Applied Behavior Analysis (ABA) Resources

You’ll find all the credentialing forms and information you need on the Join our Network page. Email completed documents and W-9 to provider.relations@premera.com.

Providers must complete a re-credentialing packet every 3 years. If this isn’t submitted in a timely manner, it puts the contract at risk for termination. 

You’ll receive a letter as soon as your application is approved. Your acceptance is based on complete application information and network requirements. The credentialing process may take 30-45 days to complete.

Note: If it has been over 30 days from the date you submitted your completed credentialing application through ProviderSource, you can:

• email the credentialing team for credentialing status or
• email the provider relations team for contracting status.

During supervision, only LBAs can be billed for their time. Registered behavior technicians’ (RBTs) supervising time isn’t a covered service since the supervision is being delivered by the program manager/lead behavioral therapist. (RBTs include therapy assistants, behavioral technicians, and paraprofessionals.)

However, when a program manager/lead behavioral therapist is supervising a RBT while they’re providing direct treatment services, both the supervision by the program manager/lead behavioral therapist and the direct treatment services by the RBT are covered services. Prep time is not covered.

During supervision of direct treatment, both the LBA and the RBT need to create separate chart notes. For supervision that doesn’t occur during direct treatment, only a chart note by the LBA is necessary.

Sign in to Availity to use our claims and payments tool to get claim status, detailed payment information, and to download your explanation of payments (EOPs).

If you still have questions about your claim, call customer service at 800-722-4714, option 2.

In addition to ASD, ABA therapy also covers autism and pervasive developmental disorders. This includes:

• Autistic disorder
• Rett’s syndrome
• Asperger’s syndrome
• Other childhood disintegrative disorder
• Pervasive development disorder unspecified

A patient’s treatment plans, as a standard, should be updated every 6 months. A treatment plan should be kept on file in the office and doesn’t need to be sent to Premera unless requested for an audit or medical records request.

For general guidance about coverage criteria for ABA services, see Premera’s medical policy 3.01.510. In addition, many member benefit booklets provide specific coverage criteria for ABA services.

Sign in to Availity to use our eligibility & benefits tool to get member benefit information. If you still have questions about member benefits, call customer service at 800-722-4714, option 2.

Some portion of the direct service provision (no specific time amount is specified) may take place in a school setting when behavioral or other difficulties that are manifestations of the individual’s autism spectrum disorder (ASD) are evident and problematic in a school setting. Direct service provision in a school setting must consist entirely of bona-fide ABA treatment activities; the ABA clinician can’t be used as a classroom aide for the patient, as a 1:1 teacher for the patient, or in any other capacity that is a function of and the responsibility of the school system.

Assisting the member with school work or functioning as a tutor isn’t covered, except when they have demonstrated a pattern of significant behavioral difficulties during school work. Provision of services that are part of an individualized educational plan (IEP) that should be provided by school personnel and other school-obligated services are also not covered.

Team meetings are only covered when they’re specifically for treatment plan development or revision or case review for one specific patient. Prep time including charting data or plotting graphs, as distinct from actual analysis of data, aren’t covered.

Direct service provision by telehealth modalities, including to parents or family members, isn’t medically necessary because there’s no credible scientific evidence that the provision of ABA by telehealth modalities is effective or safe. Therefore, direct service provision by telehealth modalities isn’t covered.

Supervision may be conducted entirely in person or may be a combination of in person and remote, but some portion of the supervision (no specific time amount is specified) should be conducted in person.

The following are considered unnecessary duplication of services and therefore not medically necessary in the provision of ABA services:

• More than one program manager/lead behavioral therapist for a member at any one time
• More than one provider group/clinic/agency/organization providing ABA services for a member at any one time
• More than one clinician (program managers/lead behavioral therapists, or RBTs, or program manager/lead behavioral therapist and RBT) providing direct ABA treatment services to the same member at the same time

ABA treatment and a different treatment (such as occupational or speech therapy) to the same patient at the same time is considered not medically necessary. Individuals with ASD can’t adequately focus on and engage in 2 different treatment modalities simultaneously.

RBTs can now provide group therapy as a covered service. However, RBTs can’t assist with occupational or speech therapy because it’s not in their legally-authorized scope of practice.

RBTs should receive weekly clinical supervision from the program manager/lead behavioral therapist as follows for each patient: Generally, 2 hours for every 10 hours of direct service provision, with a minimum of 2 hours weekly when direct service provision is 10 hours per week or less. This is a standard used by the Behavior Analyst Certification Board.

ABA services by a family member, live-in nanny, or au pair are not covered. ABA services by a provider functioning as a live-in nanny or au pair also aren’t covered.

In addition, our plans only cover training for parents and guardians. Nannies and au pairs can’t be trained in their place in parent training.