Early Intensive Behavioral Intervention Providers and Applied Behavior Analysts
Effective April 1, 2018, the South Carolina Department of Health and Human Services (SCDHHS) will implement the following changes to the policy manual for autism spectrum disorder (ASD) services.
New language regarding the SCDHHS quality improvement organization (QIO)
Providers serving Medicaid fee-for-service beneficiaries must receive prior authorization from the SCDHHS ASD program's designated QIO, KEPRO. SCDHHS contracts with KEPRO for utilization review and prior authorization services. Providers must follow the prior authorization guidelines outlined below in order to receive Medicaid reimbursement.
Prior authorization procedures
For initial treatment requests, the comprehensive testing/assessment report, behavior identification assessment results and Individualized Plan of Care (IPOC) must be submitted with the SCDHHS Applied Behavior Analysis (ABA) Prior Authorization Request Form to the QIO.
For continued treatment, the current IPOC and last two 90-day progress summaries must be submitted to the QIO with the SCDHHS ABA Prior Authorization Request Form. Continued treatment requests may be submitted up to 30 days before and no later than 10 days before the expiration of authorized visits. Failure to obtain approval prior to the provision of services could result in a claim denial.
All annual treatment reviews require submission of the SCDHHS ABA Prior Authorization Request Form, a new behavior identification assessment, the current IPOC and the previous two 90-day progress summaries to the QIO. Annual treatment requests may be submitted up to 30 days before and no later than 10 days before the expiration of authorized visits. Failure to obtain approval prior to the provision of services will result in claim denial.
Age guidelines for definitive diagnosis
Beneficiaries receiving ASD services with a presumptive diagnosis must have a comprehensive assessment/testing report documenting that the beneficiary meets the medical necessity criteria for services via a Diagnostic and Statistical Manual of Mental Disorders (DSM) or International Classification of Diseases, 10th revision, (ICD-10) ASD diagnosis by a licensed psychologist, school psychologist or developmental pediatrician by the beneficiary's fourth birthday in order to continue receiving services.
Behavior technician provider qualifications
The behavior technician is a paraprofessional who practices under the supervision of a board certified behavior analyst (BCBA) or board certified assistant behavior analyst (BCaBA). The behavior technician is primarily responsible for the direct implementation of the behavior-analytic services. The certified BCBA supervising the behavior technician is responsible for the work performed by the behavior technician. The behavior technician must be 18 years of age or older and possess a minimum of a high school diploma or national equivalent. Behavior technicians will be granted a 90-day period to acquire a registered behavior technician credential from the date of hire.
Guidelines for linking individual ABA providers to their group
In order to link an enrolled individual provider to an existing group provider, an authorized representative must send a signed letter on company letterhead, indicating all of the BCBA and BCaBA providers who need to be linked to the group practice number. The letter must include each individual provider's National Provider Identification (NPI) number. Submit this letter to asdprovider@scdhhs.gov.
Guidelines regarding transition and discharge planning
Transition and discharge planning must include a written plan containing specific details of monitoring and follow-up. Parents, caregivers and other involved professionals should be consulted three-six months before the first change in service. A description of roles and responsibilities of all providers and effective dates for behavioral targets that must be achieved before the next phase should be specified and coordinated with all providers, the beneficiary and family members. Transition and discharge planning from all treatment programs should involve a gradual step down in services over a period of six months or longer.
Should you have any questions regarding this bulletin, please contact the SCDHHS Division of Behavioral Health at (803) 898-2565.
Thank you for your continued support of the South Carolina Healthy Connections Medicaid program.