October 2016

New Preauthorization Requirement for Applied Behavioral Analysis

Effective January 1, 2017, benefit preauthorization will be required for Applied Behavior Analysis (ABA) for the treatment of Autism Spectrum Disorder for eligible Blue Cross and Blue Shield of New Mexico (BCBSNM) members. Providers may request benefit preauthorization on behalf of members by calling the number on the member’s ID card. The call must be made at least one business day prior to the scheduling of the planned outpatient service. Our online benefit preauthorization tool iExchange^® is not available for ABA preauthorization at this time.

Eligible members must have a diagnosis of Autism Spectrum Disorder 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 by the servicing provider. After the first benefit preauthorization for ABA services, additional benefit preauthorization requests may require concurrent review to ensure the member continues to meet the medical necessity guidelines, under their benefit plan.

As part of the benefit preauthorization process, submission of three forms – Diagnostic Physician/Specialist Evaluation, Provider Credentials Verification, Assessment Information and Initial Treatment Plan – will be required. These forms will be available on our Provider website. Additional information will be provided in upcoming issues of the Blue Review, as well as in the News and Updates section of bcbsnm.com/provider.

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 may not be covered, members should be notified that they may be billed directly.

If you have any questions, please contact your BCBSNM Provider Network Representative.
Please note that verification of eligibility and benefits, and the fact that a service or treatment has been preauthorized or predetermined for benefits, is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. Regardless of any benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.