Applied Behavior Analysis (ABA)
Supervision via Telehealth
Request & Attestation
For any questions, call Blue Cross and Blue Shield of Texas (BCBSTX) at 800-528-7264 or BCBSTX FEP at 800-528-7264.
Fax Form to 877-361-7646. Instructions: Please complete this form to have your request reviewed.
PROVIDER INFO
Provider/Agency Name ____________________________________________ NPI ________________ Request Submission Date _____/______/________
BCBA Supervisor Name ___________________________________________ NPI _________________ Professional Level _________________________
Provider resident state _________________ Has the Provider met state practice regulations/requirements? Yes No
Services conducted in same state? Yes No
PATIENT INFO
Patient Name __________________________________________________ Date of Birth __________________ Request Submission Date _________________
Subscriber Name _______________________________________________ Subscriber ___________________________ Group ________________________
TELEHEALTH REQUIREMENTS
Provider/BCBA has/will be submitted clinical documentation so a determination for medical necessity for this member for ABA services has been/can be made.
Provider/BCBA can provide documentation to support that this member is in a rural Health Professional Shortage Area (HPSA), or this member meets the
standards for telehealth supervision outlined in the Applied Behavior Analysis and Telehealth Supervision document.
Provider/BCBA has/will be been informed of their rights and responsibilities regarding this requested service and member written consent specic to
participation in telehealth supervision has been obtained.
Provider/BCBA has written protocols to ensure telehealth supervision meets state/federal laws, established member care standards and privacy and
condentiality (HIPAA) standards regarding electronic record transmission.
Provider/BCBA has availability of high quality video/audio equipment, up to date security software, and real time interactive connectivity using internet-based
conferencing software programs.
Provider/BCBA has written protocols for management of urgent/emergent situations.
Provider/BCBA will maintain timely, complete records of all telehealth services provided to member.
Provider/BCBA will arrange for the functional assessment every six months to be ‘face to face’ for quality treatment planning to occur.
ATTESTATION
I ______________________________________ plan on providing ABA supervision via telehealth to BCBSTX member _____________________________
starting _____/_____/________. I have read the document titled Applied Behavior Analysis and Telehealth Supervision and meet all requirements for
delivery of these supervision services via telehealth. I attest by my signature below that my professional license and practice meets all state, federal laws
and criteria. I understand that it is my responsibility to comply with all BCBSTX, state & federal telehealth regulations and guidelines. I hereby certify that
my representations contained in this document are true and accurate. I further understand that any information entered on this attestation document that
is subsequently found to be false could result in termination of any agreement I have or entered with BCBSTX.
I understand and agree that, as a part of the process for delivery of telehealth services, I am required to provide sufcient and accurate information for
proper evaluation of my current licensure, relevant training and/or experience, clinical competence, telehealth requirements or standards that must be
met, or any other criteria used by BCBSTX for determining initial and ongoing eligibility participation for these services. I acknowledge that the information
obtained relating to this process will be held condential to the extent permitted by law.
ABA Supervisor Signature:_______________________________________ ABA Supervisor Printed Name: ____________________________________
Date: _____/_____/________ Clinic Name: __________________________________________________
A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association
750821.0719
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