MetroPlusHealth Applied Behavior Analysis (ABA) Universal ABA Request Form Instructions
This form contains 72 fields organized into 20 sections. Below is a complete list of every field, its type, and what information is expected.
| Field Name | Type | Description |
|---|---|---|
| Authorization Start Date | ||
| Authorization Start Date | Date |
Enter the start date for the authorization.
|
| Diagnostic Information | ||
| Diagnosis | Text |
Please provide the patient's diagnosis.
|
| Subtype | Text |
Please specify the subtype of the diagnosis.
|
| Specifier | Text |
Please provide any specific specifier related to the diagnosis.
|
| Symptoms | Text |
Please list the patient's symptoms.
|
| Diagnosed By | Text |
Please enter the name of the professional who provided the diagnosis.
|
| Diagnoser License Number | Text |
Please provide the license number of the professional who provided the diagnosis.
|
| Date of Diagnosis | Date |
Please provide the date when the diagnosis was made.
|
| General | ||
| Continuity of Care | Checkbox |
Check this box if the request is for continuity of care.
|
| Provider’s Signature | Signature | |
| Initial Request for Assessment | ||
| Reason for Referral | Text |
Please provide the reason for this initial request for assessment.
|
| Skills Assessment Tools | Text |
Please list the skills assessment tools that will be used, such as ABLLS-R, VB-MAPP, or FBA.
|
| Member Information | ||
| Member Name | Text |
Enter the full name of the member.
|
| Date of Birth | Date |
Enter the member's date of birth.
|
| Age | Text |
Enter the member's current age.
|
| Member Gender: Male | Radiobutton |
Check this box if the member identifies as male.
|
| Member Gender: Female | Radiobutton |
Check this box if the member identifies as female.
|
| Member Gender: Other | Radiobutton |
Check this box if the member identifies with a gender other than male or female.
|
| Other Gender | Text |
Enter the member's gender if it is not male or female.
|
| Phone Number | Text |
Enter the member's phone number.
|
| Insurance ID | Text |
Enter the member's insurance identification number.
|
| Benefit Plan / Employer | Text |
Enter the member's benefit plan or employer name.
|
| Certification Number | Text |
Enter the member's certification number.
|
| Ordering Physician Information | ||
| Ordering Physician Name | Text |
Enter the full name of the ordering physician.
|
| Ordering Physician License Number | Text |
Enter the license number of the ordering physician.
|
| Ordering Physician Phone Number | Text |
Enter the phone number of the ordering physician.
|
| Ordering Physician Address | Text |
Enter the full address of the ordering physician.
|
| Provider / Agency Information | ||
| Provider Name | Text |
Please provide the name of the provider or agency.
|
| Tax ID Number | Text |
Please provide the tax identification number for the provider or agency.
|
| MetroPlusHealth Group ID | Text |
Please provide the MetroPlusHealth Group ID for the provider or agency.
|
| Services Address Line 1 | Text |
Please provide the first line of the service address for the provider or agency.
|
| Services Address Line 2 | Text |
Please provide the second line of the service address for the provider or agency.
|
| Provider Phone Number | Text |
Please provide the phone number for the provider or agency.
|
| Provider Email Address | Text |
Please provide the email address for the provider or agency.
|
| Provider Information | ||
| Provider's Printed Name | Text |
Enter the provider's full printed name.
|
| License Number | Text |
Enter the provider's professional license number.
|
| Date | Date |
Enter the current date.
|
| Rendering Provider / LBA Supervisor Information | ||
| Rendering Provider / LBA Supervisor Name | Text |
Enter the full name of the rendering provider or LBA supervisor.
|
| LBA Credential Number | Text |
Enter the LBA credential number for the rendering provider or LBA supervisor.
|
| NPI Number | Text |
Enter the National Provider Identifier (NPI) number for the rendering provider or LBA supervisor.
|
| Rendering Provider / LBA Supervisor Phone Number | Text |
Enter the phone number for the rendering provider or LBA supervisor.
|
| Rendering Provider / LBA Supervisor Email | Text |
Enter the email address for the rendering provider or LBA supervisor.
|
| MetroPlusHealth Provider Number | Text |
Enter the MetroPlusHealth provider number for the rendering provider or LBA supervisor.
|
| Service Request (CPT 0362T) | ||
| Service Request CPT 0362T Units | Text |
Please enter the number of units requested per week for this service request.
|
| Service Request CPT 0362T Place of Service | Text |
Please enter the place of service for this service request.
|
| Service Request (CPT 0373T) | ||
| Service Request CPT 0373T Units | Number |
Provide the number of units requested per week for the Service Request CPT 0373T.
|
| Service Request CPT 0373T Place Of Service | Text |
Provide the Place Of Service for the Service Request CPT 0373T.
|
| Service Request (CPT 97151) | ||
| CPT 97151 Units Per Week | Text |
Enter the number of units requested per week for the CPT 97151 service.
|
| CPT 97151 Place of Service | Text |
Enter the place of service code for the CPT 97151 service.
|
| Service Request (CPT 97152) | ||
| CPT 97152 Requested Units | Number |
Enter the number of units requested per week for CPT 97152.
|
| CPT 97152 Place of Service | Text |
Enter the place of service for CPT 97152.
|
| Service Request (CPT 97153) | ||
| CPT 97153 Units | Number |
Please enter the number of units requested per week for CPT 97153 Adaptive Behavior Treatment by Protocol.
|
| CPT 97153 Place of Service | Text |
Please enter the place of service for CPT 97153 Adaptive Behavior Treatment by Protocol.
|
| CPT 97153 Guidance | Text |
Please provide any specific guidance or additional information related to CPT 97153 Adaptive Behavior Treatment by Protocol.
|
| Service Request (CPT 97154) | ||
| CPT 97154 Units | Text |
Enter the number of units requested per week for CPT code 97154.
|
| CPT 97154 Place Of Service | Text |
Enter the place of service for CPT code 97154.
|
| CPT 97154 Guidance | Text |
Provide additional guidance specific to the authorization request for CPT code 97154.
|
| Service Request (CPT 97155) | ||
| CPT 97155 Requested Units Per Week | Number |
Enter the number of units requested per week for CPT 97155.
|
| CPT 97155 Place of Service | Text |
Enter the place of service for CPT 97155.
|
| CPT 97155 Guidance | Text |
Provide any relevant guidance or clinical justification for CPT 97155.
|
| Service Request (CPT 97156) | ||
| CPT 97156 Units Per Week | Number |
Enter the number of units requested per week for CPT 97156 service.
|
| CPT 97156 Place of Service | Text |
Enter the place of service for CPT 97156.
|
| CPT 97156 Guidance | Text |
Provide any additional guidance or notes for CPT 97156 service.
|
| Service Request (CPT 97157) | ||
| CPT 97157 Units | Number |
Enter the requested number of units per week for CPT 97157.
|
| CPT 97157 Place of Service | Text |
Enter the place of service for CPT 97157.
|
| CPT 97157 Guidance | Text |
Provide any relevant guidance or clinical justification for CPT 97157.
|
| Service Request (CPT 97158) | ||
| Units 9 | Text | |
| POS 9 | Text | |
| Text19 | Text | |
| Type of Request | ||
| Initial Assessment | Checkbox |
Check this box if the request is for an initial assessment.
|
| Initial Treatment | Checkbox |
Check this box if the request is for initial treatment.
|
| Concurrent Request | Checkbox |
Check this box if the request is for concurrent treatment.
|