Fill out Medicaid authorization forms
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Medicaid authorization forms — particularly prior authorization requests for Applied Behavior Analysis (ABA) therapy — are official documents that healthcare providers must submit to Medicaid programs or managed care organizations before delivering certain behavioral health services. These forms establish medical necessity, document clinical details, and ensure that services like ABA therapy are appropriately coordinated and covered under a member's Medicaid plan. Because Medicaid programs are administered at the state level, the specific forms and requirements vary: providers in Virginia, Louisiana, Arkansas, and other states each work with their own versions tailored to local program rules.
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About Medicaid authorization forms
These forms are typically completed by licensed behavioral health providers, board-certified behavior analysts (BCBAs), and clinical staff seeking authorization for ABA services on behalf of Medicaid-enrolled patients — often children diagnosed with autism spectrum disorder. The process requires detailed clinical information including diagnoses, treatment goals, service codes, and supporting documentation, making accuracy essential. A missing field or incorrect CPT code can delay authorization and interrupt care.
Given the complexity and volume of these requests, tools like Instafill.ai use AI to fill out these forms in under 30 seconds, helping providers handle the paperwork quickly and accurately so they can focus on patient care.
Forms in This Category
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How to Choose the Right Form
All three forms on this page are prior authorization requests for Applied Behavior Analysis (ABA) therapy billed to Medicaid — but each serves a different state or program. The fastest way to choose is to match your state and payer to the right form.
By State and Medicaid Program
- Virginia providers billing through the state's fee-for-service Medicaid program should use the Applied Behavior Analysis Concurrent Service Authorization Request Form (DMAS). This form is specifically for *ongoing/concurrent* authorizations (not initial requests) and covers CPT codes 97153–97158 and 0373T. It requires an updated Individual Service Plan and is effective for dates of service on or after September 1, 2025.
- Louisiana providers working with Healthy Blue Medicaid Managed Care members should use the Medicaid Managed Care ABA Authorization Request (BLAPEC-1989-20). This form covers both initial assessments and ABA therapy (CPT codes 97151–97158) and is designed for BCBAs, licensed psychologists, and other qualified professionals billing under Healthy Blue Louisiana.
- Arkansas providers requesting authorization through Summit Community Care should use the Arkansas Medicaid ABA Authorization Request (ARSMT-CD-095155-25). This form focuses on CPT codes 97151, 97153, 97155, and 97156, and requires detailed clinical documentation including DSM-V diagnoses, behavior reduction plans, and functional assessment results.
Quick Decision Checklist
- Are you in Virginia billing state Medicaid? → DMAS Concurrent Authorization form
- Are you in Louisiana billing Healthy Blue? → BLAPEC-1989-20
- Are you in Arkansas billing Summit Community Care? → ARSMT-CD-095155-25
> Tip: All three forms require supporting clinical documentation (e.g., treatment plans, functional assessments). Gather those materials before you start filling out the form to avoid delays in authorization.
Form Comparison
| Form | Purpose | Who Files It | When to Use |
|---|---|---|---|
| Applied Behavior Analysis Concurrent Service Authorization Request Form (CPT Codes 97153, 97154, 97155, 97156, 97157, 97158, 0373T) – Virginia Department of Medical Assistance Services | Request continued Medicaid authorization for ongoing ABA therapy services | ABA providers in Virginia Medicaid program | For members already enrolled in ABA treatment needing continued services |
| Medicaid Managed Care Applied Behavior Analysis — Authorization Request (Healthy Blue Louisiana, BLAPEC-1989-20) | Request prior authorization for new or ongoing ABA services | Licensed psychologists, BCBAs, qualified health care professionals in Louisiana | Before initiating or continuing ABA services for Louisiana Medicaid recipients |
| Arkansas Medicaid Applied Behavioral Analysis (ABA) Authorization Request | Request prior authorization for ABA therapy from Summit Community Care | Behavioral health providers and BCBAs in Arkansas Medicaid program | Before rendering ABA services to Arkansas Medicaid-enrolled members |
Tips for Medicaid authorization forms
Medicaid ABA authorization forms vary significantly by state and managed care plan — Virginia DMAS, Healthy Blue Louisiana, and Arkansas Summit Community Care each use different forms with different requirements. Submitting the wrong form or an outdated version can result in delays or denials. Always confirm you have the current, plan-specific form before beginning.
These forms require detailed clinical information including DSM-V diagnoses, current medications, functional assessment results, treatment goals, and behavior reduction plans. Having an updated Individual Service Plan, progress summaries, and BCBA credentials on hand before filling out the form will prevent incomplete submissions. Missing supporting documentation is one of the most common reasons prior authorization requests are delayed.
Each ABA authorization form requires you to specify exact CPT codes (such as 97151–97158 or 0373T) alongside the number of requested hours and units. Mismatches between the CPT codes listed and the clinical justification provided are a frequent cause of denials. Double-check that each code's requested units align with what is documented in the treatment plan.
AI-powered tools like Instafill.ai can fill out complex Medicaid prior authorization forms with high accuracy in under 30 seconds, saving providers significant administrative time — especially when managing multiple authorizations across different states or plans. Instafill.ai also converts non-fillable PDF versions into interactive forms, making the process even smoother. Your data stays secure throughout the entire process.
Payers reviewing these forms are specifically looking for evidence that ABA services are medically necessary and clinically justified. Be explicit about how treatment goals tie to the member's diagnosis, functional deficits, and progress or lack thereof. Vague or generic justifications are a leading cause of authorization denials.
For pediatric Medicaid members, authorization reviewers will check whether requested ABA services overlap with services already covered under an Individualized Family Service Plan (IFSP) or Individualized Education Program (IEP). Clearly document that the requested services are non-duplicative and address needs not covered by school or early intervention programs.
These forms require precise provider NPI numbers, BCBA certification details, taxonomy codes, and practice addresses — errors here can cause the authorization to be rejected or attributed to the wrong provider. Maintain a reference sheet with your organization's billing and credentialing details to ensure consistency across all submissions.
Concurrent authorization requests (for members already in treatment) should be submitted well before the current authorization period expires to avoid gaps in service. Build a tracking system to monitor expiration dates across all active authorizations, and note that some forms, like the Virginia DMAS form, have specific effective dates tied to service periods.
Frequently Asked Questions
Medicaid ABA authorization forms are official documents that behavioral health providers and BCBAs must submit to obtain prior approval before delivering ABA therapy services to Medicaid-enrolled members. These forms demonstrate medical necessity by capturing diagnosis information, treatment goals, service codes, and clinical justification. Each state or managed care organization has its own version of the form with specific requirements.
This category currently includes three forms: one for Virginia Medicaid (DMAS) for concurrent ABA service authorization, one for Louisiana Medicaid Managed Care through Healthy Blue, and one for Arkansas Medicaid through Summit Community Care. Each form is specific to its state's program and managed care requirements, so providers should use the form that corresponds to the member's state and insurance plan.
These forms are typically submitted by licensed behavioral health providers, Board-Certified Behavior Analysts (BCBAs), and other qualified healthcare professionals who are enrolled as Medicaid providers in their respective states. The forms must be completed on behalf of Medicaid-enrolled members who require ABA therapy services, and the submitting provider must meet the credentialing requirements of the specific state or managed care plan.
An initial authorization request is submitted before ABA services begin to establish medical necessity for a new member. A concurrent (or continued) authorization request, like Virginia's DMAS form, is submitted for members already enrolled in ABA treatment who need ongoing services beyond the initially approved period. Concurrent requests typically require additional documentation such as treatment progress summaries and updated Individual Service Plans to justify continued care.
Most ABA authorization forms require accompanying clinical documentation such as a functional behavior assessment, an updated Individual Service Plan (ISP) or treatment plan, progress notes, DSM-V diagnoses, and current medication lists. Some forms also require attestations that services are not duplicating those already covered under an IFSP or IEP. Providers should review the specific requirements for each form before submitting.
Submission methods vary by state and managed care organization. Virginia DMAS forms are submitted through the state's Medicaid system, while Louisiana's Healthy Blue and Arkansas's Summit Community Care forms are submitted directly to those managed care organizations, typically via their provider portals, fax, or mail. Providers should consult the specific plan's provider guidelines for the correct submission channel.
It is generally recommended to submit prior authorization requests well before the requested service start date or before the current authorization period expires, to avoid gaps in service coverage. Exact timelines vary by state and managed care plan, so providers should refer to the specific plan's policies for submission deadlines and processing timeframes.
Yes, AI-powered tools like Instafill.ai can fill out Medicaid ABA authorization forms in under 30 seconds by accurately extracting and placing data from source documents such as clinical records, treatment plans, and member information files. Instafill.ai can also convert non-fillable PDF versions of these forms into interactive, fillable formats, making the process faster and reducing the risk of manual data entry errors.
Manually completing ABA authorization forms can take anywhere from 20 minutes to over an hour, depending on the complexity of the member's case and the amount of clinical documentation required. Using AI tools like Instafill.ai, providers can complete these detailed forms in under 30 seconds by automatically populating fields from existing clinical documents, significantly reducing administrative burden.
The most commonly referenced CPT codes across these forms include 97151 (behavior identification assessment), 97153 (adaptive behavior treatment), 97154 (group adaptive behavior treatment), 97155 (protocol modification), 97156 (family adaptive behavior treatment guidance), 97157 (multiple-family group), 97158 (group protocol modification), and 0373T (adaptive behavior treatment with protocol modification). Providers must specify the number of requested units or hours for each applicable code.
If a prior authorization request is denied, providers and members typically have the right to appeal the decision through the managed care organization's formal appeals process. Denials are often due to insufficient clinical documentation, missing information on the form, or a determination that services are not medically necessary. Submitting a complete and well-documented authorization request the first time can help reduce the likelihood of denial.
No, ABA authorization forms vary significantly by state and managed care organization. Each plan has its own form with different fields, required documentation, CPT code sets, and submission procedures. Providers operating in multiple states must ensure they are using the correct, up-to-date form for the specific state and managed care plan covering the member receiving services.
Glossary
- Prior Authorization (PA)
- Approval required from Medicaid or a managed care plan before certain services can be provided and reimbursed. Without prior authorization, claims for those services may be denied.
- Applied Behavior Analysis (ABA)
- A therapy based on the science of learning and behavior, most commonly used to support individuals with autism spectrum disorder. It involves assessing behavior, setting treatment goals, and measuring progress over time.
- BCBA (Board-Certified Behavior Analyst)
- A credentialed professional certified by the Behavior Analyst Certification Board to design and oversee ABA therapy programs. Many authorization forms require a BCBA's signature and credential number.
- CPT Code
- Current Procedural Terminology codes are standardized numeric codes used to identify specific medical, surgical, or behavioral health services billed to insurance. ABA services use codes such as 97151–97158 and 0373T.
- Medical Necessity
- A standard used by Medicaid and managed care plans to determine whether a requested service is clinically appropriate, necessary, and likely to improve the member's condition. Authorization requests must demonstrate medical necessity to be approved.
- DMAS (Department of Medical Assistance Services)
- Virginia's state agency responsible for administering the Medicaid and CHIP programs, including setting coverage policies and authorization requirements for services like ABA therapy.
- Concurrent Service Authorization
- An authorization request submitted for a member who is already actively receiving a service, used to continue treatment beyond an initial approval period. It requires documentation of ongoing progress and continued medical necessity.
- Individual Service Plan (ISP)
- A written document outlining a member's specific treatment goals, interventions, and measurable outcomes for ABA or other behavioral health services. It is typically required as supporting documentation with authorization requests.
- DSM-V Diagnosis
- A clinical diagnosis based on the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, the standard reference used by behavioral health providers to classify conditions. Authorization forms require DSM-V diagnosis codes to establish eligibility for ABA services.
- Managed Care Organization (MCO)
- A private health plan contracted by a state Medicaid agency to coordinate and manage care for Medicaid members, such as Healthy Blue Louisiana or Summit Community Care. Members enrolled in an MCO must seek authorizations through that specific plan rather than the state directly.