6 - ABA Authorizations and CPT Codes

Once you're credentialed and contracted with your desired insurances and payers, it's time to add your first clients. The process can seem daunting. It's usually accomplished in a few simple parts:

1. Prior Authorization

   1. During this phase of the authorization process, you are attempting to get permission to assess the client. You'll typically need the client's insurance card, diagnostic evaluation, and relevant demographic information. The purpose is to request 97151 units / hours to complete you're own assessment to determine how many hours / units you will need for treatment. Many insurances cap you at 4 total hours (which is almost never enough). Once approved, you can start your assessment process.

2. Treatment Plan

   1. You are likely very familiar with this phase, as you have done this at other agencies as part of your billable caseload. Use an approved assessment tool (ABLLS, VBMAPP, PEAK, etc.). Use your 4 hours (or however many hours were approved for 97151) to first conduct the assessment and second to write the report. These hours are bundled. It's important to track dates, times, and activities that you complete for auditing purposes.

   2. For treatment plan templates, feel free to check out our TPT account.

   3. Assessment Tracking Form - feel free to utilize this free resource to assist with tracking your assessment hours for each client.

1. Initial Authorization

   1. Once you complete your assessment and treatment plan, you'll need to submit for Initial Authorization. Insurance will need the following: treatment plan, requested hours / units, requested start date, and rendering provider. Each insurance will have their own individual forms or portals for you to use, but in general, those are the items required. When requesting units, do not forget to request additional 97151 units, as assessment units are not implied with the authorization. Initial auths are typically approved for 3 months or 6 months, depending on the payer.

2. Ongoing Authorization

   1. Ongoing ABA authorizations are the same as initial authorizations, but occur following the completion of an initial authorization.

ABA Authorization Request (Initial or Ongoing)

Making your first ABA authorization request can be scary - how do I know how many units to request during a 6 month period, what if I ask for too much or worse, not enough?

• You can find more information about focused vs comprehensive treatment plans in our previous article: ABA CPT Codes for Beginners.

• You should also download and familiarize yourself with the guidelines created by CASP: Council of Autism Service Providers.

For the purpose of this article, let's focus on comprehensive. Typically, comprehensive services entail 6 months of full time treatment: somewhere around 30-40 hours of direct treatment per week (97153). A rule of thumb when requesting 97155 (BCBA Protocol Modification), you should be requesting at least 1 hour / 10 hours of 97153. For 97151 (assessment), you should be requesting the minimum of 4 hours (or greater). Many of the other codes (97158 or 97154 or 97156) apply to your individualized plan.

How do I request across a 6 month period?

• 26 weeks x 4 units x number of hours per week requested

• Example: You want to request 35 hours per week of 97153. Here is the math: 26 weeks x 4 units x 35 hours per week = 3640 units.

• You'll want to do this for all requested codes. Determine your weekly hours, and then multiply it times 4 units and 26 weeks.

Once you have determined all of your requested hours, create a table and include it in your treatment plan. The table should have the CPT code, the requested weekly hours, and the total units requested. Your table should look something like this:

• Every insurance has a different approval / denial letter format. I've included one from BCBS with redacted information to help you understand what you're looking at.

1. In this example, REQUEST ID refers to the auth number. You will need this for all future claims.

2. EFFECTIVE DATE refers to the start date of the authorization. When submitting your authorizations, you can often request for an effective date 1-2 weeks before the submission date if you have already started services.

3. EXPIRATION DATE refers to the date that this authorization expires. This is when you can no longer use the units or hours that are approved in this plan. You need to submit an ongoing auth request with a new treatment plan prior to this date.

4. BCBS shows you how many days are included in the authorization. Because this was a partial approval (we still needed to have a peer review), you can see that the plan was only approved for approximately 1 month.

5. DAYS / UNITS TOTAL shows you how many units were approved in totality. This number should match what you've requested. If it does not, you should reach out to the insurance to see if there was an error or if there was a partial denial (which should have already been conveyed to you).

In some cases the insurance will issue an Approval # for batches of codes. The Apple Plan with United does this. Above is an example of a batch: 97155, 97156, 97157, 97158. The codes are all bundled into one approval of 520 units. You have to use the units accordingly. Normally the bulk approval adds up to the same number that you requested for each individual CPT code. Make sure that the total units approved works for the codes listed.

They will often bulk the BCBA codes (listed above), the tech codes (97153, 97154) and the assessment codes (97151, 97152) separately.

In the above example, you can clearly see the effective date range (much easier to follow than the BCBS auth).