Understanding the process of using insurance benefits to cover autism treatments
The link below shares the step by step process of navigating through the insurance process including assessment, meeting medical necessity, co-pays and out-of-pocket cost and payment for services.
An insurance carriers expectation of treatment team structure and supervision
Insurance carriers expect a treatment team structure and supervision of registered behavior technicians to meet the ethical guidelines of providing ABA treatment.
Glossary of Health Coverage and Medical Terms
New American Medical Association medical billing coding for ABA
Beginning in January 2019, the newly announced AMA CPT codes for Adaptive Behavior Assessment (applied behavior analysis, ABA) and Treatment Code for insurance reimbursement take effect. Learn More
WHAT DOES IT MEAN TO MEET MEDICAL NECESSITY FOR INTENSIVE BEHAVIORAL TREATMENTS?
Medical Necessity – Elements
Learn about the Common characteristics of Medical Necessity
Illinois Autism Mandate Medical Necessity language –
“Medically necessary” means any care, treatment, intervention, service or item which will or is reasonably expected to do any of the following: (i) prevent the onset of an illness, condition, injury, disease or disability; (ii) reduce or ameliorate the physical, mental or developmental effects of an illness, condition, injury, disease or disability; or (iii) assist to achieve or maintain maximum functional activity in performing daily activities.
WHAT ARE COMMON DENIALS FOR ACCESSING ABA TREATMENT?
A part of utilizing insurance benefits to cover autism treatments is knowing a treatment request could be denied. Common denials are:
Partial denial of treatment hours
ABA is experimental or educational
Fail First Option
The location is not allowed
Treatment plan does not support the level of treatment hours requested
Not enough hours in the day
Treatment gains are plateauing
ABA is not effective after age of 12.