basis and additional rationale may be requested.
  • Clinically significant treatment goals that include core deficit(s) or excesses targeted, start date, measurable objective with mastery criteria, anticipated end date, and ABA techniques to be utilized
  • Update on goals within previously approved authorization:
    • Identification of goals and/or targets that were mastered during most recent authorization period
    • Progress toward continued goals and
    • Modifications to goals that did not meet mastery criteria
  • Identification of any barriers that would impact treatment progress, as well as how these barriers are being addressed
  • Operational definitions for challenging behaviors, data collection method, and current data, compared to historical data
    • If treatment plan contains behaviors targeted for reduction, include an FBA and BIP, or indicate when these will be completed.
      • FBA/BIP should be updated as often as necessary to achieve socially significant outcomes.
  • Updates to caregiver training goals indicating progress and/or barriers (if applicable) and how barriers are being addressed
  • Information regarding attendance of scheduled sessions for both member and caregivers
  • Crisis Plan
  • Generalization Plan
  • Transition Plan that includes:
    • Specific and measurable goals that are individualized to member that outline skills needed to be achieved to allow member to be successful in lower level of care
    • Updated progress toward attainment of transition goals achieved over authorization period
    • Community resources that will support maintenance and generalization of skills for member and family
    • Details indicating how hours are projected to be titrated based on achievement of transition plan goals.
      • If member is school-aged but is not able to participate due to attending full time ABA, please supply transition planning to school (including communication with school system, IEP status)
  • Evidence of caregiver participation in the development of the plan and their understanding of treatment plan (i.e., updated parent signature)
  • Provider signature, per within health plan requirements