Jan. 4, 2017

New Preauthorization Requirements for Applied Behavior Analysis

Beginning in 2017, Blue Cross and Blue Shield of Oklahoma (BCBSOK) members who have benefit plans that cover Applied Behavior Analysis (ABA) through the full Behavioral Health Management Program (CORE) will have to obtain preauthorization before receiving therapy. The ABA preauthorization process will be effective with the first plan or policy year on or after Jan. 1, 2017.

Note: This change will not apply to any commercial groups with inpatient-only behavioral health management.

Members can call the number located on their ID cards or contact their group benefits administrator to verify an ABA benefit and to determine if preauthorization is required.

An Oklahoma mandate outlines the covered services for autism. ASO groups must accept their specific state mandate if they want to cover ABA services. BCBSOK follows these statutes, except for the age or dollar limits.

This ABA preauthorization requirement applies to the following BCBSOK plans, networks and lines of business:

• Blue Choice PPO^SM, Blue Preferred PPO^SM, Blue Advantage PPO^SM, Blue Traditional^SM, BlueLincs HMO^SM, Blue Options^SM and Blue Options Select^SM: Non-regulated small, non-regulated mid-market and large groups. Please be aware that not all benefit plans within a particular network provide coverage for ABA services.

• Note: QHP plans – individual and small group on/off Exchange – are not included.

In addition, the preauthorization requirement will only be applicable to ASO groups that have the full CORE program.

The new preauthorization requirement for ABA therapy is similar to other behavioral health intensive outpatient programs and partial hospitalization programs that currently require preauthorization.

Some of the key requirements for ABA therapy to be preauthorized beginning Jan. 1, 2017, are:

• A member must have an autism spectrum diagnosis from a qualified diagnostician and seek treatment from a properly credentialed ABA provider.
• To be considered properly credentialed, a provider must have a master’s degree with an independent license and/or one of the following certifications:
  • Board Certified Behavior Analyst
  • Board Certified Behavior Analyst Doctoral
  • Developmental Therapist with Certified Early Intervention Specialist credential (CEIS)

Preauthorization is used to help ensure members are receiving clinically appropriate care at the right level of care. These requirements help make sure that the service or drug being requested is medically necessary and appropriate. This is one of many things we are doing to make the health care system work better — improving health care delivery and finding solutions that may also help reduce health care costs for everyone.

For additional questions, please contact your BCBSOK representative/account executive.