Applied Behavioral Analysis (ABA) Prior Authorization Form (New Hampshire) Instructions
This form contains 122 fields organized into 44 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Adaptive Behavior Treatment Units | ||
| Number of Units | Number |
Enter the total number of 15-minute units for the group adaptive behavior treatment.
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| Adaptive Behaviors Treatment by Technician Units (Code 97153) | ||
| Adaptive Behaviors Treatment by Technician Units Requested | Number |
Enter the number of units requested for adaptive behaviors treatment by technician over a 6-month time period.
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| Adaptive Behaviors Treatment Units (Code 97155) | ||
| 97155 Adaptive Behaviors Treatment Units | Number |
Enter the number of 15-minute units for adaptive behaviors treatment, administered by a physician or other qualified health care professional, corresponding to code 97155.
|
| Authorization Contact Information | ||
| Authorization Contact Person's Name and Phone Number | Text |
Enter the name and phone number of the person to contact for questions and/or authorization decision information.
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| Behavior Identification Assessment Units (Code 97151) | ||
| 97151 Units Requested | Number |
Provide the total number of Behavior Identification Assessment (code 97151) units requested for the 6-month authorization period.
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| Behavior Identification Supporting Assessment Units (Code 97152) | ||
| 97152 Units Requested | Number |
Provide the number of units requested for Behavior Identification Supporting Assessment (Code 97152) over a 6-month time period.
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| Behavioral Health Provider Communication | ||
| Primary Care Provider Name | Text |
Enter the full name of the primary care provider related to the behavioral health communication.
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| Communication Date | Date |
Provide the date of the communication related to the behavioral health provider.
|
| Behavioral Health Provider Care Coordination Description | Text |
Provide a detailed description of the care coordination activities involving the behavioral health provider.
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| Clarity/Medicare Adaptive Behaviors Treatment Units (Code 97155) | ||
| 97155 Adaptive Behaviors Treatment Units | Number |
Enter the total number of 15-minute units requested for code 97155 Adaptive Behaviors Treatment over a 6-month time period.
|
| Clarity/Medicare Family Adaptive Behavior Treatment Guidance Units (Code 97156) | ||
| Family adaptive behavior treatment guidance, administered by physician or other qualified healthcare professionals (15 minute unit) | Text | |
| Family Adaptive Behavior Treatment Guidance Units (Code 97156) | ||
| 97156 Units | Number |
Enter the total number of 15-minute units for family adaptive behavior treatment guidance.
|
| Fifth Service Provider Details | ||
| Fifth Service Provider Name | Text |
Enter the name of the fifth service provider.
|
| Fifth Service Provider Start Date | Date |
Enter the start date of services for the fifth provider.
|
| Fifth Service Provider End Date | Date |
Enter the end date of services for the fifth provider, if applicable.
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| Fifth Treatment Goal | ||
| Fifth Treatment Goal Behavior | Text |
Enter the behavior for the fifth treatment goal, specifying if it is targeted for increase or reduction.
|
| Fifth Treatment Goal Date Identified | Date |
Enter the date when the behavior for the fifth treatment goal was identified.
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| Fifth Treatment Goal | Text |
Enter the specific goal for the fifth treatment.
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| Fifth Treatment Goal Current Functioning | Text |
Enter the current level of functioning related to the fifth treatment goal.
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| Fifth Treatment Goal Target Completion Date | Date |
Enter the target date for completing the fifth treatment goal.
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| First Medication Details | ||
| First Medication | Text |
Enter the name of the first medication.
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| First Dosage | Text |
Provide the dosage for the first medication.
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| First Treatment Length and Response | Text |
Describe the length of treatment and the patient's response to the first medication.
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| First Prescribing Provider | Text |
Enter the name of the prescribing provider for the first medication.
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| First Requested Service Row | ||
| First Requested Service 97151 Units | Number |
Enter the number of units requested for the first requested service (Code 97151) over a 6-month time period.
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| First Service Provider Details | ||
| First Service Provider | Text |
Enter the name of the first other services provider from whom the patient has received ABA services.
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| First Provider Start Date | Date |
Enter the start date when the first service provider began providing ABA services.
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| First Provider End Date | Date |
Enter the end date when the first service provider ceased providing ABA services, if applicable.
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| First Treatment Goal | ||
| First Treatment Goal: Behavior | Text |
Provide a description of the behavior being targeted, indicating if it is for increase or reduction.
|
| First Treatment Goal: Date Behavior Identified | Date |
Enter the date when the behavior was identified.
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| First Treatment Goal: Goal | Text |
Describe the specific goal related to the identified behavior.
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| First Treatment Goal: Current Level of Functioning | Text |
Describe the patient's current level of functioning in relation to the behavior.
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| First Treatment Goal: Target Completion Date | Date |
Enter the target date for the completion of this treatment goal.
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| Fourth Medication Details | ||
| Medication_4 | Text | |
| Dosage_4 | Text | |
| Treatment_length_ptresponse_4 | Text | |
| Prescribing_provider_4 | Text | |
| Fourth Service Provider Details | ||
| Fourth Service Provider Name | Text |
Enter the name of the fourth other service provider.
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| Fourth Service Start Date | Date |
Enter the start date of services for the fourth service provider.
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| Fourth Service End Date | Date |
Enter the end date of services for the fourth service provider, if applicable.
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| Fourth Treatment Goal | ||
| Fourth Behavior Goal | Text |
Provide a description of the behavior targeted for increase or reduction for the fourth treatment goal.
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| Fourth Date Behavior Identified | Date |
Enter the date when the behavior was identified for the fourth treatment goal.
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| Fourth Goal | Text |
Describe the specific goal for the fourth identified behavior.
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| Fourth Current Level of Functioning | Text |
Indicate the patient's current level of functioning related to the fourth treatment goal.
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| Fourth Target Completion Date | Date |
Enter the target date for completing the fourth treatment goal.
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| General | ||
| Clear Form | Button | |
| Signature of treating BCBA professional | Signature | |
| Group Adaptive Behavior Treatment Protocol Technician Units (Code 97154) | ||
| 97154 Group Adaptive Behavior Treatment Protocol Technician Units | Number |
Provide the total number of Group Adaptive Behavior Treatment Protocol Technician (Code 97154) units requested over a 6-month time period, ensuring units are for the authorization period and not per week.
|
| Medication Consultation | ||
| Medication Consultation Yes | Radiobutton |
Check this box if the patient has received a medication consultation.
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| Medication Consultation No | Radiobutton |
Check this box if the patient has not received a medication consultation.
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| Medication Consultation Performed By Whom Line 1 | Text |
Enter the name of the person or entity who performed the medication consultation, first line.
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| Medication Consultation Performed By Whom Line 2 | Text |
Enter the name of the person or entity who performed the medication consultation, second line.
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| Medication Consultation Performed By Whom Line 3 | Text |
Enter the name of the person or entity who performed the medication consultation, third line.
|
| Medication Status | ||
| Medication Status Yes | Radiobutton |
Check this box if the patient is currently receiving medications.
|
| Medication Status No | Radiobutton |
Check this box if the patient is not currently receiving medications.
|
| Member Information | ||
| Member Name | Text |
Please enter the full name of the member, including their last name, first name, and middle initial.
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| Member ID | Text |
Please provide the identification number for the member.
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| Member Date of Birth | Date |
Please enter the member's date of birth.
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| Member Address | Text |
Please enter the full street address of the member, including street, city, state, and zip code.
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| Phone Number | Text |
Please enter the member's primary phone number.
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| Diagnosis ICD-10 | Text |
Please enter the member's ICD-10 diagnosis code.
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| Multiple-Family Group Adaptive Behavior Treatment Guidance Units (Code 97157) | ||
| 97157 Units Requested | Number |
Provide the total number of multiple-family group adaptive behavior treatment guidance units requested for a 6-month time period.
|
| Occupational Therapist Communication | ||
| Occupational Therapist Provider Name | Text |
Enter the name of the occupational therapist provider.
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| Occupational Therapist Communication Date | Date |
Provide the date of the communication regarding the occupational therapist.
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| Occupational Therapist Specialty Details | Text |
Specify additional details regarding the occupational therapist specialty.
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| Occupational Therapist Care Coordination Description | Text |
Provide a description of the care coordination for the occupational therapist.
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| Parent/Guardian Participation Description | ||
| Parent/Guardian Participation Description 1 | Text |
Enter the first line of the description detailing the parent or guardian's participation in the ABA treatment.
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| Parent/Guardian Participation Description 2 | Text |
Enter the second line of the description detailing the parent or guardian's participation in the ABA treatment.
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| Parent/Guardian Participation Description 3 | Text |
Enter the third line of the description detailing the parent or guardian's participation in the ABA treatment.
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| Patient Contact Information | ||
| Number of Patient Encounters | Number |
Enter the total number of times the patient has been seen.
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| Date of Most Recent Patient Contact | Date |
Enter the date of the most recent contact with the patient.
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| Primary Care Provider Communication | ||
| PCP Provider Name | Text |
Enter the name of the primary care provider.
|
| PCP Communication Date | Date |
Enter the date of communication with the primary care provider.
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| PCP Communication Description | Text |
Provide a description of the care coordination with the primary care provider.
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| Prior Authorization Approval Type | ||
| Request for Initial Evaluation | Radiobutton |
Check this box if prior authorization is for an initial evaluation, which requires submitting pages 1-3 along with a comprehensive diagnostic evaluation.
|
| Request for Continued Services | Radiobutton |
Check this box if prior authorization is for continued services, which requires submitting pages 1-6 of the form.
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| Provider Information | ||
| Agency Name | Text |
Enter the name of the agency providing services.
|
| NPI Number | Text |
Enter the National Provider Identifier (NPI) number for the agency.
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| BCBA NPI Number | Text |
Enter the National Provider Identifier (NPI) number for the BCBA professional.
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| BCBA License Number | Text |
Enter the license number for the BCBA professional.
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| BCBA Professional Name | Text |
Enter the full name of the BCBA professional who will perform or supervise services.
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| Provider Address | Text |
Enter the full street address, city, state, and zip code for the provider.
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| Tax ID Number | Text |
Enter the Tax Identification (Tax ID) number for the provider.
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| Fax Number | Text |
Enter the fax number for the provider.
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| Request Details | ||
| Today's Date | Date |
Enter the current date of the request.
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| Requested Sessions Start Date | Date |
Enter the start date for the requested range of sessions.
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| Requested Sessions End Date | Date |
Enter the end date for the requested range of sessions.
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| School-based Services Provider Communication | ||
| School-based Services Provider Name | Text |
Please provide the name of the school-based services provider.
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| School-based Services Communication Date | Date |
Please provide the date of the communication regarding school-based services.
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| School-based Services Communication Description | Text |
Please provide a description of the care coordination for school-based services.
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| Second Medication Details | ||
| Second Medication Name | Text |
Enter the name of the second medication.
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| Second Medication Dosage | Text |
Provide the dosage for the second medication.
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| Second Medication Treatment Length and Patient Response | Text |
Describe the treatment length and the patient's response to the second medication.
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| Second Medication Prescribing Provider | Text |
Enter the name of the prescribing provider for the second medication.
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| Second Requested Service Row | ||
| Second Service Units Requested | Number |
Enter the number of units requested for the adaptive behaviors treatment (ABA code 97153) over a 6-month time period.
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| Second Service Provider Details | ||
| Second Service Provider Name | Text |
Provide the name of the second service provider from whom the patient has received ABA services.
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| Second Service Start Date | Date |
Enter the start date of services provided by the second service provider.
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| Second Service End Date | Date |
Enter the end date of services provided by the second service provider.
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| Second Treatment Goal | ||
| Second Behavior | Text |
Provide a description of the second behavior being targeted, indicating whether it should be increased or reduced.
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| Second Date Behavior Identified | Date |
Enter the date when the second behavior was identified.
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| Second Goal | Text |
Describe the specific second treatment goal related to the identified behavior.
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| Second Current Level of Functioning | Text |
Describe the patient's current level of functioning pertaining to the second targeted behavior.
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| Second Target Completion Date | Date |
Enter the target date for the completion of the second treatment goal.
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| Signature Date | ||
| Signature Date | Date |
Provide the date the treating BCBA professional signed the form.
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| Special Services Description | ||
| Special Service 1 Description | Text |
Please provide a description of the first special service the patient is receiving at school or in the community.
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| Special Service 2 Description | Text |
Please provide a description of the second special service the patient is receiving at school or in the community.
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| Special Service 3 Description | Text |
Please provide a description of the third special service the patient is receiving at school or in the community.
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| Special Services Inquiry | ||
| Special Services Inquiry Yes | Radiobutton |
Check this box if the patient is receiving any special services at school or in the community.
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| Special Services Inquiry No | Radiobutton |
Check this box if the patient is not receiving any special services at school or in the community.
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| Third Medication Details | ||
| Third Medication | Text |
Provide the name of the third medication.
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| Third Medication Dosage | Text |
Enter the dosage for the third medication.
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| Third Medication Treatment Length and Patient Response | Text |
Describe the treatment length and the patient's response to the third medication.
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| Third Medication Prescribing Provider | Text |
Provide the name of the prescribing provider for the third medication.
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| Third Requested Service Row | ||
| Group adaptive behavior treatment protocol technician (15 minute unit) | Text | |
| Third Service Provider Details | ||
| Third Other Service Provider | Text |
Enter the name of the third other service provider.
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| Third Start Date | Date |
Provide the start date for the third service provider.
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| Third End Date | Date |
Provide the end date for the third service provider, if applicable.
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| Third Treatment Goal | ||
| Third Treatment Goal Behavior | Text |
Specify the behavior being addressed for the third treatment goal and indicate if it is targeted for increase or reduction.
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| Third Treatment Goal Date Identified | Date |
Enter the date when the behavior for the third treatment goal was first identified.
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| Third Treatment Goal | Text |
Describe the specific goal for the third treatment.
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| Third Treatment Goal Current Functioning Level | Text |
Provide the current level of functioning related to the third treatment goal.
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| Third Treatment Goal Target Completion Date | Date |
Enter the target date for the completion of the third treatment goal.
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