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Outpatient Behavioral Health (BH) –
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. Re‐evaluation 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