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Behavioral Health Treatment/Applied Behavioral Analysis/Autism Services Recommendation Form, page 1
Moderate · 47/100Form Complexity Index

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What this form asks for

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The Behavioral Health Treatment/Applied Behavioral Analysis/Autism Services Recommendation Form (ACAPEC-2326-20) is used by physicians or licensed psychologists to document the medical necessity for BHT or ABA services for a Medi-Cal member. This completed form is submitted by the BHT/ABA provider along with a preauthorization request to Anthem Blue Cross, which is contracted with L.A. Care Health Plan. Today, this form can be filled out quickly and accurately using AI-powered services like Instafill.ai, which can also convert non-fillable PDF versions into interactive fillable forms.
Fillable fields40
Pages1
Sections12
Questions that depend on earlier answers5
Form Complexity IndexModerate, 47/100

The AI checks your answers before you download

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

Member Age and Date of Birth Consistency

This check validates that the entered 'Age' is consistent with the 'Date of Birth' provided. It calculates the age from the date of birth and compares it to the value in the age field. This is important for ensuring data accuracy for eligibility and treatment planning. If the values do not match, the form submission will be flagged for manual review to correct the discrepancy.

Member ID Format Validation

This check ensures the 'Member ID' conforms to the specific format required by L.A. Care/Anthem Blue Cross. It verifies the length, character type (alphanumeric), and any required prefixes or suffixes. A valid Member ID is critical for correctly identifying the member in the system and processing the request. An invalid format will result in a rejection, requiring the user to correct the ID before resubmission.

Evaluating Provider Information Completeness

This validation ensures that all fields in the 'Evaluating provider information' section, including name, license number, type, full address, and office number, are filled out. Complete provider information is required for credentialing verification and to facilitate communication regarding the member's case. An incomplete section will prevent form submission and prompt the user to provide the missing details.

Valid Provider License Type

This check verifies that the 'Type' of provider license entered is either 'Physician' or 'Licensed Psychologist', as specified in the form's instructions. This is crucial because only these specific provider types are authorized to make this recommendation. If an invalid provider type is entered, the form will be rejected, as the recommendation would not be considered valid.

Phone and Fax Number Formatting

This validation ensures that all phone number fields ('Phone', 'Office number', 'Fax') follow a standard 10-digit format (e.g., XXX-XXX-XXXX or (XXX) XXX-XXXX). Correctly formatted numbers are essential for successful communication with the member and provider. An improperly formatted number will trigger an error, requiring the user to correct the entry before proceeding.

Primary Behavioral Health Diagnosis Requirement

This check confirms that the 'Primary' behavioral health diagnosis field is not empty. A primary diagnosis is the fundamental justification for recommending BHT/ABA services and is required for determining medical necessity. Failure to provide a primary diagnosis will result in an error, as the request cannot be evaluated without this critical information.

And 7 more checks
  • Behavioral Deficits Justification
  • Mandatory BHT/ABA Recommendation Selection
  • Conditional Requirement for Case Management Need
  • Provider Signature Date Validity
  • Provider Signature Presence
  • ZIP Code Format Validation
  • Logical Dependency for Echolalia

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How to Fill Out ACAPEC-2326-20 Online for Free in 2026

What the AI walks you through.

  1. Navigate to Instafill.ai and upload or select the Behavioral Health Treatment Recommendation Form.
  2. Provide the member's information, including their full name, date of birth, and Medi-Cal Member ID, allowing the AI to populate the correct fields.
  3. Enter your details as the evaluating provider, such as your name, license number, and office contact information.
  4. Input the evaluation details, including the primary and secondary behavioral health diagnoses and any relevant medical diagnoses.
  5. Check the applicable boxes to summarize the member's identified behavioral excesses and/or deficits.
  6. Indicate whether BHT/ABA treatment is recommended and if the family has chosen a provider agency.
  7. Review all the information populated by the AI for accuracy, then digitally sign and date the form to finalize the recommendation.

Common Mistakes in Completing ACAPEC-2326-20

The ones the AI is built to catch.

Entering an Incorrect or Incomplete Member ID
The Member ID is the primary identifier used to link the form to the correct patient file for preauthorization. A simple transcription error, such as swapping digits or omitting a character, can cause the form to be rejected or misfiled, leading to significant delays in processing the request for services. To prevent this, always double-check the ID against the member's insurance card. AI-powered form filling tools like Instafill.ai can help by validating ID formats and cross-referencing saved information to ensure accuracy.
Submitting an Unsigned or Undated Form
A missing provider signature or date is one of the most common and easily avoidable reasons for form rejection. An unsigned form is not legally valid, and a missing date makes it impossible to establish a timeline for the recommendation. This error guarantees the form will be returned to the provider for completion, which can add weeks of delay to a time-sensitive treatment request.
Form Completed by an Unqualified Provider
The form explicitly states it must be completed by a physician or licensed psychologist to be valid. If another type of professional, such as a therapist or case manager, fills it out, the recommendation will be rejected by the insurance plan. This critical error forces the family to schedule a new evaluation with a qualified provider, severely delaying the start of necessary care.
Ignoring Referral Steps When No Agency is Chosen
The form provides clear instructions if a family has not yet chosen a BHT/ABA agency: the provider must fax or email the form to the case management program. Providers sometimes check 'No' but fail to take this required next step, leaving the family in limbo without guidance on how to find a provider. This inaction stalls the entire process and places the burden back on the family to navigate a complex system alone.
Missing Provider License Number or Type
The provider's license number and type are essential for verifying that the recommendation is from a qualified professional as required. Omitting this information prevents the insurance plan from confirming the provider's credentials, leading to an automatic rejection or a request for more information. This stalls the preauthorization process until the provider's credentials can be properly validated.
Failing to Answer the Core Recommendation Question
The entire purpose of the form is to document a formal recommendation for or against BHT/ABA services. Forgetting to check 'Yes' or 'No' for the question 'Is BHT/ABA treatment assessment recommended?' renders the form incomplete and useless. This simple oversight guarantees rejection and forces the provider to resubmit, delaying the member's access to a crucial assessment.
Using Illegible Handwriting on a Printed Form
Since this form is often a non-fillable PDF, providers may print it and fill it out by hand. Illegible handwriting for critical details like the member's name, diagnoses, or provider contact information can make the form impossible to process. This leads to data entry errors or outright rejection, requiring the provider to fill it out again. Tools like Instafill.ai can convert flat PDFs into fillable versions, allowing for clear, typed entries that eliminate legibility issues.
Vague or Incomplete Diagnostic Information
The form asks for primary and secondary behavioral diagnoses, as well as medical diagnoses. Providers may list a diagnosis without specifying if it's primary or secondary, or they might omit relevant medical conditions that influence behavior. This lack of detail can make it difficult for reviewers to assess medical necessity, potentially leading to requests for more information or denial of services.
Underutilizing the 'Other Issues/Concerns' Section
Providers often focus only on the checkboxes and neglect to add crucial context in the 'Other issues/concerns' text field. This section is vital for describing unique behaviors, specific family circumstances, or other factors that don't fit into a category but are essential for justifying the need for treatment. Leaving this blank when important details exist can result in an incomplete clinical picture and weaken the case for medical necessity.
Mismatch Between Date of Birth and Age
Providers sometimes manually enter both the date of birth and the current age, but a miscalculation can create a data conflict. This discrepancy can raise red flags during processing and may require clarification, slowing down the approval. The best practice is to enter only the date of birth and let the system calculate the age, or to be extremely careful if entering both.

Frequently Asked Questions About ACAPEC-2326-20

 

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This plan is for your ACAPEC-2326-20: your own AI agent fills it as often as 5 times a month. To fill other forms and upload your own, choose a Professional plan from your account.
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How does the AI fill out ACAPEC-2326-20?
You answer a few questions in plain words, or upload your insurance card. The AI reads what you give it and puts each answer into the right field of ACAPEC-2326-20, 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 ACAPEC-2326-20 to fill out?
ACAPEC-2326-20 has a Form Complexity Index of 47 out of 100, in the moderate tier: 40 fillable fields across 1 page. 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 this Behavioral Health Treatment Recommendation Form?
This form is used to document a medical necessity recommendation for Behavioral Health Treatment (BHT) or Applied Behavioral Analysis (ABA) services for a Medi-Cal member. It is a required step for the BHT/ABA provider to request preauthorization for these services.
Who is responsible for completing this form?
A physician or a licensed psychologist who has evaluated the member must complete and sign this form to recommend services.
What do I do with the form after it is completed?
Give the completed form to the member's family or their chosen BHT/ABA provider. The BHT/ABA provider will then submit this form with a preauthorization request to Anthem Blue Cross.
What information is needed in the 'Member information' section?
You must provide the member's full name, date of birth, age, phone number, Member ID, and their preferred language for communication.
What should I do if the family has not yet chosen a BHT/ABA provider?
If no provider has been chosen, you must refer the family to the Anthem Blue Cross case management program by faxing or emailing this form as instructed. Ensure the member receives the original copy of the form.
As a provider, who can I contact if I have questions about this form?
Providers with questions can contact the intake line at 1-888-831-2246, selecting option 1 and then option 2 for assistance.
What diagnoses should be included on the form?
You should list the member's primary and secondary behavioral health diagnoses, as well as any other relevant medical diagnoses that support the need for treatment.
How do I complete the 'Summary of identified behavioral excesses and/or deficits' section?
Check all the boxes that apply to the member's condition, such as aggression, speech delay, or lack of social skills. Use the 'Other issues/concerns' field for any behaviors not listed.
Can I use an AI tool to help me fill out this form?
Yes, services like Instafill.ai use AI to accurately auto-fill form fields from your saved information, which can save time and help prevent errors.
The PDF I have is not fillable. How can I fill it out on my computer?
If your PDF is not fillable, you can use a service like Instafill.ai to convert it into an interactive, fillable form. This allows you to easily type in all the required information online.
How can I fill out this L.A. Care recommendation form online?
To fill this form out online, you can upload it to a platform like Instafill.ai. The tool will make the fields interactive so you can type your answers, save your progress, and easily share the completed document.
Who submits the final preauthorization request for BHT/ABA services?
The rendering BHT/ABA provider is responsible for submitting the preauthorization request, which must include this completed recommendation form.
Is this form for all Medi-Cal members in California?
This specific form is for Medi-Cal Managed Care members covered by L.A. Care Health Plan who receive services through Anthem Blue Cross in Los Angeles County.
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