Applied Behavioral Analysis Treatment Report Initial Authorization Request

New ABA CPT Codes

Requested Start Date for this Authorization ____/____/____

Initial Request

Patient Name:

_______________________________________________________

Date of Birth: ___________________Age: ______________  M  F

Address (City/State only): _____________________________________________

Tel #: _____________________Patient’s Insurance ID#:_____________________

Patient's Employer/Benefit Plan: ________________________________________

Provider/Supervisor Name:

________________________________________

License _______________ Certification # (if applicable)____________________

Name of Program/Clinic (if applicable): __________________________________

VO Provider ID # (if known): ________________Tel #______________________

Service Address: ___________________________________________________

City/State/Zip: ______________________________________________________

Independently licensed provider in State where treating patient?  Yes  No

ABA Provider Certification  BCBA  BCABA  State Certification

ID #: _____________________ Check Which:  SSN  Tax ID  NPI

Additional Care Team Names (use additional sheets as necessary):



Paraprofessional / Tutor: ____________________________________________

 Attestation of qualifications by supervisor



Paraprofessional / Tutor: ____________________________________________

 Attestation of qualifications by supervisor

 Consultant

: _____________________________________________________

VO Provider ID # (if known): ________________Tel #__________________

Service Address: _________________________________________________

City/State/Zip: _________________________________________________

Independently licensed provider in State where treating patient?  Yes  No

ABA Provider Certification  BCBA  BCABA  State certification

ID #: ___________________ Check Which:  SSN  Tax ID  NPI

Diagnosis

: ________________________________________________________



Qualified provider determining diagnosis (pediatrician, psychiatrist, MD, DO,

in-dependently licensed and credentialed psychologist):

Name/Credential___________________________________________________

Tel # ______________________________

Treatment History

: (please select all that apply in last 12 months)

 Mental Health  Substance Abuse  Both  None  Unknown



Outpatient  Partial/IOP  Inpatient  Residential  Group Home



Other _______________________  Other _______________________

Current Impairments: (Please select one value for each type of im pairm ent. Scale: 0=none;

1=mild/mildly incapacitating; 2=moderate/moderately incapacitating; 3=severe or severely incapacitating; na=not assessed. Initial  Danger to Self 0 1 2 3 na  Danger to Others 0 1 2 3 na  Communication 0 1 2 3 na  Social Interactions 0 1 2 3 na

 Restrictive, Repetitive, Stereotypical patterns of behaviors 0 1 2 3 na

 Mood Disturbance (Depression or Mania) 0 1 2 3 na

 Anxiety 0 1 2 3 na

 Psychosis/Hallucinations/Delusions 0 1 2 3 na  Thinking/Cognition/Memory/Concentration Problems 0 1 2 3 na  Impulsive/Reckless/Aggressive Behavior 0 1 2 3 na  Activities of Daily Living Problems 0 1 2 3 na  Weight Change Associated with a Behavioral Diagnosis 0 1 2 3 na  Medical/Physical Condition 0 1 2 3 na  Substance Abuse/Dependence 0 1 2 3 na  Job/School Performance Problems 0 1 2 3 na

 Legal Problems 0 1 2 3 na

Please indicate type(s) of service provided BY OTHERS (select all that apply):

Medication Management Indiv. Psychotherapy Family Psychotherapy Group Therapy Community Program(s) Self Help Group(s) Occupational Therapy Physical Therapy Speech Therapy __________________ ___________________ __________________

I am coordinating this patient’s case with other providers as appropriate.

 Behavioral  Y  N  NA  Medical  Y  N  NA  Community Services  Y  N  NA  Regional/State Program  Y  N  NA  Educational Program  Y  N  NA

Current Medications including Psychotropic : Dosage and Frequency

1. __________________________________________ ___________________ 2. __________________________________________ ___________________ 3. __________________________________________ ___________________ 4. __________________________________________ ___________________ 5. __________________________________________ ___________________

Treating Provider’s Signature: _______________________________________Date: ___________

Page 1 of 2 Beacon 12.15.2015

Applied Behavioral Analysis Treatment Report

Program Setting: 

Home



Facility/Clinic



School



Other:

______________________________________________________________________________________________________________________________________



Assessment

/ Follow-up Assessment

by MD/QHCP. Behavior identification

assessment, administration of tests, detailed behavioral history, observation,

care-taker interview, interpretation, discussion of findings, recommendations,

prepara-tion of report, development of treatment plan. Assessment of strengths and

weak-nesses of skill areas across skill domains (e.g., VB-MAPP, ABLLS-R, Functional

Behavior Assessment, Functional Analysis) and follow-up assessments

0359T:

Behavior Identification Assessment Initial

additional units-see 0360T/0361T

(60 minute increments—2 hour max),

Units Requested ________



0360T/0361T:

Observational Behavior Follow-up Assessment

(30 minutes increments)

Units Requested ________



0362T/0363T

Exposure Behavior Follow-up Assessment

[justification required]

(30 minute increments),

Units Requested ________



Adaptive Behavior Treatment

(Direct 1:1 ABA Therapy)



0364T, 0365T:

by technician, receiving 1 hour of supervision for every 5 to 10

hours of direct treatment. ___ hours per day ___ days per week.

(30 min. increments),

Units Requested ________

0368T, 0369T:

(may be used for supervision in addition to direct therapy)

by

MD/Qualified Health Care Professional (QHCP) (30 minute increments),

Supervision

___ hours per day ___ days per week.

Parent (w child)

_____ hours per day ___ days per week

Total Units Requested _____

0373T, 0374T: Exposure Adaptive Behavior Treatment

requiring 2 or

more technicians, for severe maladaptive behaviors ___ hours per day (based

on an initial 60 minutes with additional 30 minute increments)

by technician,

___ days per week. Units Requested ________



Group Adaptive Behavior Treatment

0366T, 0367T:

Group Adaptive Behavior Treatment Protocol by technician

___ hours per day ___ days per week.

(30 minute increments),

Units Requested ________

0372T:

Social Skills Group by MD/QHCP, __ hours per day __ days per week

(30 minute increments),

Units Requested ________





Family Adaptive Behavior Treatment Guidance

by MD/ QHCP, without

patient

0370T:

with individual family, ___ hours per day ___ days per week

(30 minute increments),

Units Requested ________

0371T:

with multiple family group, ___ hours per day ___ days per week

(30 minute increments),

Units Requested ________





Other

_____________________________ frequency:_________________

Documented justification must be provided.

I. ASSESSMENT

Capabilities/Strengths

Current Problem Areas/Skill Deficits



Social Interaction Impairments



Communications Impairments



Restricted, repetitive, stereotyped patterns of behavior, interests, and activities

Assessment Description /Assessment Tool Used



Indirect observations (record reviews, interviews)



Direct observations (ABC charting) 



Functional Behavioral Assessment (FBA) -Direct and Indirect



Verbal Behavior Milestones Assessment & Placement Program VB-MAPP



Assessment of Basic Language and Learning Skills - Revised ABLLS-R



Other—(Specify other methods to systematically evaluate abilities, and development of

structured program)



Further assessment needed—specify type and why

Assessment outcomes /Baseline data results (attach graphic display) / Conclusions

Family/Caregiver Composition and Plan for Treatment Participation/ Behavioral

Management Skill Transfer

II. TREATMENT

General Treatment Recommendations



Instructional Methods to be used (i.e., DTT, PRT, Natural Environment)



Behavioral Methods to be used (DRA, DRO, Behavioral Momentum)



Treatment Setting to be used



Describe how supervision & direct services to be delivered (address frequency on

pg 1)



Describe how coordination of care will be facilitated

Measurable Objectives to be Addressed—Specify all that apply for both Behavior

& Skill Deficits, include baseline data:



Conditions in which behavior & skill is to occur / including generalized settings



Behavioral definition of behaviors & skills - observable and measurable



Behavior mastery criteria (quantify frequency and settings to demonstrate mastery

compared to baseline measures;

Page 2 of 2 Beacon. Revised 12.15.2015

INITIAL AUTHORIZATION TREATMENT REPORT

Provider Report Guidelines

are included to ensure required elements are covered in the

initial authorization treatment report. Please attach completed authorization

Page

1 of 3 Version 1.4

Applied Behavior Analysis Provider Treatment Report Guidelines: Initial Authorization Request The following is a guide to what is expected in the individual assessment treatment plan for members with Autistic Spectrum Disorder.

I. Member’s identifying information

a. Name b. Date of birth c. Age d. Member’s insurance ID # e. Service address f. Parent/Caregiver name

g. Diagnosis, include date, name & title of the professional h. Date(s) of original assessment

i. Name, title and credential of the assessor

j. Name of the supervising BCBA – If there was a change in supervisor, indicate date of change and name of prior supervisor k. Current report date

II. Basic biopsychosocial information

a. Family composition b. Family primary concerns

c. Medical and mental health history, including treatment and medication, if applicable d. Current or prior services (i.e., ABA, speech, occupational, social skills group, etc.) e. Overall school functioning

III. Member’s capabilities / strengths and family’s support system

IV. Member’s current problem areas / skills deficits relating to their ASD diagnosis. If there is no skill deficit in an area, indicate normal / average or further assessment is required.

a. Cognitive / Pre-academic Skills b. Language / Communication Skills

c. Reduction of interfering or mild inappropriate behaviors d. Severe Behavior (aggression, property destruction) e. Safety Skills

f. Social Skills

g. Play and Leisure Skills

h. Independent Living / Self-Help Skills i. Community Integration

j. Coping and Tolerance Skills k. Other

Page

2 of 3 Version 1.4

a. Indirect observations used

i. Family/caregiver(s) interview (in-person, telephone)

ii. Records reviewed (i.e., IEP, psychological evaluations, reports from other ABA providers, etc.)

iii. Functional Assessment Screening Tool

iv. Other – Please specify

b. Direct observations used – minimum of two direct observations of the member is recommended

i. ABC charting

ii. Functional Behavioral Assessment (Direct and Indirect)

iii. Verbal Behavior Milestones Assessment & Placement Program, include grid

iv. Assessment of Basic Language & Learning Skills – Revised, include grid

v. Other – Specify other methods to systematically evaluate abilities and development of structured program.

Note: If further assessment is needed or will be used during the first authorization period, specify tool / type and why

VI. List skills to be targeted for increase (Goals):

a. Identify skills to be taught by area (See Section IV)

b. Each objective should be measurable, observable, age appropriate and achievable. The statement of the objectives should include the baseline measurement, current level of performance, and the anticipated level of achievement of the member at the end of the authorization period.

Note: Objectives should neither be educational in nature nor overlap IEP objectives. Please provide justification if objectives are included in the plan which would fit into the formerly mentioned

categories.

VII. Functional Behavior Assessment (FBA) of target behaviors / presenting problems (identified above)

a. Description of the problem (topography, onset/offset, cycle, intensity, severity) b. History of the problem (long-term and recent)

c. Antecedent analysis (setting, people, time of day, events) d. Consequence analysis

e. Impression and analysis of the function of the problem

Note: If a FBA was not conducted, provide an explanation and time frame as to when a FBA will be administered.

VIII. Recommended behavioral intervention plan

a. Instructional methods to be used (i.e., DTT, PRT, natural environment) b. Behavioral methods to be used (i.e., DRA, DRO, behavioral momentum) c. Treatment setting

d. Program observable and measureable behavior goals, including

i. Baseline data / Direct observation data described and graphically displayed ii. Operational definition for each behavior / skill

iii. Format of each goal should include the following components: 1. Goal introduction date

Page

3 of 3 Version 1.4

3. The observable response the member is expected to demonstrate or exhibit

4. The standards (mastery criteria) of performance expected when performing the task (e.g. frequency, duration, percentage, etc…) and target date for when the goal will be mastered

Example: Given at least five opportunities for social interactions with peers during a 1 hour social skills session, John will demonstrate appropriate social proximity (3-5 feet) to peers on 80% observed intervals on 3 consecutive weekly observations. Goal introduction date: 04/03/2013

Goal target mastery date: 12/03/2013

VIII. Preference Assessment:

a. Identify assessment method used (i.e., forced-choice, checklist, anecdotal reporting from care giver, etc.) b. Specify reinforcers and potential reinforcers identified for use

IX. Description of parent / caregiver behavioral management training / knowledge transfer plan

a. Condition and frequency of parent / caregiver trainings

b. Observable and measureable goals for the parent /caregiver. Refer to section VII, iii for goal components. c. Describe barriers to parent / caregiver involvement, if applicable

Note: Goals should align with member’s program goals and help the parent / caregivergeneralize and reinforce mastered goals.

X. Describe how coordination of care with other professionals, such as occupational therapist, psychotherapist, and / or psychiatrist will be facilitated

a. Have you communicated with the member’s prescriber of psychotropic drugs? b. Have you communicated with the member’s PCP?

i. Have you documented the communication or member declination?

c. Have you been in communication with other Behavior Health (BH) providers for this member? i. If yes, please indicate the type of BH provider.

XI. Describe how supervision (direct and indirect) and direct services will be delivered

XII. Crisis Plan

a. Emergency situation (i.e., weather, medical, behavioral)

b. Names and numbers of contacts that can assist in resolving the crisis

XIII. Summary and program recommendations, include program hours, parent training, supervision, social skills group (if applicable), etc.

a. A summary of the assessment should be included with justification for treatment recommendations. i. Include breakdown of number of hours requested for services by CPT code:

1. CPT Code – i.e., 0364T / 0365T

2. Description of Service – i.e., ABA Therapy by Para 3. # of total hours – i.e. 260

4. Breakdown per week – i.e. 10 hours per week

5. Location where services are to be delivered – i.e. in home