ABA Therapy Initial Assessment Authorizations—How to Maximize Each Auth

Maximizing ABA Therapy Initial Assessment Authorization

ABA Therapy Initial Assessment Authorizations—How to Maximize Each Auth

Tips for ABA Therapy intake or authorization coordinators to ensure maximized authorization for the most billable hours for your client’s initial assessment and examples of authorization processes by insurance company.

You have followed our ABA Therapy Insurance Eligibility guide, and you are now certain that your client has ABA Therapy coverage. Excellent! Now what? Set yourself up for success by maximizing your initial assessment authorization. Each insurance company handles the initial assessment authorization process and interprets the new AMA CPT3 billing codes differently. Follow these helpful tips to help position your agency for the best outcome possible.

Initial Assessment Authorization Tips

Tip #1—Always obtain a copy of the proof of diagnosis (POD) in your original intake process.

Some insurance companies require that these be signed by an MD, DO, or PhD, while others may not ask for it at all. Best practice is to have this in your client files.

Tip #2—Know as best you can how the insurance plan interprets the AMA CPT3 billing codes for ABA Therapy Initial Assessment.

Typically the insurance billing codes used for Initial Assessment are 0359T, 0360T, and 0361T.

  • 0359T is an untimed code, but insurance companies have applied a rate to these billing codes that can equal 60 minutes or 90 minutes. In some cases, they are reimbursing the flat rate single unit of 0359T with a rate equivalent to # of hours × rate (e.g., 8 hours × $$). We’ve seen several variations of reimbursement for these codes; we hope to have a more consistent pattern to report on after the first of the year once we see more consistency in claims payment.
  • In some cases, the additional hours needed for Assessment are being approved under billing codes 0360T/0361T. Depending on your contract and/or the insurance company, this code may be reimbursed at the BCBA rate. It is written as a Tech code but some plans acknowledge that Techs do not participate in the Assessment process.

Some examples of authorization processes by insurance company

Aetna

  • Has a form that will be faxed during eligibility/pre-certification phone call
  • Typically will approve the number of hours requested across billing codes 0359T to 0363T, but reimbursement rates for 0359T are 90 minutes at BCBA rate and the rest of the codes are at the Tech rate.

Anthem

  • Has a standard form to use, but cannot be signed solely by the BCBA. BCBA-D is accepted.
  • Requires the POD be sent with signature from MD, DO, or PhD.
  • Will approve up to 8 hours

    • Suggested request—1 unit (hour) 0359T, 1 unit (30 min) 0360T, 13 units (30 min each) 0361T
    • Suggest billing all units on last day of Assessment completion
    • Suggest billing all codes with BCBA rate (check with your local BCBS to see if they reimburse at the BCBA rate)

BCBS

  • Will be based on each individual state’s rules. We recommend discussing with the Care Coordinators approving auths to find the proper template and process to maximize your Initial Assessment authorization. Watch for mini blogs by state as new information becomes available.
  • Communicate with the Care Coordinators the number of hours you need to do a proper Assessment and discuss billing codes based on reimbursement rates by provider. Learn how they interpret 0359T. Some will quote it is an “untimed code” which is accurate, but they will still assign a rate to it that will tell you if they are seeing it as a 60 min reimbursement rate regardless of the number of hours you work. Therefore, you want to add the extra units with 0360T/0361T and have discussions about the BCBA performing these services and not Techs.

Cigna

  • Authorizations are obtained through the National Scheduling line.
  • Transitioned to new T codes 7/1, early information indicates 0359T only for Assessment. More information will be provided as they continue roll-out. Current auths are honored through expiration date.

United

  • Has a standard form to use—still using H0031 for Assessment—and will approve up to 8 hours.

Value Options

  • Has a standard form to use—requires POD signed by MD, DO, or PhD.
  • Will approve 2 units (2 hours) 0359T and the other 6+ hours will need to be requested with billing codes 0360T and 0361T.
  • Will reimburse 0360T and 0361T at BCBA rate.

The key to maximizing the Initial Assessment auth is understanding the parameters for billing your services and delivering those services within those parameters as best you can. This will help to maximize reimbursement for your hard work! We know this can be difficult, especially with the new CPT3 insurance billing codes and for Initial Assessments. We will do our best to provide you with the most up to date information possible. Leave a comment and let us know what you think of these tips and if there is anything else you would like to know further.

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