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

Describe the individual's current psychiatric/behavioral symptoms and related functional impairments, including frequency, intensity and duration, and explain how these symptoms affect daily functioning (referencing corresponding CNA elements 1, 6, 7, 12).

Describe the youth’s most significant non-verbal or limited functional communication and pragmatic language difficulties (including any unintelligible/echolalic speech and receptive/expressive language impairment) demonstrated within the past 30 days and how they relate to the symptoms in criteria 1. Fill only if 'Criteria 2A - Communication Impairment - Yes' is 'Yes'.

Describe the individual’s most significant current difficulties in social interaction, social reasoning, social reciprocity, and interpersonal relatedness, and connect these difficulties to the symptoms described in criterion 1. Fill only if 'Criteria 2B - Social Interaction Impairment - Yes' is 'Yes'.

Enter the full name of the clinical contact person and their professional credentials (e.g., RN, LCSW) who can provide additional clinical information.

Enter the phone number where the health plan can reach the clinical contact person.

Check this box if, within the past 30 calendar days, the youth has demonstrated the communication impairment described in Criteria 2A.

Check this box if, within the past 30 calendar days, the youth has not demonstrated the communication impairment described in Criteria 2A.

Check this box if, within the past 30 calendar days, the youth has had a severe impairment in social interaction/social reasoning/social reciprocity and interpersonal relatedness.

Check this box if, within the past 30 calendar days, the youth has not had a severe impairment in social interaction/social reasoning/social reciprocity and interpersonal relatedness.

Check this box if the member has frequent intense behavioral outbursts that are self-injurious or aggressive toward others.

Check this box if the member does not have frequent intense behavioral outbursts that are self-injurious or aggressive toward others.

Check this box if the individual has disruptive, obsessive, repetitive, or ritualized behaviors that apply to this criterion.

Check this box if the individual does not have disruptive, obsessive, repetitive, or ritualized behaviors that apply to this criterion.

Enter the date the member's current participation in this service began.

Enter the best estimated date this individual will be discharged from this service.

Enter the names and relationship to the youth for any family members or caregivers who are available to participate in ABA services.

Enter the total hours per day and number of days per week requested for CPT 97157 (e.g., hours/day and days/week).

Enter the total number of service hours requested per week for CPT 97157.

Enter the total number of hours requested for CPT 97157 for the full authorization period.

Enter the total number of units requested for CPT 97157 for the full authorization period.

Provide any additional notes or explanations related to the CPT 97157 service request.

Enter the name of the provider or organization that delivered the first ABA (Applied Behavior Analysis) treatment period within the past 12 months.

Enter the start and end dates (or overall date range) when ABA services were provided during the first treatment period.

Describe the outcomes or results of the first ABA treatment period (e.g., progress made, goals met, response to treatment, or reason for discharge).

Enter the total amount of service provided per day and the number of days per week requested for CPT 97153.

Enter the total number of hours per week being requested for CPT 97153.

Enter the total number of hours requested for CPT 97153 across the entire requested time period.

Enter the total number of units requested for CPT 97153 for the full requested time period.

Provide any notes or additional details relevant to the CPT 97153 service request.

Enter the total daily service hours and number of service days per week requested for CPT 97156.

Enter the total number of service hours requested per week for CPT 97156.

Enter the total service hours requested across all weeks for CPT 97156.

Enter the total number of units requested for CPT 97156.

Provide any notes or additional details supporting the request for CPT 97156.

Enter the member’s primary ICD-10 diagnosis code.

Enter any secondary ICD-10 diagnosis code(s) for the member, if applicable.

Enter the date the assessment or applicable addendum for this service was completed.

Enter the printed name of the LMHP (or LMHP-R/LMHP-S/LMHP-RP) or LABA who is attesting.

Enter the professional credentials of the LMHP/LABA who is attesting (e.g., license type/designation).

Enter the date the LMHP/LABA signed the attestation.

Enter the member's primary phone number.

Enter the full name(s) of the member's parent(s) and/or legal guardian(s).

Enter the phone number for the member's parent or legal guardian.

Enter the member's street address, including apartment or unit number if applicable.

Enter the member's city, state, and ZIP code.

Enter the member's first name.

Enter the member's last name.

Enter the member's Medicaid identification number.

Enter the member's date of birth.

Enter the member's plan ID number.

Enter the member's gender (e.g., Male, Female, Other) as recorded in their medical or enrollment records.

Provide details explaining any other medical or behavioral health concerns (e.g., substance use issues, personality disorders, dementia, cognitive impairments) that could impact services. Fill only if 'Other medical/behavioral health concerns - Yes' is 'Yes'.

Check this box if the member has other medical or behavioral health concerns (e.g., substance use issues, personality disorders, dementia, cognitive impairments) that could impact services.

Check this box if the member does not have any other medical or behavioral health concerns that could impact services.

Enter the first preliminary treatment goal related to the symptoms above, including when/under what conditions interventions will be provided via telemedicine versus in-person services and, if telemedicine is recommended, the clinical evidence supporting its appropriateness.

Enter the preliminary treatment goal addressing the individual’s communication difficulties, including when/under what conditions interventions will be provided (telemedicine vs. in-person) and, if telemedicine is recommended, the clinical evidence supporting its appropriateness. Fill only if 'Criteria 2A - Communication Impairment - Yes' is 'Yes'.

Enter the preliminary treatment goal addressing the individual’s social interaction, social reasoning/reciprocity, and interpersonal relatedness difficulties, including any notes on whether services will be provided via telemedicine or in-person and the clinical rationale for telemedicine if recommended. Fill only if 'Criteria 2B - Social Interaction Impairment - Yes' is 'Yes'.

Describe the barriers to progress/recovery identified by the individual, their natural supports, and/or the service provider.

Describe the types of outreach, additional formal services, natural supports, or resources that will be necessary to reach progress/recovery.

Describe the anticipated level of care the individual may need at discharge from this service.

Enter the provider’s main phone number for general contact.

Enter the provider’s general email address for communications about this request.

Enter the provider’s fax number for sending or receiving documents related to this request.

Enter the legal name of the provider organization.

Enter the provider organization’s Group National Provider Identifier (NPI).

Enter the National Provider Identifier (NPI) for the LBA/LMHP associated with this request.

Enter the provider organization’s Tax Identification Number (TIN).

Enter the provider’s servicing street address (street number, street name, and suite/unit if applicable).

Enter the city, state, and ZIP code for the provider’s servicing address.

Describe what meaningful progress and recovery would look like for this individual, including observable improvements and outcomes that indicate readiness for discharge or a lower level of care.

Enter the start date for the requested service period.

Enter the end date for the requested service period.

Check this box if the request is being submitted as a retro review request.

Check this box if the request is not being submitted as a retro review request.

Enter the detailed schedule for services totaling 20 hours or more (e.g., days of week, times, and hours). Fill only if 'Total Weekly Hours' is '20 hours or more (80 units) per week'.

Provide any additional notes or comments related to the 20-hours-or-more schedule. Fill only if 'Total Weekly Hours' is '20 hours or more (80 units) per week'.

Enter the name of the provider who delivered the second ABA treatment period within the past 12 months.

Enter the dates of service for the second ABA treatment period (the service date range when treatment was provided).

Describe the outcomes or results of the second ABA treatment period, including progress achieved or response to treatment.

Enter the typical daily service hours and number of service days per week requested for the second service line (CPT 97154).

Enter the total number of service hours requested per week for the second service line (CPT 97154).

Enter the total service hours requested for the entire authorization period for the second service line (CPT 97154).

Enter the total number of units requested for the entire authorization period for the second service line (CPT 97154).

Provide any additional notes or clarifying details related to the second service line (CPT 97154).

Describe the youth’s frequent intense behavioral outbursts that are self-injurious or aggressive, including repeated occurrences and how they endanger self/others, are difficult to control, cause distress, or negatively affect health. Fill only if 'Criteria C: Frequent intense behavioral outbursts - Yes' is 'Yes'.

Enter the preliminary treatment goal related to the intensive behavioral outbursts, including planned intervention conditions (telemedicine vs. in-person scheduling) and clinical evidence supporting telemedicine if recommended. Fill only if 'Criteria C: Frequent intense behavioral outbursts - Yes' is 'Yes'.

Describe the individual’s most significant disruptive, obsessive, repetitive, or ritualized behaviors and connect them to the symptoms described in criteria 1. Fill only if 'Criteria D - Yes' is 'Yes'.

Enter the preliminary treatment goal addressing disruptive, obsessive, repetitive, or ritualized behaviors, including when/under what conditions telemedicine will be used versus in-person services and the clinical rationale for telemedicine if recommended. Fill only if 'Criteria D - Yes' is 'Yes'.

Describe the individual’s most significant sensory integration difficulties and explain how they relate to the symptoms described in Criteria 1. Fill only if 'Difficulty with sensory integration - Yes' is 'Yes'.

Enter a treatment goal addressing the sensory integration difficulties, including when/under what conditions telemedicine will be used, when services will be in-person, and any clinical evidence supporting the appropriateness of telemedicine if recommended.

Check this box if the individual has difficulty with sensory integration.

Check this box if the individual does not have difficulty with sensory integration.

Enter the total number of hours per day and the number of days per week requested for CPT 0373T.

Enter the total number of service hours per week requested for CPT 0373T.

Enter the total number of hours requested for CPT 0373T for the full authorization period.

Enter the total number of units requested for CPT 0373T for the full authorization period.

Provide any additional notes or explanations related to the requested CPT 0373T services and totals.

Enter the total number of hours per day and number of days per week requested for CPT 97158 services.

Enter the total number of service hours requested per week for CPT 97158.

Enter the total hours requested for CPT 97158 across the full authorization period.

Enter the total number of units requested for CPT 97158 for the full authorization period.

Provide any additional notes or explanations related to the CPT 97158 service request and totals.

Enter the total daily hours and number of days per week requested for the third service line (CPT 97155).

Enter the total number of hours per week requested for the third service line (CPT 97155).

Enter the total hours requested across the full authorization period for the third service line (CPT 97155).

Enter the total number of units requested for the third service line (CPT 97155).

Provide any notes or additional details related to the requested third service line (CPT 97155).