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Uniform Medical Plan coverage

limits Updates effective 6/1/2018

The benefit coverage limits listed below apply to these UMP plans: Uniform Medical Plan Classic (UMP Classic) UMP Consumer-Directed Health Plan (UMP CDHP) UMP Plus–Puget Sound High Value Network UMP Plus–UW Medicine Accountable Care Network

Some services listed under these benefits have coverage limits. These limits are either determined by a Health Technology Clinical Committee (HTCC) decision or a Regence BlueShield medical policy. The table below does not include every limit or exclusion under this benefit. For more details, refer to your plan’s Certificate of Coverage.

Chemical Dependency and Mental Health Pre-authorization is required for the following services. Emergency services do not require pre-authorization, but are subject to admission notification requirements.

MCG is used as the basis for determining medical necessity for Mental Health and Substance Abuse services. Visit MCG's website (http://www.careguidelines.com/products/) for information on purchasing their criteria, or contact us and we will be happy to provide you with a copy of guidelines for specific services.

These services or supplies have coverage limits The rules or policies that define the coverage limits

Mental health and/or chemical dependency services:

• Pre-authorization is required prior to patient admission• Supplement to MCGTM Discharge Criteria for Residential

Treatment• Supplement to MCGTM Criteria for Adult Substance-

Related Disorders, Inpatient and Residential BehaviorHealth Level of Care

Residential treatment

Partial hospitalization

Intensive outpatient

Detoxification Pre-authorization is required prior to patient admission

Important information regarding specific services

Applied behavioral analysis (ABA) therapy

June 1, 2018 These criteria do not imply or guarantee approval. Please check with your plan to ensure coverage. Preauthorization requirements are only valid for the month published. They may have changed from previous months and may change in future months.

http://www.hca.wa.gov/about-hca/health-technology-assessment/health-technology-reviews

http://www.hca.wa.gov/UMP/Pages/index.aspx

ABA Therapy is for the treatment of Autism Spectrum Disorders (ASD) when medically necessary. Pre-authorization is required prior to the initial treatment and concurrent review is required for additional treatment.

• Procedure codes 0360T-0374T and H2020.

The following clinical providers, with expertise in using evidenced-based tools to establish or confirm the diagnosis of autism and experience in developing multidisciplinary autism treatment plans, can provide the diagnostic assessment, comprehensive evaluation report, and recommend treatment approach:

• Neurologist• Pediatric Neurologist• Developmental Pediatrician• Psychiatrist, or• Doctorate level psychologist

Initial pre-authorizations must contain the following information; View specific details on what each of these items need to contain.

• ABA authorization request form (to be completed by the Lead Behavior Therapist)• Clinical evaluation, which includes confirmation of an ASD diagnosis, and

recommended treatment approach from a clinician meeting the criteria above(clinical evaluation needs to have been completed within the 12 months prior to theinitial pre-authorization request)

• Written Clinical Order, Directive, or Prescription for ABA Therapy services from aclinician meeting the criteria above

• ABA initial report that includes an ABA assessment treatment plan (to be completedby the Lead Behavior Therapist). This sample ABA assessment and treatment planform can be filled out and submitted or used as a reference tool.

A cover letter may be submitted; however it is not required. A sample cover letter template is provided for your reference. Other documentation may be submitted and must collaborate and support the severity scores recorded on the ABA authorization request form.

View ABA therapy clinical considerations for information about hours of service and documentation requirements.

Concurrent Review

The following document should be submitted within 5 business days prior to the end of a current authorization:


• Updated ABA assessment treatment plan (to be completed by the Lead BehaviorTherapist). This sample ABA assessment and treatment plan form can be filled out andsubmitted or used as a reference tool.

• A new ABA authorization request form (to be completed by the Lead BehaviorTherapist)

Following the submission of the concurrent review documentation, the plan may request additional information prepared and submitted by a clinician meeting the above clinical criteria. The plan will specify what must be included in this report which is intended to assess progress and prospective treatment in further detail and may include a written Clinical Order, Directive or Prescription for ABA Therapy services.


Medical Policy Manual Behavioral Health, Policy No. 21

Supplement to MCG™ Discharge Criteria for Residential Treatment

Effective: May 27, 2017

Next Review: May 2018 Last Review: May 2017

IMPORTANT REMINDER

Medical Policies are developed to provide guidance for members and providers regarding coverage in accordance with contract terms. Benefit determinations are based in all cases on the applicable contract language. To the extent there may be any conflict between the Medical Policy and contract language, the contract language takes precedence.

PLEASE NOTE: Contracts exclude from coverage, among other things, services or procedures that are considered investigational or cosmetic. Providers may bill members for services or procedures that are considered investigational or cosmetic. Providers are encouraged to inform members before rendering such services that the members are likely to be financially responsible for the cost of these services.

MCG™ CARE GUIDELINES The health plan uses MCG (formerly Milliman Care Guidelines) per licensed agreement, as the basis for determining medical necessity for Mental Health and Substance-Related Disorders. This policy provides additional clarification to the residential discharge criteria as outlined below.

These clarifications are ancillary information intended to be used as supplements to the MCG residential treatment guidelines above; they are not intended to replace MCG guidelines. The health plan’s supplemental criteria are identified through the use of blue italic text.

SUPPLEMENT TO MCG RESIDENTIAL DISCHARGE GUIDELINES I The supplemental residential discharge criteria in blue italic text below applies to the

following MCG guidelines:

→ Anorexia Nervosa: Residential Care, ORG: B-001-RES (BHG)


→ Anxiety Disorders (excluding Posttraumatic Stress Disorder): Residential Care, ORG:B-002-RES (BHG)

→ Attention-Deficit and Disruptive Behavior Disorders: Residential Care, ORG: B-003-RES (BHG)Autism Spectrum Disorders: Residential Care, ORG: B-012-RES

→ Bipolar Disorders: Residential Care, ORG: B-004-RES (BHG)

→ Bulimia Nervosa, Binge-Eating Disorder, and Other Specified Feeding or EatingDisorders: Residential Care, ORG: B-005-RES (BHG)

→ Dementia: Residential Care, ORG: B-007-RES (BHG)

→ Major Depressive Disorder: Residential Care, ORG: B-008-RES (BHG) Other

→ Other Psychiatric Disorders: Residential Care, ORG: B-010-RES (BHG) Other

→ Other Psychotic Disorders: Residential Care, ORG: B-011-RES (BHG) Persistent

→ Persistent Depressive Disorder (Dysthymia): Residential Care, ORG: B-009-RES(BHG)

→ Posttraumatic Stress Disorder: Residential Care, ORG: B-013-RES (BHG)

→ Schizophrenia Spectrum Disorders: Residential Care, ORG: B-014-RES (BHG)MCG Discharge Criteria:o Residential care no longer appropriate due to patient progress record or consent as

indicated by 1 or more of the following: Patient deterioration requires higher level of care Patient (or guardian) no longer consents to treatment

Supplemental Criteria Patient inadequately participates in program Following 60 days of residential treatment, patient has not made progress

despite participation and is judged not likely to improveII The supplemental residential discharge criteria in blue italic text below applies to the

following 2 MCG guidelines:

→ Substance-Related Disorders: Residential Care, ORG: B-015-RES (BHG)MCG Discharge Criteria:o Residential care no longer appropriate due to patient progress record or consent as

indicated by 1 or more of the following: Patient deterioration requires higher level of care Patient (or guardian) no longer consents to treatment

Supplemental Criteria Patient inadequately participates in program


Following 30 days of residential treatment, patient has not made progressdespite participation and is judged not to have the capacity to resolve his or herproblem. In addition, no new problems have been identified that are appropriatelytreated at the present level of care.

CROSS REFERENCES 1. Supplement to MCG™ Criteria for Adult Substance-Related Disorders, Inpatient and Residential Behavioral

Health Level of Care, Behavioral Health, Policy No. 23

REFERENCES

1. American Academy of Child and Adolescent Psychiatry Practice Parameters. [cited04/22/2017]; Available from: www.aacap.org/index.ww

2. MCG™ - 21st Edition (formerly Milliman Care Guidelines®). [cited 04/22/2017].3. American Society of Addition Medicine (ASAM) Treatment Criteria for Addictive,

Substance-Related, and Co-Occurring Conditions, Third Edition. [cited 04/22/2017];Available from: http://www.asam.org/publications/the-asam-criteria

[1-3]

CODES Codes Number Description CPT None HCPCS None

Date of Origin: August 2013


Medical Policy Manual Behavioral Health, Policy No. 23

Supplement to MCG™ Criteria for Adult Substance-Related Disorders, Inpatient and Residential Behavioral Health Level of Care

Effective: May 27, 2017

Next Review: May 2018 Last Review: May 2017

IMPORTANT REMINDER

Medical Policies are developed to provide guidance for members and providers regarding coverage in accordance with contract terms. Benefit determinations are based in all cases on the applicable contract language. To the extent there may be any conflict between the Medical Policy and contract language, the contract language takes precedence.

PLEASE NOTE: Contracts exclude from coverage, among other things, services or procedures that are considered investigational or cosmetic. Providers may bill members for services or procedures that are considered investigational or cosmetic. Providers are encouraged to inform members before rendering such services that the members are likely to be financially responsible for the cost of these services.

MCG™ CARE GUIDELINES The health plan uses MCG (formerly Milliman Care Guidelines) per licensed agreement, as the basis for determining medical necessity for adult substance-related disorders in adult patients. This policy provides additional clarification to criteria pertaining to adult substance-related disorders.

These clarifications are ancillary information intended to be used as supplements to the MCG substance-related guidelines above; they are not intended to replace MCG guidelines. The health plan’s supplemental criteria are identified through the use of blue italic text.

SUPPLEMENT TO MCG SUBSTANCE-RELATED DISORDERS, INPATIENT AND RESIDENTIAL CARE GUIDELINES

Note: This policy addresses adults only. For the purposes of this policy, adult is defined as age 18 years or older. The supplemental residential discharge criteria in blue italic text below applies to the


following 2 MCG guidelines:

→ Substance-Related Disorders: Inpatient Care, ORG: B-015-IP (BHG)

→ Substance-Related Disorders: Residential Care, ORG: B-015-RES (BHG) Supplemental Criteria After a combination of 3 or more residential or inpatient facility admissions for opioid

detoxification treatment during the most recent 24 months, additional residential or inpatient admissions may be considered medically necessary only if a clinical rationale based upon the specific member’s particular circumstances clearly establishes a reasonable expectation of effectiveness despite the multiple previous, recent post-admission relapses.

CROSS REFERENCES 1. Supplement to MCG™ Discharge Criteria for Residential Treatment, Behavioral Health, Policy No. 21

REFERENCES 1. MCG™ - 21st Edition (formerly Milliman Care Guidelines®). [cited 04/22/2017]. [1]

CODES

Codes Number Description CPT None HCPCS None

Date of Origin: May 2015


01/22/2014

ASD DOCUMENTATION REQUIREMENTS

Documentation of the diagnosis of an Autism Spectrum Disorder will be based on criteria defined by the most current DSM version (such as DSM‐5 299.00). The diagnosis must be made by a neurologist, pediatric neurologist, developmental pediatrician, psychiatrist, or doctorate level psychologist for an Autism Spectrum Disorder (ASD).

For a diagnosis to be accepted there must be:

Documentation of the confirmed presence of the core symptoms of autism: communication, behavioral,and social impairments; AND

Documentation of the tool and/or observations used to make/confirm the diagnosis.

To determine eligibility for services, there must be a report documenting a diagnostic assessment, comprehensive evaluation, and treatment plan with recommendations. The report must include these elements:

Specific to Diagnostic Assessment & Comprehensive Evaluation Report (cannot be more than a year old) For children who are current patients, it is acceptable to send the initial evaluation, most current notes or recent evaluation, as well as a letter certifying the diagnosis and providing any other required elements below that are not in other documentation being submitted. The letter should serve as an addendum and refer to the documentation being submitted, rather than reiterate this content. The following documentation is required:

a. Documentation of routine developmental surveillance performed by providers at well child visits;Examples of source documentation are: IEP, primary care practitioner or health care provider whoreferred the child, e.g. Occupational therapist, etc. if available;

b. Audiology and vision assessment results if available; or that vision and hearing were determined to bewithin normal limits during assessment and not a barrier to completing a valid evaluation;

c. If applicable, name of screening questionnaire, date completed, and significant results;

d. If applicable, documentation of formal diagnostic procedures performed by an experienced clinician,including name of measure, date and results, including scores. Examples of diagnostic measures are:

Autism Diagnostic Observation Schedule (ADOS);

Autism Diagnostic Interview (ADI);

e. Documentation of formal cognitive and/or developmental assessment performed by a qualifiedclinician, including name of measure, dates, results, and standardized scores providing verbal,nonverbal, and full scale scores, as available. Examples are:

Mullen;

Weschler; or

Bayley;


01/22/2014

f. Documentation of formal adaptive behavior assessment performed by a qualified clinician, includingname of measure, dates, results, and standardized scores providing scores for each domain asavailable. Examples are:

Vineland Adaptive Behavior Scales; or

Adaptive Behavior Assessment System (ABAS);

e. Documentation of the observed or family reported behaviors having an adverse impact ondevelopment, communication and of the injurious behavior, as applicable;

f. Expanded laboratory evaluation, if clinically indicated;

g. Documentation of less intrusive or less intensive behavioral interventions have been tried and notbeen successful; OR that there is no equally effective and substantially less costly alternativeavailable for reducing interfering behaviors, increasing pro‐social behaviors, or maintaining desiredbehaviors, if ABA is included on the treatment plan;

Specific to Treatment Plan with Recommendations: (If child not a new patient, can be in prescription.)

A multi‐disciplinary Individualized Treatment Plan (ITP) with recommendations that consider the full range of autism treatments with ABA as one treatment component, if clinically indicated;

The Prescription must include these elements: a. The order or prescription for ABA for the child, without specifying hours or how services are to be

provided;

b. Documentation that the child’s behaviors are having an adverse impact on development and/orcommunication, and/or demonstrating injurious behavior, such that

The child cannot adequately participate in home, school, or community activitiesbecause behavior interferes; OR

The child presents a safety risk to self or others;

c. A statement that the requested ABA services will result in measurable improvement in the child’sbehavior and/or skills.


ABA Assessment and Treatment Plan This report is confidential and for professional use only. The content may not be divulged to any person

or agency without consent of the parent, legal guardian, or patient, as appropriate. Fax to Regence BlueShield 1-888-496-1540 or by mail to: Regence BlueShield PO Box 1271 MS E9H, Portland, OR 97207-

1271 Patient Name: Treatment Agency Name:

Patient Birth Date: Lead Behavior Therapist Name:

UMP ID Number (Include Alpha Characters): Therapist Assistant Name(s):

RECOMMENDED TREATMENT HOURS/SESSIONS

Direct Patient Support - hours (weekly)

Caregiver/Parent Training - 1 session per day

(monthly) Recommended Hours and Setting (indicate # of Sessions for Caregiver/Parent Training)

e.g., 10 hours in home2 hours in community

Program Supervision - includes observation of the treatment being delivered, observation of the child in his/her

natural setting, and communication with BCBAs/Techs delivering ABA services.

(weekly)

ABA treatment day program in a clinic or outpatient hospital setting

(weekly)

Recommended Hours and Setting

e.g., 10 hours in home2 hours in community

Rationale for this treatment plan should be reflected in the body of the report below, as well as the severity ratings on the Applied Behavior Analysis Authorization Request Form submitted with this treatment plan.


BACKGROUND AND HISTORY Indicate at least the following or indicate NA.

Past psychiatric history:

For diagnosis of autism spectrum disorder, include date of diagnosis and diagnosing provider name. Also include initial diagnosis documentation and comorbid diagnoses if this is an initial preauthorization request.

Chief Complaint and History of Present Illness (HPI): Include all core deficit areas of autism, challenging behaviors, adaptive, motor, vocational, and cognitive skills, and any other related relevant areas. In addition to addressing the chief complaint, one should be able to understand the patient’s level of functioning by reading this section. Please provide a detailed summary of information below for both Preauthorization and Concurrent review requests.

Social Communication: includes persistent deficits in social communication and social interaction, as outlined in DSM-5

Behavior: includes restricted interests and repetitive behaviors, as well as related challenging behaviors (e.g., tantrums, aggression, etc.)

Adaptive skills:

Motor:

Vocational:


Cognitive:

Family history: Focus on relevant family psychiatric history and related family training in support of performing ABA therapy

Social history: Information about where the patient lives, with whom, as well as any other relevant information about social context or stressors.

Medical history:

Active medical problems:

Current medical providers:

Current medications, dose, purpose, and potential major side effects:

Allergies, special diets, etc.:

Past medical problems:


Educational History: Summarize past and current educational plan, including what services are being provided in the educational setting. Discuss whether functional behavior assessments, behavior plans, and/or aversive plans have been used in the school setting. State where the information was obtained (e.g., review of records, interview, etc.).

History:

Current:

Past and Current Services: Outline all additional services being provided outside school through any other agency or funding source. Include frequency, provider, and funding source.

Ensure there is not redundancy with recommended ABA treatment plan.

Outline previous courses of ABA therapy; including dates, setting, and the outcome.

ASSESSMENTS COMPLETED FOR EVALUATION

Measures used: Discuss all sources of information used in evaluating the patient, including standardized (norm-referenced) and curriculum-based measures, interviews (e.g., parent, caregivers, teacher), direct observation at home/school/community, etc. Please complete the Applied Behavior Analysis Authorization Form and attach to this treatment plan.


Evaluation Findings: Briefly summarize findings, including test scores if available. Summary can be brief; a couple sentences per measure. E.g., Vineland-II results demonstrated delays in communication and socialization are present. Tables and score reports can be used if easier to present information. Present in appendices if desired. Briefly summarize findings derived from observations in natural settings (e.g., home, school).

Functional behavior assessment/analysis findings: Functional assessment or analysis results should be included here. The following components should be included:

1) Operational definition of behavior

2) Hypotheses or analysis about functions supported by indirect and direct assessment results

3) Functional assessment or analysis data to support function hypotheses or analyses

4) Baseline data, including frequency, duration, and intensity data, as appropriate to behavior.

Include assessment of risk (e.g., due to elopement or other unsafe behavior) as appropriate.

Goal domains derived from assessment: Include statement about how the information obtained supports goals in specific areas. E.g., Assessment information suggests CHILD needs treatment goals in the areas of Social Communication, Behavior, Adaptive skills, Motor skills, Vocational skills, and Cognitive skills.


TREATMENT PLAN IMPLEMENTATION

Treatment Plan: This section should include a brief overview of the treatment plan, including:

1) How ABA will be applied to the patient (e.g., ABA as applied to CHILD will include home andcommunity based 1-1 intervention for (x) hours per week to target social, communication, andadaptive goals)

2) Whether a positive behavior support plan is required to address challenging behaviors

3) The parent/caregiver training plan

4) How the treatment plan will be coordinated with other providers, including school (e.g., speechpathologist, medical providers, outpatient psychologist, teachers, etc.).

Goals and objectives can be found in Appendices A, B and C of this report.


Maintenance/Generalization/Discharge Plan: This section should include a statement about how maintenance and generalization will be addressed, how services will be reduced or transitioned to the parents and/or how the patient will be transitioned into other less intensive services (e.g., school, outpatient, etc.). This should be more specific as the patient progresses in therapy. The transition or discharge plan should be specific, data driven, and include criterion for discharge.

Goals and objectives can be found in Appendix D of this report.

ABA Agency or ABA Service Coordinator: _______________________________________________

__________________________________ __________________________________

Print Name of Lead Behavior Therapist Signature of Lead Behavior Therapist

__________________________________ __________________________________

Print Name of Therapist Assistant Signature of Therapist Assistant

__________________________________ __________________________________

Print Name of Therapist Assistant Signature of Therapist Assistant

__________________________________ __________________________________

Print Name of parent/caregiver Signature of parent/caregiver


Appendix A: Goals and Objectives for Skill Acquisition

Include goals and objectives in all relevant areas. Goals should be worded in such a way that they can be measured to track progress. Objectives should be clear steps toward a goal. Goals and objectives should be worded in such a way that they are easily interpretable to readers who are not familiar with behavioral terminology (i.e., parents, case managers, etc). The specified domains were decided upon by the HCA and include social communication, behavior (restricted interests, repetitive behaviors, other challenging behaviors), adaptive, motor, vocational, and cognitive. Broadly defined, all relevant goals (e.g., play skills, self-help, etc.) should fit into one of these categories. Goals for reduction of problem behavior should be outlined in Appendix B: Positive Behavior Support Plan.

Skill Acquisition Goals: All skill acquisition goals and their corresponding objectives should be outlined here. Goals should be organized by skill area (e.g., social communication), should be titled with a short 2-3 word title, should include a broad goal that demonstrates the expected outcome, and then be broken down into specific objectives(also titled) that clearly outline target skills to be taught (e.g., within communication, expressive labels and requesting might be two specific objectives). Objectives should be measurable and measurement strategies, including mastery criteria, should be clearly stated (e.g., mastery criteria are met when a correct response occurs on 9 out of 10 opportunities across three sessions). Goals should be written in a manner that is consistent with how the therapists are taking data so data can easily be reported back for utilization review of progress. If progress will be documented by using a formal assessment tool (e.g., a measure associated with a curriculum), this should be stated in how the goal is written (e.g., patient will show improvement according to the ____ assessment).

If the patient is receiving ABA therapy services primarily to address reduction of challenging behaviors, this section may be marked NA and the Positive Behavior Support Plan should be outlined in Appendix B.

Goal 1:

Baseline: Treatment Approaches to be Used: Progress:

Objective 1A

Baseline: Progress:

DOMAIN: Social Communication


Goal 2:


Objective 2A

Baseline: Progress:

Goal 1:


Objective 1A

Baseline: Progress:

Goal 2:


Objective 2A

Baseline: Progress:

DOMAIN: Adaptive


Goal 1:


Objective 1A

Baseline: Progress:

Goal 2:


Objective 2A

Baseline: Progress:

Goal 1:


Objective 1A

Baseline: Progress:

DOMAIN: Motor

DOMAIN: Vocational


Goal 2: Baseline: Treatment Approaches to be Used: Progress:

Objective 2A Baseline: Progress:

Goal 1:



Goal 2:



DOMAIN: Cognitive


Appendix B: Positive Behavior Support Plan

Positive Behavior Support (PBS) Plan for Reducing Challenging Behaviors: Should follow from functional assessment/analysis results discussed above and include, 1)operational definitions of behaviors, 2) a brief statement of identified functions of behavior, 3) suggested parent/caregiver/staff response to behaviors when they occur, 4) recommended antecedent interventions to prevent behaviors, 5) plan for teaching replacement behaviors with clear goals, 6) statement about how the proposed interventions were derived from the functional assessment/analysis, 7) plan for coordinating PBS Plan across settings.

If the patient has minimal challenging behaviors and the primary focus of their ABA treatment plan is on skill acquisition, this section may be marked NA and the skill acquisition goals should be outlined in Appendix A.

Goal 1:



Goal 2:



DOMAIN: Behavior


Appendix C: Parent/Caregiver Training Goals

This section should address caregiver goals for skill acquisition (e.g., parents will learn to implement the PBS Plan). It should include clear goals and objectives, written in the same format as the patient’s skill acquisition goals.

All children should have parent/caregiver training goals in their treatment plan, regardless of the nature of the child’s goals/objectives. If the treatment plan is for an adult or an individual living in a group setting, this portion of the plan should focus on training caregivers. This section may not be marked NA.

Goal 1:


Objective 1A

Baseline: Progress:

Goal 2:


Objective 2A

Baseline: Progress:


Appendix D: Maintenance/Generalization/Discharge Plan

This section should include a statement about how maintenance and generalization will be addressed, how services will be faded and/or how the patient will be transitioned into other less intensive services (e.g., school, outpatient, etc.). This should be more specific as the patient progresses in therapy. The fading plan should be specific, data driven, and include criterion for discharge.

Statement about how maintenance and generalization will be addressed, etc.

Goal 1:

Criterion for Discharge: Referral Program:

Objective 1A


Goal 2:


Objective 2A


DOMAIN: Social Communication


Goal 1:


Objective 1A Criterion for Discharge: Referral Program:

Goal 2:



Goal 1:



DOMAIN: Adaptive

DOMAIN: Motor


Goal 2:


Objective 2A


Goal 1:


Objective 1A


Goal 2:


Objective 2A


DOMAIN: Vocational


Goal 1:



Goal 2:



DOMAIN: Cognitive


SAMPLE COVER LETTER

CHILD was formally evaluated on DATE at SITE OF EXAM by PROVIDER. CHILD demonstrated impairments in social interaction, social communication and atypical behavior consistent with an Autism Spectrum Disorder. CHILD’s behaviors and/or impairments are having an adverse impact on development and/or communication as documented on DATE by the presence of severe behaviors and/or functional impairments that interfere with CHILD’s ability to participate adequately in their home, school or community environments and/or the health and safety of CHILD or others are at significant safety risk. Please see the attached report/COE report/treatment plan and DSM-IV-TR checklist for details.

Applied behavioral analysis services are recommended given the adverse impact of CHILD’s behaviors and/or core impairments. CHOOSE HERE [Less intensive behavioral treatment or other therapy has been tried and not been successful, or it is not accessible, or there is no equally effective alternative available for reducing severe interfering or disruptive behaviors, increasing pro-social behaviors, or achieving desired behaviors]; and Applied Behavioral analysis services are reasonably expected to result in a measureable improvement in CHILD’s skills and behaviors.


Applied Behavior Analysis (ABA) Services Authorization Form

Please follow the steps below to request authorization for ABA services. Uniform Medical Plan may deny the request if you fail to provide complete information.

• Print your answers to the questions below.• Sign and date the form.• Attach the required supporting documentation:

A copy of the evaluation. The prescription for ABA services. The BCBA’s assessment with the functional analysis. The BCBA’s treatment plan.

• Return completed form and supporting documentation to Regence BlueShield as soon as possible. Contact information islisted at the end of this form.

New request Extension

Subscriber’s name Patient’s name UMP ID number (include alpha characters)

Provider’s name Provider’s NPI number

Provider’s telephone number Provider’s fax number Diagnosis code

Symptom Severity Checklist

Instructions: For each item, choose the number that best describes the child’s current behavior over the past 2 weeks, taking into account all available information: 0: No impairment = age appropriate or typical behavior 1: Mild impairment = behavior that is occasionally disruptive to everyday functioning 2: Moderate impairment = behavior that is frequently disruptive to everyday functioning 3: Severe impairment = behavior that is consistently disruptive to everyday functioning

Domain Social communication and interaction 0, 1, 2 or 3

1a Impairments in the use of eye contact during social interactions 1a Deficits in the use of facial expressions to communicate 1a Lack or reduced use of gestures to communicate 1b Impairments in back and forth conversation (appropriate to language level) 1b Lack of, reduced, or impaired responses to social initiations of others (e.g., responding to name,

acknowledging others) 1b Lack of, reduced, or impaired initiations of interactions with others 1c Lack of, or reduced interest in, peers (appropriate to developmental level) 1c Reduced preference for some peers over others/impaired friendships 1c Delays in, or lack of, varied, age-appropriate play with peers

Social communication subtotal (sum of domain 1 scores):

Domain Restricted, repetitive patterns of behavior, interests, and activities 0, 1, 2 or 3 2a Has atypical speech characteristics (e.g., echoing, jargon, unusual rhythm or volume) 2a Has repetitive body mannerisms


2a Uses objects in a repetitive or rigid manner 2b Reacts negatively to changes in schedule/Insists on sameness 2b Has behavioral rituals 2b Has verbal rituals (e.g., has to say things, or have others say things, in a particular way) 2c Has specific interests that are unusual in focus (e.g., traffic lights, street signs) 2c Has specific interests that are unusual in intensity (e.g., hobby of unusual intensity) 2c Engages in a limited range of activities/Has a limited behavioral repertoire 2d Shows hyper-reactivity to sensory input 2d Shows hypo-reactivity to sensory input 2d Shows unusual sensory interests and preferences

Behavioral subtotal (sum of domain 2 scores):

Domain Disruptive behavior 0, 1, 2 or 3

3 Engages in aggressive and/or destructive behaviors toward self, others, or objects If score > 0, please list behaviors below (e.g., self-injury, elopement, property destruction):

Overall Severity Assessment Overall Severity Level: For each domain, please indicate the level of severity by circling the number corresponding to the most appropriate descriptor: Level 0 = Requiring no support Level 1 = Requiring minimal support Level 2 = Requiring substantial support Level 3 = Requiring very substantial support

Social communication Support level required (circle one)

Behaviors in this area do not require specific supports at this time. 0

Without supports in place, deficits in social communication cause noticeable impairments. Individual has difficulty initiating social interactions and demonstrates clear examples of atypical or unsuccessful responses to social overtures of others; may appear to have decreased interest in social interactions.

1

Individual has marked deficits in verbal and nonverbal social communication skills; social impairments apparent even with supports in place; limited initiation of social interactions and reduced or abnormal response to social overtures from others.

2

Severe deficits in verbal and nonverbal social communication skills cause severe impairments in functioning; very limited initiation of social interactions and minimal response to social overtures from others.

3

Restricted interests & repetitive behavior (RRBs) Support level required (circle one)

Behaviors in this area do not require specific supports at this time. 0

Rituals and repetitive behaviors (RRBs) cause significant interference with functioning in one or more contexts. Resists attempts by others to interrupt RRBs or to be redirected from fixated interest. 1

RRBs and/or preoccupations or fixated interests appear frequently enough to be obvious to the casual observer and interfere with functioning in a variety of contexts. Distress or frustration is apparent when RRBs are interrupted; difficult to redirect from fixated interest.

2

Preoccupations, sensory fixated rituals, and/or repetitive behaviors markedly interfere with functioning in all spheres. Marked distress when rituals or routines are interrupted; very difficult to redirect from fixated interest or returns to it quickly.

3


Age of client:

1. What is the confirmation date for the diagnosis?

2. The client may have tried and failed other therapies. What other therapy(ies) have been tried? What were the outcomes?

3. Have other treatments been tried? If not, please explain.

Additional information:

Provider signature Provider specialty Date

Lead behavior therapist name and qualifications

Therapy assistant name and qualifications

Additional therapy assistant(s) name and qualifications

Reminder: You must attach a copy of the evaluation, the prescription for ABA services, the BCBA’s assessment with the functional analysis, and the BCBA’s treatment plan to this request.

Please submit this ABA Services Authorization form and all required supporting documentation to Regence BlueShield by fax or mail:

• Fax : 1-888-496-1540• Mail: Regence BlueShield

PO Box 1271 MS E9H Portland, OR 97207-1271


Effective November 21, 2016

Uniform Medical Plan ABA Therapy Clinical Considerations

ABA Therapy hours of service should reflect the number of and type of behavioral targets and key functional skills to be addressed and include a clinical summary justifying the hours requested for each behavioral target. The total hours of ABA Therapy requested should be comprised of fewer than 40 hours per week.

Any requests for greater than 40 hours per week should show documentation as to why more than 40 hours of therapy is medically necessary.

ABA therapy documentation should show the following: The client‘s response to ABA therapy services and progress being made Meaningful, measurable, and functional improvement, changes, or progress

o Meaningful changes should be demonstrated by: Data confirming the changes or progress Documentation in charts and graphs Durability over time beyond the end of the actual treatment session Generalizable outside the treatment setting to the client’s residence or the

community within which the client resides Compliance with treatment plan, including keeping appointments, attending and

participating in treatment and family training sessions, completion of homeworkassignments, and family application of training techniques as directed by the therapyassistant or LBAT.


chemical dependency and mental health · ump plus–uw medicine accountable care network some...

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