Date: January 19, 2021
Medical Assistance Program Providers
Re: Coverage for
Applied Behavioral Analysis (ABA) Services for Children 0 through 20 Years –
This notice outlines the process for licensed clinical
psychologists (LCPs) and licensed clinical social workers (LCSWs) enrolled to
provide applied behavioral analysis (ABA) services to request prior approval.
The prior approval process described in this notice is specific to children
covered under Medicaid fee-for-service. For children covered under a Medicaid
managed care plan, please contact the plan for guidance on their approval
notice dated October 30, 2020, the Department announced coverage
for ABA services for children with a diagnosis of autism spectrum disorder when
ordered by a physician licensed to practice medicine in all its branches. That
notice also identified provider qualifications and summarized the steps
involved for enrollment of LCPs, LCSWs, and Registered Behavioral Technicians
(RBTs) specifically for ABA services.
LCPs and LCSWs may request prior approval and provide approved services as
ABA Service Description
Behavioral Assessment and Treatment Planning (BATP). BATP is the formal process of information
gathering and service planning to: 1) evaluate current maladaptive or
disruptive behaviors, skills and needs; and 2) identify individualized
treatment goals, objectives and recommendations for the delivery of ABA
Services. The BATP is expected to be completed, or updated:
Once every 180 days;
Be reviewed, approved, and signed by
a BCBA; and
Be signed, and a copy provided to
the participant, or the participant’s parent or guardian, upon completion or
Behavioral Analytic Intervention
(BAI). BAI consist of services identified on the participant’s BATP for the
maximum reduction of mental disability through the use of behavioral stimuli
and consequences, to produce socially significant improvement in behavior,
including the use of direct observation, measurement, and functional analysis of
the relationships between environment and behavior. BAI may be provided:
At all service locations and
settings deemed appropriate for reimbursement, consistent with Department
In an individual or group modality,
as defined by the service code.
ABA Fee-for-Service Fee Schedule
HFS approved ABA Service codes and their associated
reimbursement rate is available on the HFS website as a component of theLicensed
Clinical Psychologists and Licensed Clinical Social Workers Fee Schedule.
Prior Approval for ABA Services
BATP services exceeding six hours (24 units) per a 180-day
period and all BAI services require prior authorization. Providers must
complete the Prior
Authorization for Applied Behavioral Analysis (ABA) Services
form and submit all required documentation to HFS.ABA@Illinois.gov.
ABA Prior Authorization Clinical
The following attachments may be required to obtain approval
for ABA services.
Physician Order. The physician order
and referral for ABA service delivery is required with the first submission for
ABA services and is valid for one year.
Comprehensive Diagnostic Evaluation
(CDE). The participant’s completed CDE, performed by a physician or a clinical
psychologist, must be submitted with the first submission for ABA services, and
upon request for all subsequent submissions.
CDE is an assessment, evaluation, or test that is required to establish a
diagnosis of ASD. The CDE must include:
Direct interaction and assessment of
Assessment of the individual
outlining behaviors consistent with ASD per DSM-V criteria, resulting in one of
the following completed assessments:
Diagnostic Observation Schedule (ADOS);
Autism Rating Scale (GARS);
Diagnostic Interview (ADI); or
Autism Rating Scale (CARS)
A review of the individual’s
developmental and psychosocial history (milestones);
Current functional ability in both
verbal and nonverbal areas; and
A primary caregiver interview.
CDE may also include a review of standardized cognitive and developmental
testing; neurological testing; hearing screening; vision screening; genetic
testing; and other non-specified medical testing required to rule out other
disorders and conditions.
Documentation of Functional
Impairment. If the participant’s CDE was completed more than 24 months prior to
the date of request for prior authorization, current individualized
documentation of functional impairment by a physician or a clinical
psychologist is required.
Clinical Narrative. Requests for
BATP services exceeding six (6) hours per 180-day period should be accompanied
by a clinical narrative detailing why more than six (6) hours of assessment and
treatment planning are needed to complete the participant’s BATP.
Behavioral Assessment and Treatment
Plan (BATP). Requests for BAI services must be accompanied by the participant’s
BATP, completed within 30 days of request date for prior authorization of BAI
Prior Authorization Review Timelines
Pursuant to 89
Ill. Admin. Code 140.Table E, Item 26, prior authorization
determinations shall be made within 30 days of submission.
Review Outcomes. The provider and
the participant will be notified of the outcome of the prior authorization
review and the right to appeal, if applicable, consistent with 89
Ill. Admin. Code Section 102.70. ABA service approvals are not
transferable, as they are specific to a participant, provider, and service
Missing or Incomplete Documentation.
If a prior authorization request is incomplete, or requires additional clinical
documentation to be properly considered, the Department will suspend the prior
authorization review process, stopping the 30-day time limit for prior
authorization review, and request additional clinical information from the provider.
All requests for additional clinical information must be remedied by the
provider in order to re-start the prior authorization review process with a new
30-day review window.
Questions regarding the prior approval process for ABA
services may be directed to HFS.ABA@illinois.gov.
Kelly Cunningham, Administrator
Division of Medical Programs