December 2016
Reminder: New Preauthorization Requirement for Applied Behavior Analysis for Blue Choice PPOSM Members
Effective Jan. 1, 2017, there will be a preauthorization requirement for Applied Behavior Analysis (ABA) for the treatment of Autism Spectrum Disorder for Blue Choice PPO members. Preauthorization for these services is processed through a Behavioral Health Medical Management review, by calling the number on the back of the member’s ID card.
The updated Blue Choice PPO Preauthorization Requirements list is located under Standards & Requirements/General Reimbursement Information in the General Reimbursements page of our website.
At Blue Cross and Blue Shield of Texas, we use preauthorization requirements to help make sure that the service or drug being requested is medically necessary and appropriate, follows up-to-date medical recommendations, is the most economical treatment, is not being duplicated and is actually helping.
This is one of many things we are doing to make the health care system work better – focusing on improving health care delivery, as well as finding solutions to aid in reducing unnecessary health care costs for everyone. We want our members to receive the best health outcomes for all of the dollars spent on their care.
Reminders:
- The member must have an Autism Spectrum Disorder diagnosis from a qualified diagnostician.
- The ABA service provider must have the credentials necessary to conduct ABA services.
- An initial functional assessment, including a treatment plan that identifies any deficient skills and the appropriate interventions, must be completed.
- After the first authorization for ABA services, additional authorizations may require concurrent review to ensure the member continues to meet the medical necessity guidelines.
- iExchange® is not available for ABA preauthorization or behavioral health at this time, therefore please call the number on the back of the member’s ID card for ABA preauthorization requests.
We will be providing additional information about ABA in the coming months on our provider website and in later issues of Blue Review. Be on the lookout for:
- Preauthorization forms: Diagnostic Physician/Specialist Evaluation, Provider Credentials Verification, Assessment Information and Initial Treatment Plan
Eligibility and Benefit Quotes
Member eligibility and benefits should be checked prior to every scheduled appointment. Eligibility and benefit quotes include membership status, coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts. It is strongly recommended that providers ask to see the member’s ID card for current information and a photo ID to guard against medical identity theft. When services might not be covered, members should be notified that they may be billed directly.