First, let's take a deep breath! The insurance process can be overwhelming and challenging, but we will do everything we can to help the process go smoothly. To simplify, we will break the process down into three steps: Prior Authorization, Assessment Authorization, and Treatment Authorization.
Who initiates: ABA provider OR PCM/diagnostic professional
Authorization time: Up to 24 hours
Prior authorization can also be known as pre-certification, pre-cert, or pre-auth. Simply put; prior authorization will determine the level of care your insurance plan is willing to cover for the treatment you seek. You are coming to Behavior Change, so you are looking for Applied Behavior Analysis (ABA) therapy. It also will determine what documentation is required to meet their medical-necessity criteria for treatment.
Depending on your insurance, general criteria for ABA services will require the following:
The child has an official diagnosis of Autism Spectrum Disorder (ASD)
Dual diagnoses are allowed and are common; however, ASD must be one of the diagnoses provided.
The child is within a specific age range (this will depend on state mandates)
The insurance plan has ABA coverage
Required documents: Neurologist/psychologist diagnostic report, ABA prescription/ referral
Who submits: ABA provider OR PCM/diagnostic professional
Authorization time: 5-10 business days
You are now another step closer to services. When you complete the intake packet, we will ask you to provide supporting documents such as a diagnostic report and ABA prescription/ referral for medical necessity.
Each insurance company is different and, therefore, will have specific requirements for required supporting documents. Our intake coordinator will review all paperwork to ensure your insurance criteria are met or what needs to be completed to increase chances of approval for assessment.
Sometimes your insurance plans do not require prior authorization or assessment authorization for ABA services.
Note: The assessment is critical because before developing a treatment plan for your child, we need to conduct an assessment to determine his/her needs. Our assessment will be a detailed look at your child's acquisition skills and behaviors to determine where the gaps are and how an ABA program can address their needs.
Required documents: Behavior Intervention Plan, Neurologist/physiologist diagnostic report, ABA prescription/ referral, Assessment results
Who submits: ABA provider
Authorization time: 5-14 business days (dependent on your insurance company's turnaround time)
Assessment completed. Behavior Intervention Plan completed. What’s next?
Now, this is the most important step. On your completed Behavior Intervention Plan (BIP), you will see the recommended hours of treatment your child will need. To obtain authorization for initial or ongoing ABA services, we will submit your BIP along with the assessment report(s) to your insurance company for hours of approval.
Hours approved by your insurance company will determine the number of hours your child can receive for services.
It is important to understand there are many moving factors between your provider(s) and insurance company – this process can take weeks, but please do not be discouraged. We are with you every step of the way. Patience is key.
It is also important the remember that just because all states have mandates for insurance coverage does not mean all insurance plans will cover ABA therapy.
Several issues can delay your authorization process but do not worry; we should be able to navigate any issues that may occur. What are the potential barriers?
Diagnostic Report Issues: Some insurance companies are very particular with the diagnostic requirements to receive services. For example, the area discussed in the report or if an approved evaluation was used to determine the diagnosis.
ABA services not covered – This happens more than you know but guess what? It is possible that your insurance plan does not have ABA coverage.
Peer review: Some initial or continuing authorization for services may require a peer review which can also be called a utilization review. This means your BCBA and a medical representative from your insurance company will go over the treatment plan to determine if fewer hours are required.