Customer Information
Provider Information
Applied Behavior Analysis (ABA)
Prior Authorization Form
In the hope to save you, our provider, some time on the phone, we invite you to fill out this form for ABA treatment
requests. In filling out this form, you are doing so in lieu of the telephonic clinical review. This form should be completed
by a provider who has a thorough knowledge of the Cigna customer's current clinical presentation and his/her treatment
history. Please note: The information contained in this form may be released to the customer or the customer's representative.
Please save this form to your computer, complete & save the form using Adobe Acrobat Reader DC, then email it to:
ABA@Cigna.com* (preferred) or fax 1.860.687.9230
TIPS FOR COMPLETING THIS FORM:
Our regular business hours are Monday – Friday, from 7:30am – 5:00pm Central Time
.
To help expedite this request, please complete sections as specifically and as clearly as possible. Omissions,
generalities, and illegibility may result in this request being returned for additional information or clarification
.
Typed responses are preferred. If completing by hand, please use blue or black ink and print legibly.
.
If you have any questions, call ABA Scheduling at 1.877.279.7603
.
Customer Name: Member ID:
Address:
928213b Rev. 02/2020 Page 1 of 4
All fields are required.
Date of Birth
M M D D
Y Y Y Y
If treatment plan is referenced for response, please indicate page number.
.
Is the customer diagnosed with Autism Spectrum Disorder (ASD): Yes No
Date of most current diagnostic evaluation and evaluator's name/credentials:
List any current medications:
Supervising Provider's Name:
Tax ID:
Email Address:
Please list the best times our team could contact you within the next five business days for questions, concerns,
or determination information:
( )
Phone Number:
Clinic Name: Clinic Contact (if different from provider):
Clinic/Practice Address:
The form below is based on our Medical Necessity Criteria for ABA. Please find the detailed criteria online at:
https://cignaforhcp.cigna.com/public/content/pdf/coveragePolicies/medical/
mm_0499_coveragepositioncriteria_intensive_behavioral_interventions.pdf
Is Voicemail confidential?
Yes No
If No, what is the current diagnosis (please include diagnosis and diagnostic code).
* Please note that Cigna assumes no responsibility for the protection of electronically transmitted information prior to its actual
receipt of that information. It is your responsibility to take any steps necessary to protect the email or documents prior to receipt by
Cigna.
Please indicate if authorization is requested to the supervising provider or clinic:
Please check what applies. The supervising provider is credentialed or licensed as:
BCBA
BCBA-D LBA Licensed Psychologist
Other Licensed (Please specify)
Is the provider above providing all supervision for the customer's ABA case?
Yes
No - If No, please list who else is providing supervision and their credentials.
Page 2 of 4928213b Rev. 02/2020
Please indicate level of benefit requested:
I am an in-network provider with Cigna and requesting an in-network authorization
I am an out of network provider with Cigna and requesting an out of network authorization
I am an out of network provider and I am requesting an in-network exception. If Yes, what specialized
experience, training or certification in a particular clinical area or patient population do you poses that
would support the need for an in network exception request?
Treatment History and Coordination of Care
ABA
How long has the customer been receiving ABA treatment from your agency:
Is the customer receiving any additional services?
Other Treatment
Speech Therapy Mental Health Services Primary Care (Pediatrician)
Occupational Therapy
Other:
Physical Therapy Services through the school system
Do you collaborate with all of the providers above?
Yes No Plan to collaborate very soon
If no, please explain why:
If Yes, (check all that apply)NoYes
Standardized Assessment
Please indicate which standardized assessment(s) were administered (or indicate page numbers in the
documents submitted):
1. Name of Assessment:
a. Current Score:
b. Previous Score:
c. Baseline Score:
Date:
Date:
Date:
2. Name of Assessment:
a. Current Score:
b. Previous Score:
c. Baseline Score:
Date:
Date:
Date:
If additional assessments were used, please include the assessment, dates of administration, and scores
Current ABA Treatment Information
Please attach clinical information to show that an individualized treatment plan has been developed. This should
include specific targeted behaviors/skills for improvement, along with clearly defined, measurable, and realistic
goals for improving those behaviors/skills and addresses the following:
- Treatment goals are directly related to the core symptoms of ASD as defined by the DSM-5.
- Baseline, interim and current data are reported for all goals.
- The treatment plan includes a measurable parent/caregiver (including teachers and other stakeholders
as appropriate) goals to train them in the basic behavioral principles of ABA and to continue behavioral
interventions in the home and community with data to demonstrate parent progress with those goals.
- The treatment plan includes a plan to ensure maintenance and generalization of skills.
- The treatment plan includes clearly defined, measurable, realistic discharge criteria and transition plan
across all treatment environments.
This can be a current treatment plan and/or progress report.
Treatment Goals
For the current request, please indicate the following numbers:
Goals for behavior reduction: Goals for skill acquisition: Parent Training Goals:
During the previous authorization period, please indicate the following numbers:
Total Goals:
Goals Mastered: Goals Modified: Goals Put on hold: Goals Added:
928213b Rev. 02/2020 Page 3 of 4
BCBA/Supervisor Hours Technician/RBT Hours
Code Hours Units Time Frame
Per authorization period97151
Per authorization period
0362T
97155
97156
97157
0373T
All Cigna products and services are provided exclusively by or through operating subsidiaries of Cigna Corporation, including Cigna Health and Life Insurance Company, Connecticut
General Life Insurance Company, Cigna Behavioral Health, Inc., and HMO or service company subsidiaries of Cigna Health Corporation. The Cigna name, logo, and other Cigna marks
are owned by Cigna Intellectual Property, Inc.
© 2020 Cigna. Some content provided under license.
928213b Rev. 02/2020 Page 4 of 4
Please save this form to your computer, complete & save the form using Adobe Acrobat Reader DC, then email it to:
ABA@Cigna.com* (preferred) or fax 1.860.687.9230
Start date of service:
Current Requested Treatment
Code Hours Units Time Frame
Per authorization period97152
97153
97154
Supervisor's Signature/E-Signature:
Date:
97158
We encourage you to make any requests for services no earlier than 2-3 weeks prior to the requested start date.
This will ensure we have the most up to date clinical information.
* Please note that Cigna assumes no responsibility for the protection of electronically transmitted information prior to its actual
receipt of that information. It is your responsibility to take any steps necessary to protect the email or documents prior to receipt by
Cigna.
CLEAR FORM
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