Yes! You can use AI to fill out The Department of Medical Assistance Services Applied Behavior Analysis Preservice Service Authorization Request Form (Effective Dates of Service 09/01/2025 and after)

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.

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.