A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
749120.1118
Applied Behavior Analysis (ABA)
Clinical Service Request Form
(Page 1 of 5)
Check one:
Initial Request
Concurrent Request
For any questions, call BCBSTX at 800-528-7264 or BCBSTX FEP at 800-528-7264 Fax Forms to 877-361-7646
1) For the Initial Treatment Request (ITR)
Submit: Completed Clinical Service Request Form (pages 1-5), Diagnostic Evaluation Report, Provider Baseline and Skills Assessment
Instruments and Comprehensive Treatment Plan (additional information may be requested by a clinician once the case is reviewed)
2) For the Concurrent Treatment Request (CCR)
Submit: Completed Clinical Service Request Form (pages 1-5), Skills Re-Assessment Report and Comprehensive Treatment Plan
(additional information may be requested by a clinician once the case is reviewed)
PATIENT INFO
Patient Name __________________________________________________ Patient Date of Birth _______________ Today’s Date _____________________
Subscriber Name _______________________________________________ Subscriber ID _________________________ Group ______________________
Patient resides in what state? __________________________ Services conducted in same state?
Yes
No If no, what state? ____________________
DIAGNOSTIC PRACTITIONER INFO
Diagnostic Practitioner Name _____________________________________________________________________ NPI ______________________________
Diagnostic Practitioner Type, if PCP:
Family Practice
Internal Medicine
Pediatrics
Diagnostic Practitioner Type, if Specialized ASD-Diagnosing Provider:
Developmental Behavioral Pediatrics
Neurodevelopmental Pediatrics
Child Neurology
Adult or Child Psychiatry
Licensed Clinical Psychology
Other (specify) _______________________________________________
Primary Diagnosis Code ________ Secondary Diagnosis Code __________ Dates of Evaluations: Initial _________________ Follow Up ________________
BCBA, BCBA-D, PROFESSIONALLY LICENSED PRACTITIONER INFO
ABA/Team Supervisor Name ______________________________________________________________ License/Cert # _____________________________
Team Supervisor Certification and /or License (check what applies):
Certified through the Behavior Analyst Certification Board (BACB):
BCBA
BCBA-D
Professional Licensed Practitioners (minimum of six months specialized training):
Licensed Clinical Psychology (PhD)
Other Licensure ____________
Master’s level clinician/state-recognized professional credential or certification _______________________________________ State __________________
CERTIFICATION OF DX & TREATMENT EXPECTATION
I,
Diagnostic Practitioner or
ABA Services Supervisor (having confirmed with the diagnostician), am recommending ABA services and certify
there is a reasonable expectation that this member can actively participate and demonstrates the capacity to learn and develop generalized skills to
assist in his/her independence and functional improvements.
Line Therapist
Requirements
ABA Supervisor
Requirements
Requirements for line staff providing 1:1 therapy: 1) 18+ years of age; 2) High school diploma or GED; 3) criminal
background check prior to active employment; 4) via practice expense, completed training of ASD & behavioral
related subjects/evidence based techniques (40 hours) and 5) have on-going supervisory oversight by the BCBA or
ABA treatment supervisor for a minimum of 5% of hours directly worked with members.
As the ABA Supervisor (above), I attest that I follow outlined guidelines for supervision by the BACB and have an
active license in the state where this member’s services are rendered. 
Yes 
No
CERTIFICATION OF PROVIDER QUALIFICATIONS
By signing and returning this form to Blue Cross and Blue Shield, I hereby certify: (1) credentials/license as noted above; (2) the line therapists for
whom I, or an outpatient mental health agency or clinic, will bill meet the qualifications set forth above; (3) if staff changes at any time, new staff must
meet the same qualifications; (4) time spent meeting the training requirements are not billable to BCBS or BCBS’s members and (5) BCBS may,
in its discretion, review its claim history or request supporting information in order to verify the accuracy of this certification.
ABA Supervisor Signature __________________________________________________________ Date __________________________________________
ABA Supervisor Printed Name _______________________________________________________ Clinic Name ____________________________________
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signature
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A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
749120.1118
PROVIDER INFO
Patient Name ________________________________________________________ Patient Date of Birth ___________________________________________
Facility Name _________________________________________________________________________ NPI _______________________________
Address _________________________________________________ City ________________________ State _______ Zip Code ______________
Telephone __________________________ ext ________ Fax __________________________ Contact Name _____________________________
Rendering BCBA Name _________________________________________ License/Cert # __________________ NPI ________________________
Address (if not same as above) ________________________________________ City ___________________ State _____ Zip Code ____________
Telephone __________________________ ext ________ Fax __________________________
PROVIDER TREATMENT REQUEST
Treatment Request Start Date _______________________ Requested Service Intensity:
Focused
Comprehensive
Total Requested Hours Per Week _____ (Note: Re-assessment package, for full clinical assessment, will be authorized every 6 months based on state plan)
Codes
97153
Direct
Treatment,
Tech or QHP
97155
Protocol
Modification &
Supervision
of Tech
QHP
97154
Group
Treatment,
Tech
97158
Group
Treatment,
QHP
97156
Family
Treatment,
QHP
97157
Multi Family
Treatment,
QHP
Units per 15
minutes
Additional Code(s) Request and Reason
ABA TREATMENT HISTORY
Initial/First Date of ABA Services from current provider/facility __________________________
Has this member had ABA services with any other provider?
No
Yes When was the initial date? ____________________
Intensity of these services:
Focused
Comprehensive Avg. # of hours/week ______________
Continuous ABA services since start?
Yes
No If break from services, when and why?
Medical History
Sleep Issues Related to ASD?
Yes
No If yes, please describe
Eating Issues Related to ASD?
Yes
No If yes, please describe
Is the patient taking medication?
Yes
No
If yes, prescribed by __________________________________________Professional Licensure/Credential __________________________________
Current Medications (Dosages)
Applied Behavior Analysis (ABA)
(Page 2 of 5)
ABA
Procedure
Code Request
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
749120.1118
Applied Behavior Analysis (ABA)
(Page 3 of 5)
BASELINE & ASSESSMENT INFO
Date Current Assessment Completed _______/ _______ / ________ Conducted by (name) ____________________ License/Cert ______________________
Assessment Participants:
Patient Only
Parents/Caregivers
Patient and Parents/Caregivers
Please select one (1) instrument that will be utilized for the member’s entire treatment episode so progress can effectively be measured. Choose a
recognized instrument such as the VB MAPP, ABLLS, AFLS, ABAS or the Vineland. Also, please attach standardized measurement scoring summaries
if the member has been in treatment prior to this request.
Name of Assessment Instrument Current Test Date Current Score Previous Test Date Previous Test Score
______ /______ /______ ______ /______ /______
Name of Assessment Instrument Current Test Date Current Score Previous Test Score Previous Test Score
______ /______ /______ ______ /______ /______
CURRENT MALADAPTIVE BEHAVIORS
(1) Behavior _____________________________________________________________ Freq _________ per
hour
session
day or
week
(2) Behavior _____________________________________________________________ Freq _________ per
hour
session
day or
week
(3) Behavior _____________________________________________________________ Freq _________ per
hour
session
day or
week
(4) Behavior _____________________________________________________________ Freq _________ per
hour
session
day or
week
MEMBER TREATMENT PLAN
Intro
Date
Baseline
(%)
Measurable Member Treatment Goals
(Goals from Different Domains)
Current
Progress/Data (%)
Expected
Mastery Date
1
2
3
4
5
Patient Name ________________________________________________________ Patient Date of Birth ___________________________________________
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
749120.1118
PARENT INVOLVEMENT
The parent/caregiver is expected to participate in training sessions _____________ hours per week.
Applied Behavior Analysis (ABA)
(Page 4 of 5)
Intro
Date
Baseline
(%)
Measurable Member Treatment Goals Current
Progress/Data (%)
Expected
Mastery Date
1
2
3
TREATMENT FADE/ TRANSITION/ DISCHARGE PLAN
Member’s Fade Plan: Member will step down from current ________ hrs/week to _______ hrs/week, on date _____ / _____ / _______ or
within ________ months.
Measurable Fade Plan with Criteria
Discharge Plan
Other referrals/supports recommended at time of discharge
Parent/Caregiver in agreement?
Yes
No
Patient Name ________________________________________________________ Patient Date of Birth ___________________________________________
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
749120.1118
Patient Name ________________________________________________________ Patient Date of Birth _____________________________________________
Member ABA
Schedule
Member School and
Other Therapy Schedule
Day of Week Time Span Location Lunch / Breaks Day of Week Time Span
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Time ___:___ ___ to ___:___ ___ Time ___:___ ___ to ___:___ ___
Monday
Tuesday
Wednesday
Thursday
Saturday
Sunday
Friday
Monday
Tuesday
Wednesday
Thursday
Saturday
Sunday
Friday
Supports Outside
ABA Treatment
Member accessing other school program?
Public
Private
Home
Other (Specify) ______________________
Member has IEP, ISP, 504 or ARD in place?
Yes
No If no, why not?
Is this member accessing other therapeutic services?
Physical Therapy
Occupational
Speech
NA
Is there coordination of care with other medical or BH providers?
Yes
No; Those are _____________________
Is the family accessing community supports?
Yes
No Which ones _____________________________________
Applied Behavior Analysis (ABA)
(Page 5 of 5)
My signature confirms that I am providing/supervising the requested ABA services:
ABA Supervisor Signature __________________________________________________________Date ________________________
ABA Supervisor Printed Name ___________________________________________Clinic Name ______________________________
click to sign
signature
click to edit
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