Request for Authorization for Applied Behavior Analysis (ABA) Services Instructions

Check this box if the request is for comprehensive applied behavior analysis (ABA) services.

Check this box if the request is for focused applied behavior analysis (ABA) services.

Enter the number of 15-minute units requested for the physician/QHCP-administered behavior identification assessment (CPT code 97151) for the authorization period.

Enter the number of 15-minute units for the behavior identification supporting assessment administered by a technician under the direction of a physician/QHCP, face-to-face with the patient during the authorization period.

Enter the number of 15-minute units of the behavior identification supporting assessment for severe behaviors (CPT code 0362T) to be provided per authorization period.

Enter the number of 15-minute units of adaptive behavior treatment by protocol administered by a technician under the direction of a physician/QHCP for CPT 97153 PER WEEK

Specify the timeframe (weekly or monthly) for the authorization period corresponding to the units of adaptive behavior treatment under CPT 97153.

Enter the number of 15-minute units for group adaptive behavior treatment by protocol by technician under the direction of a physician/QHCP, face-to-face with two or more patients (CPT code 97154). Enter number of units per week

Specify whether the authorization period for group adaptive behavior treatment by protocol (CPT code 97154) is measured weekly or monthly.

Enter the number of 15-minute units of adaptive behavior treatment with protocol modification (CPT code 97155) per week

Specify the authorization period (weekly or monthly) for the adaptive behavior treatment with protocol modification (CPT code 97155).

Enter the number of 15-minute units of Family Adaptive Behavior Treatment Guidance (CPT code 97156) requested per week

Specify the authorization period (weekly or monthly) for the requested Family Adaptive Behavior Treatment Guidance units (CPT code 97156).

Check this box to indicate that you are requesting Multiple-Family Group Adaptive Behavior Treatment Guidance (CPT code 97157) per week

Specify the total number of 15-minute units requested for Multiple-Family Group Adaptive Behavior Treatment Guidance (CPT code 97157).

Enter the number of 15-minute units of social skills group adaptive behavior treatment (CPT 97158) you are requesting per week

Specify the authorization period (weekly or monthly) for the adaptive behavior treatment with protocol modification (CPT code 97158).

Enter the number of 15-minute increments of adaptive behavior treatment with protocol modification for severe maladaptive behaviors under CPT code 0373T per week

Specify the authorization period (weekly or monthly) for for adaptive behavior treatment with protocol modification for severe maladaptive behaviors under CPT code 0373T.

Enter the fax number where the agency will receive approval communications for this treatment plan request.

Enter the agency’s Tax Identification Number (TID).

Enter the agency’s National Provider Identifier (NPI) number.

Enter the full legal name of the agency or organization providing the ABA services.

Enter the primary phone number for the agency, including area code and any extension if applicable.

Check this box if the agency’s voicemail should be kept confidential.

Check this box if the agency’s voicemail is not to be treated as confidential.

Enter the full address (street, city, state, ZIP code) where the agency will provide services. Do not confuse it with client address.

Enter the full name of the agency’s designated contact person for service coordination.

Provide the telephone number, including area code, where the agency contact person can be reached.

Provide the email address of the agency’s contact person for service-related communications.

Enter the caregiver’s primary phone number, including area code, for contact regarding the member’s treatment plan.

Enter the caregiver’s email address for contact regarding the member’s treatment plan.

Enter the full name of the member’s primary caregiver.

List all member’s current DSM-V diagnosis codes or codes relevant to their condition.

Provide the full name and professional credentials of the clinician who diagnosed the member’s autism spectrum disorder.

Enter the member's age at the time of their first ABA treatment, in years.

Enter the start date of the current ABA treatment request in MM/DD/YYYY format.

Check this box if the member’s gender is male.

Check this box if the member’s gender is female.

Check this box if the member’s gender is other.

Check this box if the provider is in network with the member’s local Blue plan.

Check this box if the provider is not in network with the member’s local Blue plan.

Enter the member’s full legal name as it appears on their insurance records. This is also Client name from general information at the treatment plan

Enter the member’s date of birth in MM/DD/YYYY format. Get this information from Date of Birth field in treatment plan document

Enter the member’s insurance identification number exactly as shown on their member ID card.

Enter the U.S. state in which the member currently resides.

Enter the date (MM/DD/YYYY) when the physician or psychologist signed the form to confirm participation in coordination of care for this treatment plan.

Enter the rendering provider’s full name in printed text.

Provide the rendering provider’s professional license type and number.

Enter the date on which the provider signed this form.

Enter the email address for the rendering provider as an additional contact method.

Enter the full address for the rendering provider if it is different from the agency address provided above.

Enter the full name of the Board-Certified Behavior Analyst (BCBA) or other rendering provider who will deliver the requested ABA services.

Enter the Tax Identification Number (TID) for the rendering provider’s organization as recognized by Anthem.

Enter the National Provider Identifier (NPI) assigned to the rendering provider who will perform the services.

Enter the rendering provider’s direct phone number, including area code.

Check this box if the rendering provider’s voicemail messages should be kept confidential.

Check this box if the rendering provider’s voicemail messages are not confidential.

Check this box if services are conducted in the member’s state of residence.

Provide the state where ABA services will be conducted if they are not performed in the member’s state of residence. Fill only if the 'Services conducted in same state?' is 'No'.

Check this box if services are conducted in a different state than the member’s state of residence.