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The Department of Medical Assistance Services Applied Behavior Analysis Preservice Service Authorization Request Form (Effective Dates of Service 09/01/2025 and after), page 1
Complex · 68/100Form Complexity Index

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What this form asks for

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This is an official Department of Medical Assistance Services (DMAS) form used to request preservice (prior) authorization for Applied Behavior Analysis (ABA) services billed under specific CPT codes (97153–97158 and 0373T). It captures member and provider details, requested service hours/units, diagnoses, admission criteria, and preliminary treatment goals, including documentation of telemedicine when applicable. The form is important because DMAS/health plans use it to determine medical necessity and approve the amount, type, and duration of ABA services before they are delivered (or for retro review when indicated).
Fillable fields108
Pages8
Sections43
Tables and lists2
Questions that depend on earlier answers12
Form Complexity IndexComplex, 68/100

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 identity fields are complete and non-placeholder

Validates that Member First Name, Member Last Name, Member Date of Birth, Medicaid #, and Member Plan ID # are present and not left blank or filled with placeholders (e.g., underscores). These fields are required to correctly match the request to the right beneficiary and avoid misrouting PHI. If validation fails, the submission should be rejected as incomplete and returned for correction before clinical review.

Member Date of Birth is a valid date and logically consistent

Checks that the Member Date of Birth is a real calendar date in an accepted format (e.g., MM/DD/YYYY) and is not in the future. Because the form repeatedly references a "youth," the DOB should also indicate a minor (or the system should require an explicit attestation if the member is not a minor). If the date is invalid or inconsistent, the request should be pended for clarification to prevent eligibility and medical-necessity errors.

Member contact information format validation (phone and address)

Validates that Member Phone # contains a valid 10-digit US phone number (allowing standard punctuation) and that the street address and City/State/ZIP are complete with a valid 5-digit or 9-digit ZIP code. Accurate contact data is necessary for care coordination, notices, and potential audits. If validation fails, the form should be returned for correction or flagged for outreach before authorization processing.

Provider identifiers (NPI and Tax ID) format and checksum validation

Ensures Group NPI # and LBA/LMHP NPI # are 10-digit NPIs and pass the NPI Luhn check, and that Provider Tax ID is 9 digits (EIN/SSN format as applicable). Correct identifiers are essential for provider enrollment matching, claims payment, and compliance. If any identifier fails validation, the request should be rejected or pended until corrected to avoid authorizing services under the wrong provider.

Provider contact information completeness and format (phone, fax, email)

Checks that Provider Phone and Provider Fax (if provided) are valid US phone numbers and that Provider E-Mail matches a standard email pattern (e.g., [email protected]). The health plan must be able to contact the provider/clinical contact for additional clinical information. If invalid or missing, the submission should be pended and the provider prompted to correct contact details.

Clinical Contact Name and Credentials required when provided as point of contact

Validates that Clinical Contact Name and Credentials are present and that Clinical Contact Phone # is provided in valid format. This is the designated person the health plan will contact for clinical questions, so missing or ambiguous information delays review. If validation fails, the request should be pended until a reachable clinical contact is supplied.

And 10 more checks
  • Retro Review Request logic and current participation start date requirement
  • Requested service date range validity (From/To) and effective date rule
  • CPT code selection restricted to allowed ABA codes on the form
  • Service table arithmetic validation (daily/weekly hours, total hours, total units)
  • Provider qualification alignment with CPT code requirements
  • High-intensity threshold rule: schedule required when ≥20 hours/week (≥80 units/week)
  • Diagnosis fields completeness and ICD-10 format validation
  • Admission criteria #2: at least two sub-criteria marked Yes with supporting narratives
  • Telemedicine documentation required when telemedicine is referenced in any goal
  • Signature attestation block completeness and date consistency

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How to Fill Out DMAS ABA Preservice Authorization Request Online for Free in 2026

What the AI walks you through.

  1. Enter member information (name, Medicaid number, DOB, gender, plan ID, address/phone) and parent/legal guardian contact details.
  2. Enter provider information (organization name, Group NPI, LBA/LMHP NPI, tax ID, servicing address, phone/fax/email) and identify the clinical contact person and credentials.
  3. Complete the request for approval section: indicate whether this is a retro review, list current start date if already receiving services, and specify the requested date range (from/to).
  4. Fill in the proposed/requested service table for each CPT code (97153–97158, 0373T): provider qualifications, daily hours/days per week, total weekly hours, total hours for the requested period, total units requested, and any required notes.
  5. Document prior ABA/behavior therapy treatment periods in the past 12 months (provider, dates of service, outcomes).
  6. Complete clinical justification: ICD-10 primary/secondary diagnoses, DSM diagnosis/provisional diagnosis, symptom description and functional impairment, admission criteria checkboxes (2A–2E) with narratives, and preliminary treatment goals including telemedicine vs in-person details and clinical evidence when telemedicine is recommended.
  7. Finish recovery/discharge planning (progress definition, barriers, supports/resources, anticipated discharge level of care and estimated discharge date), attach required supporting documents (assessment, preliminary ISP, discharge plan, and schedule if requesting 20+ hours/week), and obtain LMHP/LABA attestation signature, printed name, credentials, and date.

Common Mistakes in Completing DMAS ABA Preservice Authorization Request

The ones the AI is built to catch.

Leaving required member/provider identifiers blank or inconsistent
People often omit or mismatch key identifiers such as Medicaid #, Member Plan ID, Member DOB, Group NPI, and LBA/LMHP NPI because the information is stored in different systems or copied from prior authorizations. Missing or inconsistent identifiers can prevent the health plan from matching the request to the correct member/provider record, causing delays or outright rejection. To avoid this, verify all identifiers against the eligibility/roster and NPI registry before submission and ensure the same member name/Medicaid # appears on every page where requested.
Using the wrong address fields (mailing vs servicing) or incomplete addresses
A common error is entering the organization’s mailing address where the form asks for the Provider Servicing Address, or leaving out city/state/ZIP because it seems redundant. This can create network/credentialing and service-location mismatches, which may trigger pends or denials if the service location cannot be validated. Always enter the physical service location in the servicing address field and complete city/state/ZIP for both member and provider sections.
Not identifying a valid clinical contact (or listing someone without credentials)
Submitters sometimes list a front-desk contact or omit credentials, even though the form specifies a clinical contact the health plan can reach for additional clinical information. This leads to back-and-forth, missed outreach, and delays when the plan cannot obtain clarifications about medical necessity or goals. Provide a reachable clinical staff member’s name, role/credentials, and direct phone number, and ensure the email/phone are monitored.
Retro review request marked incorrectly or missing the current start date
Many requests incorrectly check “Retro Review Request” without meeting retro criteria, or they forget to provide the start date when the member is already receiving services. Incorrect retro status can route the request to the wrong workflow and may result in denial for timeliness or missing retro documentation. Confirm whether services have already started, enter the actual start date, and only mark retro when you are truly requesting authorization after services began per plan policy.
Service date range errors (missing dates, reversed dates, or dates outside the effective period)
People frequently leave the “From/To” dates blank, reverse them, or request dates that conflict with the form’s effective dates (09/01/2025 and after) or the assessment completion date. Date errors can cause automatic pends because the plan cannot determine the requested authorization span or because the request appears invalid. Always enter a clear start and end date, ensure the range is chronological, and confirm it aligns with policy and the assessment date.
Incorrect CPT selection or misunderstanding code intent (97153–97158, 0373T)
A frequent mistake is requesting codes that don’t match the described service (e.g., using group codes for 1:1 services, or using 0373T without meeting the “two or more technicians and LBA/LMHP/LABA team rate” requirement). This can lead to denials, downcoding, or requests for clarification because the billed model does not align with code definitions and provider qualifications. Choose CPT codes that match the delivery format (individual vs group vs family), document the required staffing model, and ensure the provider qualifications listed align with each code’s requirements.
Hours/units math mistakes (weekly totals, total hours, and units conversion)
Because units are in 15-minute increments, people often miscalculate Total Weekly Hours, Total Hours (weekly hours × weeks), or Total Units Requested (total hours × 4). Math errors can cause the request to exceed limits unintentionally or appear internally inconsistent, triggering pends and rework. Use a consistent method: compute daily hours × days/week = weekly hours, multiply by number of weeks for total hours, then multiply total hours by 4 for units, and double-check totals for each CPT line.
Failing to include the required “Schedule of activities” for requests ≥20 hours/week
Requests at or above 20 hours (80 units) per week are often submitted without the individualized schedule of activities, or with a generic clinic schedule that doesn’t tie activities to treatment goals. Missing or non-individualized schedules commonly result in pends/denials because the form explicitly requires a schedule that defines the therapeutic function of sessions and distinguishes therapeutic vs recreational/non-reimbursable time. Provide an individualized schedule in the Notes section or as an upload, explicitly linking each block of time to goals and identifying non-therapeutic time separately.
Not documenting telemedicine details and clinical appropriateness in goals
The form repeatedly requires that each preliminary treatment goal specify when services will be via telemedicine vs in-person and, if telemedicine is recommended, the clinical evidence supporting appropriateness. Many submissions include goals but omit modality details, which can lead to pends because the plan cannot determine whether the requested delivery method meets policy. For each goal, state the modality (telehealth/in-person), conditions for use, and a brief clinical rationale supporting telemedicine when applicable.
Admission criteria not fully met or not clearly connected to symptoms and functional impairment
Submitters sometimes provide a diagnosis but fail to describe current symptoms with frequency/intensity/duration, functional impairment, or how criteria 2A–2E connect back to criterion 1. If the narrative doesn’t demonstrate that all required criteria are met (including “at least two” items in section 2 within the past 30 days), medical necessity may not be established and the request may be denied. Explicitly document symptom details, functional impact, check Yes/No appropriately, and write narratives that clearly link each selected criterion to the diagnosis and impairment.
Missing required attachments or incomplete supporting documentation list
A common reason for pends is forgetting one of the required items: the LBA/LABA/LMHP assessment, the preliminary ISP (including telemedicine documentation per the Mental Health Services Manual), or the preliminary discharge plan with referrals. Without these, the plan cannot validate medical necessity, service model, or transition planning. Before submission, use a checklist to confirm all required documents are completed, dated, and uploaded, and ensure the content matches what is referenced in the form.
Signature/attestation section incomplete (missing assessment date, credentials, or signer type)
People often leave the assessment completion date blank, omit printed name/credentials, or have the wrong professional sign (the attestation requires an LMHP/LMHP-R/LMHP-S/LMHP-RP or LABA). Incomplete attestation can invalidate the request because it is the formal confirmation that medical necessity criteria are met based on an appropriate assessment. Ensure the correct credentialed professional signs (actual or electronic), prints their name, lists credentials, and enters both the assessment completion date and signature date.

Frequently Asked Questions About DMAS ABA Preservice Authorization Request

 

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How does the AI fill out DMAS ABA Preservice Authorization Request?
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 DMAS ABA Preservice Authorization Request, 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 DMAS ABA Preservice Authorization Request to fill out?
DMAS ABA Preservice Authorization Request has a Form Complexity Index of 68 out of 100, in the complex tier: 108 fillable fields across 8 pages. Instafill.ai's AI fills it in under a minute, with every field there for you to review before you download.
What is this form used for?
This is the Department of Medical Assistance Services (DMAS) Applied Behavior Analysis (ABA) Preservice Service Authorization Request Form. It is used to request approval for ABA services (e.g., CPT 97153–97158 and 0373T) before services are provided.
Who needs to complete and submit this ABA preservice authorization request?
The requesting ABA provider/organization completes and submits the form, including the clinical sections. An LMHP (or LMHP-R/LMHP-S/LMHP-RP) or LABA must review the psychiatric history, complete the assessment/addendum, and sign the attestation.
What dates of service does this version of the form apply to?
This form is effective for dates of service on or after 09/01/2025. Use it for any ABA authorization requests that start on or after that date.
What information is required in the Member Information and Provider Information sections?
You must provide identifying and contact details for the member (name, Medicaid ID, DOB, address/phone, plan ID, guardian info) and the provider (organization name, NPIs, tax ID, servicing address, phone/fax/email). You also must list a clinical contact name/credentials and phone number for follow-up questions.
What documents must be included with every preservice authorization request?
Every request must include: (1) the completed Preservice Service Authorization Request Form, (2) a provider assessment completed by the LBA, LABA, or LMHP, (3) a preliminary ISP including any telemedicine documentation required by the Mental Health Services Manual, Chapter IV, and (4) a description of the preliminary discharge plan with referrals as goals are met.
When do I need to include a schedule of activities, and where do I put it?
If you are requesting more than 20 hours (80 units) per week, you must include an individualized schedule of activities. It can be written in the “Notes” section at the end of the form or uploaded with the service authorization request.
What makes an acceptable schedule of activities for requests over 20 hours per week?
The schedule must be individualized and clearly tied to treatment goals and the behavior modification plan. For clinic-based services, it must distinguish therapeutic intervention time from recreational or other non-therapeutic/non-reimbursable activities; a generic clinic schedule is not sufficient.
How do I fill out the CPT code table (hours, weeks, and units)?
Enter the daily hours/days per week and total weekly hours for each CPT code requested, then calculate total hours as (weekly hours Ă— number of weeks requested). Total units requested are calculated as (total hours Ă— 4) because units are in 15-minute increments.
Which provider qualifications are expected for each CPT code listed?
The form indicates that 97153/97154 are delivered by qualified staff, while 97155–97158 and 0373T involve LBA/LMHP/LABA-level oversight or delivery (with specific notes about technicians/caregivers and team-based rates). Use the table’s “Provider qualifications” column to ensure the requested code matches the staff who will provide the service.
What is a “Retro Review Request,” and when should I mark Yes?
A retro review request is used when you are seeking authorization after services have already started. If the member is currently participating, mark “Yes” and provide the start date of service; otherwise mark “No” and request prospective dates.
Do I need to list prior ABA/behavior therapy services from the last 12 months?
Yes. The form asks you to identify all known treatment periods in the past 12 months (including services from other providers), with dates of service and outcomes.
What diagnoses do I need to include, and how should I document them?
You must list the primary ICD-10 diagnosis and any secondary diagnoses, and also specify the corresponding DSM diagnosis or provisional diagnosis. You must describe current symptoms (frequency, intensity, duration) and functional impairments that support medical necessity.
What are the admission criteria in Section I, and what does “must meet ALL criteria #1–3” mean?
To qualify, the individual must meet criteria 1, 2, and 3 as described in Section I. Criterion 2 also requires that within the past 30 days the youth has demonstrated at least two of the listed areas (A–E), and you must document and connect them to the symptoms in criterion 1.
How do I write the Preliminary Treatment Goals, and what must be included about telemedicine?
Each goal should directly address the symptoms/difficulties you documented and be tied to the relevant criterion (e.g., communication, social interaction, outbursts, repetitive behaviors, sensory integration). If telemedicine is used or recommended, specify when/under what conditions services will be via telemedicine versus in-person and include clinical evidence that telemedicine is appropriate.
What is required in the Recovery & Discharge Planning section?
You must describe what progress/recovery would look like, barriers to progress, supports/services/resources needed, the expected level of care at discharge, and an estimated discharge date. This should align with the preliminary discharge plan you submit with the request.
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medical authorization forms: Department of Medical Assistance Services Applied Behavior Analysis (97155, Et al.) Initial Service Authorization Request Form, Applied Behavior Analysis Concurrent Service Authorization Request Form (CPT Codes 97153, 97154, 97155, 97156, 97157, 97158, 0373T) – Virginia Department of Medical Assistance Services, Blue Shield of California Prior Authorization Request Form, Kaiser Permanente Authorization for Use or Disclosure of Patient Health Information, Kaiser Permanente Washington Request for Authorization, Blue Shield Promise Durable Medical Equipment (DME) Treatment Authorization Request Form, MC 315, Authorization for Release of Medical Information

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VA medical forms: Form OWCP-915, Claim for Medical Reimbursement, Form 8994, Employer Credit for Paid Family and Medical Leave, Form OF-178, Certificate of Medical Examination, Form N-648, Medical Certification for Disability Exceptions, U.S. Coast Guard Form CG-719K, Application for Medical Certificate, State of Illinois Department of Children and Family Services Medical Report on an Adult in a Child Care Facility (CFS 602), Carer Payment and Carer Allowance – Medical Report (SA431) for a child under 16 years, Medically Prescribed Treatment (Non-Medication) Form — Provider Treatment Order Form | Office of School Health | School Year 2025–2026, VA Form 10-7959f-2, Foreign Medical Program (FMP) Claim Cover Sheet, Department of Medical Assistance Services Applied Behavior Analysis (97155, Et al.) Initial Service Authorization Request Form, Applied Behavior Analysis Concurrent Service Authorization Request Form (CPT Codes 97153, 97154, 97155, 97156, 97157, 97158, 0373T) – Virginia Department of Medical Assistance Services, Department of Medical Assistance Services Enhanced Services Individual Service Plan (ISP) Template, Form DS-1843, Medical History and Examination for Individuals Age 12 and Older, Scheduled Medical Leave of Absence (MLOA) - BLET 13, Admissions Application, School of Diagnostic Imaging, Mills-Peninsula Medical Center, Albany Medical Center 2024 Benefits Guide, Form BWC-1141, Request for Medical Information, VA Form 21P-8416, Medical Expense Report, Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers, CMS-855S, Form HFS 2243, Provider Enrollment Application Illinois Medical Assistance Program

Medi-Cal forms: Form OWCP-915, Claim for Medical Reimbursement, Form 8994, Employer Credit for Paid Family and Medical Leave, Form OF-178, Certificate of Medical Examination, Form N-648, Medical Certification for Disability Exceptions, U.S. Coast Guard Form CG-719K, Application for Medical Certificate, State of Illinois Department of Children and Family Services Medical Report on an Adult in a Child Care Facility (CFS 602), Carer Payment and Carer Allowance – Medical Report (SA431) for a child under 16 years, Medically Prescribed Treatment (Non-Medication) Form — Provider Treatment Order Form | Office of School Health | School Year 2025–2026, VA Form 10-7959f-2, Foreign Medical Program (FMP) Claim Cover Sheet, ABA Authorization Request (Medi-Cal) – Initial and Concurrent Requests, Department of Medical Assistance Services Applied Behavior Analysis (97155, Et al.) Initial Service Authorization Request Form, Applied Behavior Analysis Concurrent Service Authorization Request Form (CPT Codes 97153, 97154, 97155, 97156, 97157, 97158, 0373T) – Virginia Department of Medical Assistance Services, Department of Medical Assistance Services Enhanced Services Individual Service Plan (ISP) Template, Form DS-1843, Medical History and Examination for Individuals Age 12 and Older, Scheduled Medical Leave of Absence (MLOA) - BLET 13, Admissions Application, School of Diagnostic Imaging, Mills-Peninsula Medical Center, Albany Medical Center 2024 Benefits Guide, Form BWC-1141, Request for Medical Information, VA Form 21P-8416, Medical Expense Report, Medicare Enrollment Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers, CMS-855S

authorization forms: Form I-765, Application for Employment Authorization, Form CMS-588, EFT Authorization Agreement, Form 8821, Tax Information Authorization, Form 8879, IRS e-file Signature Authorization, Form SSA-827, Authorization to Disclose Information, Form I-905, Application for Authorization to Issue Certification for Health Care Workers, Form G-1650, Authorization for ACH Transactions, Arizona Form 285, General Disclosure/Representation Authorization Form, Arizona Form 285-I, Individual Income Tax Disclosure/Representation Authorization Form, Form CH-006: PA-BH-Res-PCS, Oregon Behavioral Health Support Program Plan of Care Authorization (Plan of Care Request for Behavioral Health Residential or Personal Care Services), Continental American Insurance Company (CAIC) / Aflac Group Critical Illness Claim Form (with Attending Physician’s Statement, HIPAA Authorization to Obtain Information, and Electronic Funds Transaction Authorization), HIPAA Authorization Form, Authorization for the Release of Protected Health Information, Form G-1450, Authorization for Credit Card Transactions, Prior Authorization (PA) Request Form – Adult Palliative Care (Alameda Alliance for Health), Alameda Alliance for Health Prior Authorization (PA) Request Form – Adult Palliative Care, Manulife Group Benefits Drug Prior Authorization Form – Mounjaro (Tirzepatide) (GL5197E), Manulife Group Benefits Drug Prior Authorization Form (Ozempic/Semaglutide) – GL5197E, Out-of-Network Pre-Authorization and Exception Request Form, Form SSA-827 (06-2024), Authorization to Disclose Information to the Social Security Administration (SSA), Manulife Group Benefits Drug Prior Authorization Form (Wegovy/Semaglutide) – GL5197E - MLI (08/2025-WEGOV)

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medical assistance forms: Department of Medical Assistance Services Applied Behavior Analysis (97155, Et al.) Initial Service Authorization Request Form, Applied Behavior Analysis Concurrent Service Authorization Request Form (CPT Codes 97153, 97154, 97155, 97156, 97157, 97158, 0373T) – Virginia Department of Medical Assistance Services, Department of Medical Assistance Services Enhanced Services Individual Service Plan (ISP) Template, Form HFS 2243, Provider Enrollment Application Illinois Medical Assistance Program, Addendum for Maryland Medical Assistance Program Application School Based Health Center, Form SY061, Medical statement - Assistance for Isolated Children (AIC) Scheme

service authorization forms: Form CH-006: PA-BH-Res-PCS, Oregon Behavioral Health Support Program Plan of Care Authorization (Plan of Care Request for Behavioral Health Residential or Personal Care Services), Department of Medical Assistance Services Applied Behavior Analysis (97155, Et al.) Initial Service Authorization Request Form, Applied Behavior Analysis Concurrent Service Authorization Request Form (CPT Codes 97153, 97154, 97155, 97156, 97157, 97158, 0373T) – Virginia Department of Medical Assistance Services, Plan–to-Plan Transfer, Plan Exchange, or Service Credit Authorization Form, Empower Plan Service Center Authorization Form (PSC Plan Sponsor Username Request Form), Texas Standard Prior Authorization Request Form for Health Care Services, Merrill RMD Service Enrollment and Authorization Form, Anthem Blue Cross Community-Based Adult Services (CBAS) Authorization Request Form, Request for Authorization for Applied Behavior Analysis (ABA) Services, Applied Behavior Analysis (ABA) Services Request for Authorization Form, Service Authorization Request Form, Community Based Adult Services (CBAS) Treatment Authorization Request

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