Page 1 of 4 GR-69017-3 (11-18) EDI
BHVH
Outpatient Behavioral Health (BH) –
ABA Treatment Request:
Required Information for Precertification
Applies to:
Aetna plans
Innovation Health® plans
Health benefits and health insurance plans offered, underwritten and/or
administered by the following:
Allina Health and Aetna Health Insurance Company (Allina Health | Aetna)
Banner Health and Aetna Health Insurance Company and/or Banner Health and
Aetna Health Plan Inc. (Banner|Aetna)
Sutter Health and Aetna Administrative Services LLC (Sutter Health | Aetna)
Texas Health + Aetna Health Plan Inc. and Texas Health + Aetna Health Insurance
Company (Texas Health Aetna)
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including
Aetna Life Insurance Company and its affiliates (Aetna). Aetna provides certain management services on behalf of its affiliates.
Page 2 of 4 GR-69017-3 (11-18) EDI
BHVH
Outpatient Behavioral Health (BH) –
ABA Treatment Request:
Required Information for Precertification
About this form – Do not use for Maryland and Massachusetts
You can’t use this form to initiate a precertification or assessment only request. To initiate a
request, you have to call the number on the member’s card. Or you can submit your request
electronically.
Effective, January 1, 2019, this form replaces all other Applied Behavioral Health Analysis (ABA)
precertification information request documents and forms.
This form will help you supply the right information with your precertification request. You don’t have to use
the form. But it will help us adjudicate your request more quickly.
How to fill out this form
As the patient’s attending physician, you must complete all sections of the form.
You can use this form with all Aetna health plans, except Aetna’s Medicare Advantage plans. You can
also use this form with health plans for which Aetna provides certain management services. This
includes Innovation Health Plan, Inc. and Innovation Health Insurance Company. You can’t use the form
with Traditional Choice/Indemnity plans.
When you’re done
Once you’ve filled out the form, submit it and all requested supportive documentation to our Autism Care
Team. You can send it via confidential fax to 1-860-607-7406.
What happens next?
Once we receive the requested documentation, we will perform a clinical review. Then we’ll make a
coverage determination and let you know our decision. Your administrative reference number will be on
the electronic precertification response.
How we make coverage determinations
We encourage you to review Clinical Policy Bulletin #648: Autism Spectrum Disorders, and Applied
Behavior Analysis Medical Necessity Guide, before you complete this form. You can find the policy by
visiting the website on the back of the member’s ID card. The Applied Behavior Analysis Medical
Necessity Guide can be found by visiting: http://www.aetna.com/healthcare-
professionals/documents-forms/applied-behavioral-analysis.pdf
Questions?
If you have any questions about how to fill out the form or our precertification process, call us at
1-800-424-4047.
Aetna is the brand name used for products and services provided by one or more of the Aetna group of subsidiary companies, including Aetna Life Insurance
Company and its affiliates (Aetna). Innovation Health is the brand name used for products and services provided by Innovation Health Insurance Company
and Innovation Health Plan, Inc. Aetna and its affiliates provide certain management services for its affiliates, including Innovation Health.
Page 3 of 4 GR-69017-3 (11-18) EDI
Outpatient Behavioral Health (BH) –
ABA Treatment Request:
Required Information for Precertification
/ /
- - -
/ /
Fax to
Autism Care Team
Fax number
1-860-607-7406
Section 1 – Provide the following general information
Member name Administrative reference number (if available)
Member telephone number
Member ID Member date of birth
Facility, Physician, Provider or Vendor name Facility, Physician, Provider or Vendor TIN or PIN
number, and Billing State: State:
TIN number: PIN number:
Facility, Physician, Provider or Vendor fax number
1
Facility, Physician, Provider or Vendor status
Participating Non-participating
Facility, Physician, Provi
der or Vendor Address Facility, Physician, Provider or Vendor phone number
Name, telephone number and email address (if available) of Contact person (if not the provider)
Planned start date of procedure or service
Current diagnosis code(s):
Select the CPT codes which best describe the service(s) that you will provide and enter the hours
needed.
Assessment Codes
97151 Hours per auth period
97152 Hours per auth period
0362T Hours per auth period
Treatment Codes
97153 Hours per Week Month
97154 Hours per Week Month
97155 Hours per Week Month
97156 Hours per Week Month
97157 Hours per Week Month
97158 Hours per Week Month
0373T Hours per Week Month
Page 4 of 4
Outpatient Behavioral Health (BH) –
A
BA Treatment Request:
Required Information for Precertification
Section 2 – Provide the following patient-specific information
1. Diagnosing/Referring Provider(s) for ABA service Credentials
2. Who will be directly providing the service (working with the child)? Credential/Certification
3. Check box to ensure the following essential elements are met
Diagnosis on the Autism Spectrum
There are identifiable target behaviors
Parents/Guardians involved in treatment
Time limited, individualized treatment plan
Involvement of community resources
Service providers are appropriately licensed/certified
4. The patient displays impairment in the following areas (attach
supporting data that demonstrates current
status) select all that apply:
Self-injurious behavior
Destructive behavior
Aggressive behavior
Elopement
Communication skills
Socialization skills
Poor general development skills (ex: imitation,
identifying objects,
sharing skills)
Self-stimulatory behavior
Verbal outbursts
Tantrum behavior/verbal outbursts
5. Please include the follo
wing supporting documentation with your request, where applicable
How was the diagnosi
s of Autism made? What is the memb
er’s IQ? Current medications?
Documentation that Essential Elements are met
A functional behavioral assessment is planned to be completed within th
e first 60 days where specific
target behaviors are clearly defined. Reevaluation has been performed (every 6 months) to assess the
need for ongoing ABA; OR, validated assessments (such as IQ, communication level, an autism scale)
have been done every 12 months
Treatment plan, when applicable, includes the frequency, rate, symptom intensity or duration, or other
objective measure of baseline levels of each target behavior, along with quantifiable criteria for progress
established. Specific type, duration and frequency of interventions are tied to the function served by the
specific target behaviors. Treatment plan documents a gradual tapering of higher intensities of intervention
and a shifting to supports from other sources (schools as an example) as progress occurs. Collaboration
with any other treatment providers should be documented.
Supporting data that demonstrates the level/severity of impairment that justifies
the number of hours
requested
Documentation that supports parent
(s) or guardian(s) are/will be trained and required to provide specific
additional interventions.
Any additional details to be considered for this request
Section 3 – Read this important information
Any person who knowingly files a request for authorization of coverage of a medical procedure or service with
the intent to injure, defraud or deceive any insurance company by providing materially false information or
conceals material information for the purpose of misleading, commits a fraudulent insurance act, which is a crime
and subjects such person to criminal and civil penalties.
Section 4 – Sign the form
Just remember: You can’t use this form to initiate a precertification request. To initiate a request,
call the number on the member’s card. Or you can submit your request electronically.
Form completed by Title
GR-69017-3 (11-18) EDI
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