The Department of Medical Assistance Services Applied Behavior Analysis Preservice Service Authorization Request Form (Effective Dates of Service 09/01/2025 and after) Completed Form Examples and Samples

Patient Intake Summary: Liam O'Connell, born on May 10, 2019, is a male child presenting with a diagnosis of Autism Spectrum Disorder (F84.0) and Expressive Language Disorder (F80.1). His Medicaid ID is VAMED1234567890, and his health plan ID is CVP7890123. Liam resides with his parents, Sarah and David O'Connell, at 456 Elm Street, Richmond, VA 23220. The best contact number for the family is (804) 555-5678. Liam's primary phone is (804) 555-1234. No other significant medical or behavioral health concerns are identified beyond his ASD diagnosis.

Clinically, Liam exhibits significant communication difficulties, primarily using 2-3 word phrases and PECS for requests, which directly contributes to frequent tantrums. These outbursts occur 4-5 times daily, lasting 10-15 minutes, often triggered by demands or removal of preferred items. They impact his participation in preschool and family activities. Socially, he struggles with joint attention and engaging in reciprocal play with peers. He also displays repetitive hand flapping when excited or overstimulated and shows over-responsivity to loud noises and certain textures. Liam previously received ABA services at ABA Kids Co. from March 2023 to March 2024, demonstrating progress in PECS but continued challenges with tantrum frequency. This is a request for prospective authorization, not a retro review. We anticipate services will commence on September 1, 2025, and continue through February 28, 2026. Liam's current service start date with our organization was January 15, 2025.

Our proposed treatment plan includes 15 hours per week of CPT 97153 (individual direct ABA services), scheduled as 3 hours daily, 5 days a week, focusing on skill acquisition. Additionally, 1 hour per week of CPT 97155 (supervision/parent training) will be provided, including parent training and RBT supervision. We also plan for 2 hours per week of CPT 97156 (group ABA), 1 hour daily, 2 days a week, for social skill development. The total duration of this authorization period is 26 weeks. Liam will primarily receive services at Behavioral Progress Partners, located at 789 Oak Avenue, Richmond, VA 23225. Our Group NPI is 1234567890, and Dr. Emily Carter, LBA, with NPI 9876543210, is the clinical contact and responsible LBA. Our Provider Tax ID is 88-7777777. Our main phone is (804) 777-8888, fax (804) 777-8889, and email [email protected]. Dr. Carter can be reached directly at (804) 777-8888 for clinical inquiries.

Preliminary treatment goals include: 1) Liam will increase functional communication for requests and manding across settings, using verbal approximations or PECS, to reduce problem behaviors (in-person, clinic/home); 2A) Increase verbal requests and responses to simple instructions; 2B) Engage in reciprocal play with a peer for 5 minutes; 2C) Reduce frequency of tantrums by 50%; 2D) Engage in appropriate leisure activities without self-stimulatory behavior; and 2E) Tolerate unexpected loud noises and novel textures with minimal distress.

Sarah and David O'Connell are available for weekly parent training sessions. Barriers to progress include inconsistent strategy implementation at home and limited community resources for peer interaction. We envision a transition to mainstream kindergarten with minimal support by the estimated discharge date of February 28, 2026. Outreach will focus on community playgroups and respite care. This assessment was completed on August 15, 2025. Dr. Emily Carter, LBA, signed this attestation on August 15, 2025.