Navigate Insurance
Understanding the process of using insurance benefits to cover autism treatments
The link below shares the step by step process of navigating through the insurance process including assessment, meeting medical necessity, co-pays and out-of-pocket cost and payment for services.
Navigating the Insurance Process May 2017
An insurance carriers expectation of treatment team structure and supervision
Insurance carriers expect a treatment team structure and supervision of registered behavior technicians to meet the ethical guidelines of providing ABA treatment.
Structure of an ABA Treatment Service Model
February 2019 Update: Clarifications Regarding Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers (2nd ed.)
Supplemental Guidance on Interpreting and Applying the 2019 CPST Codes for Adaptive Behavior Services
FINAL+CPT+Supplemental+Guidance+1.9.19 (1)
New American Medical Association medical billing coding for ABA
Beginning in January 2019, the newly announced AMA CPT codes for Adaptive Behavior Assessment (applied behavior analysis, ABA) and Treatment Code for insurance reimbursement take effect. Learn More
Glossary of Health Coverage and Medical Terms
INSURANCE APPEAL TYPES
Internal appeal: If your claim is denied or your health insurance coverage canceled, you have the right to an internal appeal. You may ask your insurance company to conduct a full and fair review of its decision. If the case is urgent, your insurance company must speed up this process.
External review: You have the right to take your appeal to an independent third party for review. This is called external review. External review means that the insurance company no longer gets the final say over whether to pay a claim. This reviewer needs to be an expert in the field of treatment autism such as a BCBA-D or BCBA.
Consumer Complaint: Do you have a health insurance complaint because your health care service or treatment was denied, reduced, or terminated by your health plan? You can file a consumer complaint with the Ohio Department of Insurance.
WHAT ARE COMMON DENIALS FOR ACCESSING ABA TREATMENT?
A part of utilizing insurance benefits to cover autism treatments is knowing a treatment request could be denied. Common denials are:
ADOS Requirement
Partial denial of treatment hours
ABA is experimental or educational
Fail First Option
The location is not allowed
Treatment plan does not support the level of treatment hours requested
Not enough hours in the day
Treatment gains are plateauing
ABA is not effective after age of 12.