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Yes! You can use AI to fill out Applied Behavior Analysis Concurrent Service Authorization Request Form (CPT Codes 97153, 97154, 97155, 97156, 97157, 97158, 0373T) – Virginia Department of Medical Assistance Services

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Applied Behavior Analysis Concurrent Service Authorization Request Form (CPT Codes 97153, 97154, 97155, 97156, 97157, 97158, 0373T) – Virginia Department of Medical Assistance Services, page 1
Moderate · 59/100Form Complexity Index

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What this form asks for

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The Applied Behavior Analysis (ABA) Concurrent Service Authorization Request Form is an official Virginia Department of Medical Assistance Services (DMAS) document required for providers to obtain continued Medicaid authorization for ABA therapy services (CPT codes 97153–97158 and 0373T) for members currently enrolled in treatment. The form captures member and provider details, requested service units by CPT code, medication updates, care coordination activities, treatment progress, and recovery and discharge planning to demonstrate ongoing medical necessity. It is effective for dates of service on or after September 1, 2025, and must be accompanied by supporting clinical documentation including an updated Individual Service Plan and treatment progress summary. Today, providers can fill out this detailed form quickly and accurately using AI-powered services like Instafill.ai, which can also convert non-fillable PDF versions into interactive fillable forms.
Fillable fields106
Pages6
Sections33
Form Complexity IndexModerate, 59/100

The AI checks your answers before you download

16 checks built for this form, so a wrong date or a missing answer is caught before anyone else sees it.

Member Date of Birth Format and Validity

Validates that the Member Date of Birth is entered in a recognized date format (MM/DD/YYYY) and represents a logically valid date (e.g., not a future date, not more than 120 years in the past). This field is critical for confirming member identity and ensuring the correct individual's record is being processed. If the date is missing, improperly formatted, or logically impossible, the authorization request cannot be accurately matched to the correct Medicaid member record.

Medicaid ID Format and Presence

Validates that the Member Medicaid ID is present and conforms to the expected Virginia Medicaid identifier format (typically a numeric string of a defined length). This identifier is the primary key used to link the authorization request to the member's Medicaid account and eligibility record. A missing, malformed, or incorrect Medicaid ID will result in the request being unprocessable or matched to the wrong member, potentially causing claim denials or compliance issues.

Group NPI and LBA/LMHP NPI Format Validation

Validates that both the Group NPI and the LBA/LMHP NPI fields contain exactly 10-digit numeric values, consistent with the National Provider Identifier standard established by CMS. NPIs are required to identify the billing and rendering providers and are used to verify provider enrollment and credentialing with the health plan. If either NPI is missing, non-numeric, or not 10 digits, the authorization cannot be properly attributed to a credentialed provider, which may result in denial of the request.

Provider Tax ID Format Validation

Validates that the Provider Tax ID is entered in the standard EIN format (XX-XXXXXXX, a 9-digit number with a hyphen after the second digit) or as a 9-digit numeric string. The Tax ID is required for billing and payment processing and must match the provider's enrollment record with DMAS. An incorrectly formatted or missing Tax ID will prevent proper provider identification and may result in payment errors or authorization rejection.

Phone Number Format Validation for All Phone Fields

Validates that all phone number fields — Member Phone Number, Parent/Legal Guardian Phone Number, Provider Phone, Clinical Contact Phone Number, and Provider Fax — are entered in a standard 10-digit U.S. phone number format (e.g., (XXX) XXX-XXXX or XXX-XXX-XXXX). Valid contact numbers are essential for the health plan to reach the member, guardian, or clinical contact when additional information is needed to process the authorization. Missing or improperly formatted phone numbers may delay or prevent timely communication and processing of the request.

Proposed Service Date Range Logical Consistency

Validates that the Proposed/Requested Service From Date is earlier than or equal to the Proposed/Requested Service To Date, and that both dates fall on or after the effective date of 09/01/2025. The service date range defines the authorization period and must be logically coherent to ensure services are approved for a valid future or concurrent timeframe. If the start date is after the end date, or if dates fall before the policy effective date, the authorization period is invalid and the request must be corrected before processing.

And 10 more checks
  • CPT Code Total Units Calculation Accuracy
  • Total Weekly Hours Threshold Triggers Schedule Requirement
  • Retro Review Request Indicator Completeness
  • Assessment/Addendum Completion Date Presence and Validity
  • LMHP Printed Name and Credentials Required for Attestation
  • Provider Email Address Format Validation
  • Clinical Contact Name Includes Credentials
  • Care Coordination Activities Description Completeness
  • Discharge Planning Fields Completeness
  • Member Full Name Consistency Across Form Pages

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How to Fill Out ABA Concurrent Authorization Form Online for Free in 2026

What the AI walks you through.

  1. Navigate to Instafill.ai and upload the ABA Concurrent Service Authorization Request Form PDF or select it from the available form library to begin filling it out online.
  2. Complete the Member Information section by entering the member's first and last name, Medicaid ID, date of birth, gender, plan ID, street address, phone number, and parent/legal guardian name and phone number.
  3. Complete the Provider Information section by entering the organization name, Group NPI, LBA/LMHP NPI, provider tax ID, phone, email, servicing address, fax number, and clinical contact name, credentials, and phone number.
  4. Fill in the Request for Approval of Services section, indicating whether this is a retro review request, the current service start date if applicable, and the proposed service date range (from/to).
  5. Enter the requested service details for each applicable CPT code (97153, 97154, 97155, 97156, 97157, 97158, and/or 0373T), including total daily hours/days per week, total weekly hours, total hours requested, total units requested, and any relevant notes; also complete the medication update table with current medications, doses, frequencies, and any changes since the last authorization.
  6. Complete Sections I through III by documenting care coordination activities and services, attaching or summarizing treatment progress (including ISP goals, graphical data, family involvement, and generalization progress), and filling in the recovery and discharge planning fields including barriers, outreach needs, vision for discharge level of care, and estimated discharge date.
  7. Review all sections for completeness, attach required supporting documentation (CNA addendum, updated ISP, progress summary, and schedule if 20+ hours/week are requested), then have the supervising LMHP, LMHP-R/S/RP, or LABA sign, print their name, enter their credentials and attestation date, and submit the completed form to the health plan.

Common Mistakes in Completing ABA Concurrent Authorization Form

The ones the AI is built to catch.

Incorrect or mismatched NPI numbers for Group and LBA/LMHP
Providers frequently confuse the Group NPI with the individual LBA/LMHP NPI, entering the same number in both fields or transposing digits. These are distinct identifiers — the Group NPI belongs to the organization, while the LBA/LMHP NPI belongs to the licensed individual clinician. Submitting mismatched or incorrect NPIs will result in authorization denial or processing delays. Always verify both NPIs against your credentialing records before submission, and tools like Instafill.ai can help auto-populate and validate NPI numbers to prevent this error.
Arithmetic errors in CPT code unit calculations
The form requires a multi-step calculation: daily hours × days per week = weekly hours, then weekly hours × number of weeks = total hours, then total hours × 4 = total units. Providers commonly make errors at one or more of these steps, especially when rounding partial hours or mixing up the number of weeks in the authorization period. Incorrect unit totals can lead to underpayment, overpayment, or outright denial of the authorization request. Double-check every calculation independently for each CPT code row, and consider using a spreadsheet or an AI-assisted tool like Instafill.ai that can automatically compute these values.
Failing to include the schedule for requests exceeding 20 hours per week
When requesting more than 20 hours (80 units) per week, providers must include a detailed, individualized schedule of activities in the 'Schedule' section at the end of the form or as an uploaded attachment. Many providers overlook this requirement entirely or submit a generic clinic-based schedule that does not distinguish between therapeutic and non-therapeutic/recreational time. This omission is a common cause of authorization denial for high-intensity requests. Carefully review the threshold requirement and ensure the schedule is individualized, session-specific, and clearly tied to treatment goals.
Omitting or incorrectly documenting medication changes
Providers often leave the medication update section blank or fail to note whether a medication is new, ended, or changed in dose or frequency since the last authorization. This section is critical for demonstrating clinical continuity and medical necessity. Reviewers use medication information to assess the member's current clinical status, and incomplete entries can raise questions about the quality of care coordination. For each medication listed, explicitly state whether it is unchanged, new, ended, or modified, even if the change seems minor.
Leaving the Retro Review checkbox unanswered or incorrectly marked
Providers sometimes skip the Retro Review question or mark it incorrectly, not realizing that a retroactive review requires different supporting documentation and has specific submission timelines. Failing to correctly identify a request as retroactive can result in the request being processed under the wrong review pathway, leading to denial. Review the dates of service carefully — if services have already begun or been delivered, the retro review box must be marked 'Yes' and the service start date must be accurately entered.
Incomplete or missing care coordination documentation in Section I
Section I requires providers to list all medical, behavioral, and community services the member has participated in since the last authorization, including any changes in frequency or intensity. Providers frequently list service names without providing provider contact information or frequency details, or they fail to describe care coordination activities with those services. Incomplete care coordination documentation signals poor clinical oversight and can jeopardize authorization approval. Ensure every service listed includes provider contact info, frequency, and a clear notation of any changes since the last authorization.
Submitting a generic or non-individualized ISP and treatment progress summary
Section II requires a detailed, individualized treatment progress summary including graphical data on each goal, family involvement, generalization of skills, and discharge planning progress. Providers often submit templated or boilerplate progress notes that do not reflect the specific member's data, or they omit the graphical presentation of goal progress entirely. Reviewers are trained to identify non-individualized documentation, and such submissions are frequently returned or denied. Each goal must have objective, measurable data presented graphically, and all narrative sections must be specific to the individual member.
Using percentages as the sole objective measure without clear computation basis
The form explicitly cautions against using percentages as objective measures unless the percentage completion is obvious and easily computed. Providers habitually write goals such as '80% accuracy' without defining what constitutes a trial, how trials are counted, or who measures them. This makes progress tracking ambiguous and difficult for reviewers to verify. Instead, use frequency counts of observable behaviors, severity ratings with clearly defined anchors, or standardized validated assessments, and always describe how, how often, and by whom the measure will be tracked.
Missing or vague discharge planning responses in Section III
Section III asks for specific, individualized responses about what recovery looks like, identified barriers, necessary supports, vision for level of care at discharge, and a best-estimate discharge date. Providers frequently leave fields blank, provide one-sentence generic answers, or fail to provide a discharge date estimate because they feel it is too uncertain. However, the form explicitly states that discharge planning should begin at first contact, and vague or missing responses suggest a lack of recovery-oriented planning. Provide thoughtful, individualized answers for each question, even if the discharge date is an estimate with a noted range.
Incorrect or missing credentials and signature on the attestation section
The attestation at the end of the form must be signed by an LMHP, LMHP-R, LMHP-S, LMHP-RP, or LABA — not by a technician, BCBA candidate, or other unlicensed staff. Providers sometimes have the wrong staff member sign, omit credentials entirely, or leave the assessment completion date blank. An invalid signature invalidates the entire authorization request. Verify that the signing clinician holds one of the specifically listed credentials, include their full printed name and credentials, and ensure the assessment or addendum completion date is accurately recorded.
Entering proposed service dates that do not align with the authorization period or are left blank
The 'From' and 'To' date fields for the proposed/requested service period are frequently left blank, entered in inconsistent formats (e.g., MM/DD/YY vs. MM/DD/YYYY), or set to dates that fall outside the allowable authorization window or before the effective date of 09/01/2025. Incorrect or missing service dates prevent the health plan from processing the request and may result in gaps in coverage. Always use a consistent date format, confirm the requested period aligns with plan authorization windows, and verify that the start date is not prior to the form's effective date. AI-powered tools like Instafill.ai can automatically validate date formats and flag inconsistencies.
Failing to repeat Member Full Name and Medicaid number on continuation pages
The form has multiple pages, each with fields for 'Member Full Name' and 'Medicaid #' at the top. Providers often complete these fields on the first page but leave them blank on subsequent pages (pages 2–6), assuming the information carries over. If pages become separated during faxing or electronic processing, incomplete continuation pages cannot be matched to the correct member record, causing significant processing delays or loss of documentation. Always fill in the member's full name and Medicaid number on every page of the form before submission.

Frequently Asked Questions About ABA Concurrent Authorization Form

 

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How does the AI fill out ABA Concurrent Authorization Form?
You answer a few questions in plain words, or upload a document you already have. The AI reads what you give it and puts each answer into the right field of ABA Concurrent Authorization Form, on every page, in seconds. It checks the answers against the form's own rules, and you review and change anything before you download, print or sign.
What happens to my information?
It is encrypted in transit and at rest, and it is never used to train AI.
How complex is ABA Concurrent Authorization Form to fill out?
ABA Concurrent Authorization Form has a Form Complexity Index of 59 out of 100, in the moderate tier: 106 fillable fields across 6 pages. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.
What is the purpose of the ABA Concurrent Service Authorization Request Form?
This form is used to request continued (concurrent) authorization for Applied Behavior Analysis (ABA) services through Virginia's Department of Medical Assistance Services (DMAS). It is required when a member is already receiving ABA services and needs ongoing approval for CPT codes 97153, 97154, 97155, 97156, 97157, 97158, and/or 0373T. The form is effective for services dated September 1, 2025 and after.
Who needs to complete and sign this form?
The form must be completed by the ABA provider organization and signed by a Licensed Mental Health Professional (LMHP, LMHP-R, LMHP-S, LMHP-RP) or a Licensed Behavior Analyst (LABA). The signing clinician is attesting that the member meets medical necessity criteria for the requested ABA services.
What documents must be submitted along with this form?
All concurrent authorization requests must include the completed form with all sections filled out. Additionally, you must submit the original Comprehensive Needs Assessment (CNA) with an addendum, an updated Individual Service Plan (ISP), and a summary of the youth's treatment progress including graphical data on each goal. Requests exceeding 20 hours (80 units) per week must also include an individualized schedule of activities.
What additional requirements apply if requesting more than 20 hours per week?
If requesting 20 or more hours (80 or more units) per week, you must include a detailed, individualized schedule of activities that structures the service sessions and explains how each activity facilitates the behavior modification plan. Each session must be clearly linked to treatment goals, and clinic-based schedules must distinguish between therapeutic time and recreational or non-reimbursable activities. A general clinic schedule is not sufficient.
How do I calculate the total units requested for each CPT code?
Each CPT code is billed in 15-minute increments, so total units are calculated by multiplying the total hours requested by 4. For example, if you request 240 total hours for CPT 97153, the total units would be 960. Total hours are calculated by multiplying the total weekly hours by the number of weeks in the requested authorization period.
What information is required in the Treatment Progress section (Section II)?
Section II requires a graphical presentation of progress on each ISP goal and objective, an overview of family involvement, a summary of progress toward generalization of skills across multiple settings, and a description of progress toward discharge including plans to reduce services. The ISP must include person-centered treatment goals, objective measures, interventions, dosage, and identified strengths and barriers.
What should be included in the Recovery and Discharge Planning section (Section III)?
Section III requires you to describe what progress or recovery looks like for the individual, identify barriers to recovery, outline outreach or additional supports needed, describe the anticipated level of care at discharge, and provide a best estimate of the discharge date. Discharge planning should begin at the first contact and reflect the most current understanding of the member's recovery trajectory.
What is a Retro Review Request, and when should I select 'Yes'?
A Retro Review Request is when you are seeking authorization for services that have already been provided rather than for future services. You should select 'Yes' for the Retro Review option if you are requesting approval retroactively for ABA services already delivered to the member.
What provider information is required on this form?
You must provide the organization name, Group NPI number, LBA/LMHP NPI number, Provider Tax ID, provider phone number, email, fax, and servicing address. You also need to include the clinical contact name with credentials and their phone number, as this is the person the health plan will contact for additional clinical information if needed.
How should medication updates be reported on this form?
For each medication the member is taking, you must list the medication name, dose, and frequency. If there have been any changes since the last authorization, you must note whether the medication is new, has ended, or has had a change in dose or frequency. Up to four medications can be listed directly on the form.
What care coordination information needs to be included in Section I?
Section I requires you to list all medical, behavioral, and community services or supports the member has participated in since the last authorization, including the provider contact information, frequency, and any changes (new, ended, or changed in frequency/intensity). You must also describe the care coordination activities that occurred between these services since the last authorization.
Can AI tools help me fill out this ABA Concurrent Authorization form?
Yes, AI-powered services like Instafill.ai can help you accurately auto-fill form fields, saving significant time especially given the complexity and length of this form. These tools can help ensure all required fields are completed correctly and consistently across multiple authorization requests.
How can I fill out this form online using Instafill.ai?
You can upload the ABA Concurrent Authorization form to Instafill.ai, where the AI will guide you through each field and auto-fill information based on the member and provider data you provide. This is especially helpful for calculating CPT code units, organizing medication updates, and ensuring all required sections are completed before submission.
What if the PDF version of this form is not fillable?
If you have a flat, non-fillable PDF version of this form, Instafill.ai can convert it into an interactive fillable form so you can type directly into the fields digitally. This eliminates the need to print and handwrite the form, reducing errors and saving time.
What are the ISP goal-writing requirements for this concurrent authorization?
ISP treatment goals must be person-centered, recovery-oriented, and trauma-informed, written in collaboration with the individual using understandable language. Each goal must have objective measures (such as frequency counts or severity ratings), a description of how progress will be tracked, and clearly defined interventions. Goals should leverage individual strengths and address barriers to participation in care.
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