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Washington Apple Health (Medicaid)Applied BehavioralAnalysis (ABA) ProgramBilling Guide(For clients age 20 and younger)January 1, 2020Every effort has been made to ensure this guide’s accuracy. If an actual or apparent conflict between thisdocument and an agency rule arises, the agency rules apply.
Applied Behavior Analysis (ABA) Programfor Clients Age 20 and YoungerAbout this guide This publication takes effect January 1, 2020, and supersedes earlier guides to this program.HCA is committed to providing equal access to our services. If you need an accommodation orrequire documents in another format, please call 1-800-562-3022. People who have hearing orspeech disabilities, please call 711 for relay services.Washington Apple Health means the public health insurance programs for eligibleWashington residents. Washington Apple Health is the name used in WashingtonState for Medicaid, the children's health insurance program (CHIP), and stateonly funded health care programs. Washington Apple Health is administered bythe Washington State Health Care Authority.What has changed?SubjectEntire guideBehavioral HealthOrganization (BHO)Integrated ManagedCare Regions ChangeHyperlink and typographicalerror corrections, and generalhousekeepingRemoved this sectionEffective January 1, 2020,integrated managed care is beingimplemented in the last threeregions of the state:Reason for ChangeTo improve usabilityEffective January 1, 2020,behavioral health services inall regions will be providedunder integrated managedcare.Effective January 1, 2020,HCA completed the move towhole person care to allowbetter coordination of care forboth body (physical health)and mind (mental health and Great Rivers (Cowlitz,Grays Harbor, Lewis, Pacific, substance use disordertreatment, together known asand Wahkiakum counties)“behavioral health”). This Salish (Clallam, Jefferson,delivery model is calledand Kitsap counties)Integrated Managed Care Thurston-Mason (Mason(IMC).and Thurston counties)This publication is a billing instruction.2
Applied Behavior Analysis (ABA) Programfor Clients Age 20 and YoungerHow can I get agency provider documents?To access provider alerts, go to the agency’s provider alerts webpage.To access provider documents, go to the agency’s provider billing guides and fee scheduleswebpage.Where can I download agency forms?To download an agency provider form, go to HCA’s Billers and Providers webpage, selectForms & publications. Type the HCA form number into the Search box as shown below(Example: 13-835).Copyright disclosureCurrent Procedural Terminology (CPT) copyright 2019 AmericanMedical Association. All rights reserved. CPT is a registeredtrademark of the American Medical Association (AMA).Fee schedules, relative value units, conversion factors and/orrelated components are not assigned by the AMA, are not part ofCPT, and the AMA is not recommending their use. The AMA doesnot directly or indirectly practice medicine or dispense medicalservices. The AMA assumes no liability for data contained or notcontained herein.3
Applied Behavior Analysis (ABA) Programfor Clients Age 20 and YoungerTable of ContentsResources Available . 7Definitions . 8Program Overview . 9Who should read this guide? . 9What is ABA? . 9What is the purpose of the ABA program? . 9Client Eligibility . 10How do I verify a client’s eligibility? . 10Are clients enrolled in an agency-contracted managed care organization (MCO)eligible? . 11Managed care enrollment . 12Apple Health – Changes for January 1, 2020 . 13Clients who are not enrolled in an agency-contracted managed care plan forphysical health services. 14Integrated managed care (IMC) . 14Integrated Apple Health Foster Care (AHFC) . 16Fee-for-service Apple Health Foster Care . 16Provider Eligibility. 17Who may provide services under the applied behavior analysis (ABA) program? . 17What is a Center of Excellence (COE)? . 17What are the qualifications for a COE? . 17How does a provider become recognized as a COE? . 19Will the agency accept an evaluation that was not completed by a COE? . 19Who can apply to provide ABA services? . 19Who can enroll with the agency as a lead behavior analysis therapist (LBAT)? . 20Additional requirements for LBAT enrollment . 20How do providers enroll with the agency as a certified behavior technician (CBT)? . 20Additional requirements for CBT enrollment . 21Becoming a facility-based day treatment program . 21Accessing ABA Services . 22What is the applied behavior analysis (ABA) pathway to care? . 22Stage one of the pathway to care . 22Referral . 22What does the COE do? . 23Required documentation . 23The comprehensive diagnostic evaluation . 23Stage two of the pathway to care . 25Selecting an ABA provider . 25Parent training only while the child is on a waitlist for individual ABA services. 25Alert! This Table of Contents is automated. Click on a page number to go directly to the page.4
Applied Behavior Analysis (ABA) Programfor Clients Age 20 and YoungerThe ABA assessment and treatment plan . 26Stage three of the pathway to care . 27LBAT responsibilities . 28CBT responsibilities. 28ABA delivery methods and settings . 29Community-based program services. 29Home and community services: . 29What is the early intensive behavioral intervention day treatment program (daytreatment program)? . 30Purpose of the day treatment program . 30Providers in the day treatment program . 31Requirements for the day treatment program . 31Day Treatment Program Model . 33What client files and records does the agency require? . 34Telemedicine . 36What is telemedicine? . 36Originating site. 36Distant site . 36Which services may be provided via telemedicine? . 37What services are not paid for under telemedicine? . 37Authorization. 38What is prior authorization (PA)? . 38When is PA required? . 38What forms and documents are required for PA for fee-for-service clients? . 39Does PA for ABA services expire? . 40What if additional units of service are needed to continue providing ABA services? . 40What are the requirements for recertification of ABA services? . 41Additional requirements for recertification of ABA services . 41Why might the agency deny recertification of ABA services?. 42What is a limitation extension (LE)? . 42How do I obtain an LE? . 43Coverage . 44What is covered? . 44ABA treatment – home and community-based settings . 44ABA treatment – group settings . 45What modifiers do providers bill with? . 46What about services covered under other agency programs? . 46Which services are not covered?. 47Billing . 48What are the general billing requirements? . 48What procedure codes do I use to bill for home and community-based services? . 48What codes do day treatment programs use to bill the agency? . 49Alert! This Table of Contents is automated. Click on a page number to go directly to the page.5
Applied Behavior Analysis (ABA) Programfor Clients Age 20 and YoungerHow do I bill claims electronically? . 49Rendering and individual provider taxonomy numbers . 49Alert! This Table of Contents is automated. Click on a page number to go directly to the page.6
Applied Behavior Analysis (ABA) Programfor Clients Age 20 and YoungerResources AvailableTopicPrior Authorization (PA) orLimitation Extension (LE)ResourceFor all requests for PA or LE, the following documentation isrequired: A completed, TYPED, General Information forAuthorization form, HCA 13-835. This request form MUSTbe the initial page when you submit your requestA completed Applied Behavior Analysis Services requestform, HCA 12-411, for initial PA requests andrecertification.A completed Assessment and Behavior Change Plan form,HCA 13-400, for PA requests and recertification.For information about downloading agency forms, see Where canI download agency forms?Becoming a provider orsubmitting a change of address orownershipContacting Provider EnrollmentFinding out about payments,denials, claims processing, oragency managed careorganizationsSee the agency’s ProviderOne Resources webpageElectronic billingFinding agency documents (e.g.,billing guides, fee schedules)Private insurance or third-partyliability, other than agencycontracted managed careAccess E-learning toolsSee the agency’s ProviderOne Resources webpageMore informationSee the agency’s Autism and Applied Behavior Analysis (ABA)therapy webpage7
Applied Behavior Analysis (ABA) Programfor Clients Age 20 and YoungerDefinitionsThis list defines terms and abbreviations, including acronyms, used in this billing guide. Refer toChapter 182-500 WAC for a complete list of definitions for Washington Apple Health.Comprehensive treatment model – Amodel that meets a child’s individual needsin addressing core symptom areas of autismand related disorders, disrupts challengingbehaviors, and builds a foundation forlearning-readiness across multiple domainsof functioning.Autism diagnostic tool - A tool used toestablish the presence (or absence) of autismand to make a definitive diagnosis, whichwill be the basis for treatment decisions andthe development of a treatment plan.Examples of autism diagnostic tools include: Diagnostic and Statistical Manual ofMental Disorders (DSM-5) - The manualpublished under this title by the AmericanPsychiatric Association that provides acommon language and standard criteria forthe classification of mental disorders.Autism diagnosis interview (ADI).Autism diagnostic observationschedule (ADOS).Autism screening tool - A tool used by aprimary care provider to detect indicators orrisk factors for autism and may indicate asuspicion of the condition, which wouldthen require confirmation, which would thenrequire a referral to a Center of Excellencefor confirmation.Managed care organization (MCO) – SeeWAC 182-538-050.National Provider Identifier (NPI) – SeeWAC 182-500-0075.Examples of screening tools include: Ages and stages questionnaire(ASQ).Communication and symbolicbehavior scales (CSBS).Parent's evaluation anddevelopmental status (PEDS).Modified checklist for autism intoddlers (MCHAT).Screening tools for autism intoddlers and young children (STAT).8
Applied Behavior Analysis (ABA) Programfor Clients Age 20 and YoungerProgram OverviewWho should read this guide?This guide contains instructions for: Centers of Excellence (COEs) who conduct the clinical diagnostic evaluation, andApplied behavior analysis (ABA) providers offering ABA services.This guide may also be helpful to primary care providers who want to assist children and theirfamilies in accessing ABA services and navigating the pathway to care.What is ABA?ABA is an approach to improve behavior and skills related to core impairments associated withautism and a number of other developmental disabilities. ABA therapy involves application ofvalidated principles of human behavior to change inappropriate behaviors. Providers monitor andmeasure how well therapy is working using validated methods. ABA therapy also focuses onsocial significance, which promotes a family-centered, whole-life approach.What is the purpose of the ABA program?WAC 182-531A-0100Apple Health includes coverage for ABA services for children age 20 and younger to address thecore symptoms associated with autism spectrum disorders or other developmental disabilities.ABA services support learning and assist with the development of social, behavioral, adaptive,motor, vocational, and cognitive skills.9
Applied Behavior Analysis (ABA) Programfor Clients Age 20 and YoungerClient EligibilityMost Apple Health clients are enrolled in an agency-contracted managed care organization(MCO). This means that Apple Health pays a monthly premium to an MCO for providingpreventative, primary, specialty, and other health services to Apple Health clients. Clients inmanaged care must see only providers who are in their MCO’s provider network, unless priorauthorized or to treat urgent or emergent care. See the agency’s Apple Health managed care pagefor further details.It is important to always check a client’s eligibility prior toproviding any services because it affects who will pay for the services.How do I verify a client’s eligibility?Check the client’s Services Card or follow the two-step process below to verify that a client hasApple Health coverage for the date of service and that the client’s benefit package covers theapplicable service. This helps prevent delivering a service the agency will not pay for.Verifying eligibility is a two-step process:Step 1. Verify the patient’s eligibility for Apple Health. For detailed instructions onverifying a patient’s eligibility for Apple Health, see the Client Eligibility, BenefitPackages, and Coverage Limits section in the agency’s ProviderOne Billing andResource Guide.If the patient is eligible for Apple Health, proceed to Step 2. If the patient is noteligible, see the note box below.Step 2. Verify service coverage under the Apple Health client’s benefit package. Todetermine if the requested service is a covered benefit under the Apple Health client’sbenefit package, see the agency’s Program Benefit Packages and Scope of Serviceswebpage.10
Applied Behavior Analysis (ABA) Programfor Clients Age 20 and YoungerNote: Patients who are not Apple Health clients may submit an application forhealth care coverage in one of the following ways:1.By visiting the Washington Healthplanfinder’s website at:www.wahealthplanfinder.org2.By calling the Customer Support Center toll-free at: 855-WAFINDER(855-923-4633) or 855-627-9604 (TTY)3.By mailing the application to:Washington HealthplanfinderPO Box 946Olympia, WA 98507In-person application assistance is also available. To get information about inperson application assistance available in their area, people may visitwww.wahealthplanfinder.org or call the Customer Support Center.Are clients enrolled in an agency-contractedmanaged care organization (MCO) eligible?Yes. Most Medicaid-eligible clients are enrolled in one of the agency’s contracted managed careorganizations (MCOs). For these clients, managed care enrollment will be displayed on the clientbenefit inquiry screen in ProviderOne.All medical services covered under an agency-contracted MCO must be obtained by the clientthrough designated facilities or providers. The MCO is responsible for: Payment of covered servicesPayment of services referred by a provider participating with the plan to an outsideproviderNote: A client’s enrollment can change monthly. Providers who are notcontracted with the MCO must receive approval from both the MCO and theclient’s primary care provider (PCP) prior to serving a managed care client.Send claims to the client’s MCO for payment. Call the client’s MCO to discuss payment priorto providing the service. Providers may bill clients only in very limited situations as described inWAC 182-502-0160.11
Applied Behavior Analysis (ABA) Programfor Clients Age 20 and YoungerNote: To prevent billing denials, check the client’s eligibility prior to schedulingservices and at the time of the service, and make sure proper authorization orreferral is obtained from the agency-contracted MCO, if appropriate. See theagency’s ProviderOne Billing and Resource Guide for instructions on how to verifya client’s eligibility.Managed care enrollmentApple Health (Medicaid) places clients into an agency-contracted MCO the same month they aredetermined eligible for managed care as a new or renewing client. This eliminates a person beingplaced temporarily in FFS while they are waiting to be enrolled in an MCO or reconnected witha prior MCO. This enrollment policy also applies to clients in FFS who have a change in theprogram they are eligible for. However, some clients may still start their first month of eligibilityin the FFS program because their qualification for MC enrollment is not established until themonth following their Medicaid eligibility determination.New clients are those initially applying for benefits or those with changes in their existingeligibility program that consequently make them eligible for Apple Health managed care.Renewing clients are those who have been enrolled with an MCO but have had a break inenrollment and have subsequently renewed their eligibility.Checking eligibility Providers must check eligibility and know when a client is enrolled and with whichMCO. For help with enrolling, clients can refer to the Washington Healthplanfinder’s GetHelp Enrolling page. MCOs have retroactive authorization and notification policies in place. The provider mustknow the MCO’s requirements and be compliant with the MCO’s policies.12
Applied Behavior Analysis (ABA) Programfor Clients Age 20 and YoungerApple Health – Changes for January 1, 2020Effective January 1, 2020, the Health Care Authority (HCA) completed the move to wholeperson care to allow better coordination of care for both body (physical health) and mind (mentalhealth and substance use disorder treatment, together known as “behavioral health”). Thisdelivery model is called Integrated Managed Care (formerly Fully Integrated Managed Care, orFIMC, which still displays in ProviderOne and Siebel).IMC is implemented in the last three regions of the state: Great Rivers (Cowlitz, Grays Harbor, Lewis, Pacific, and Wahkiakum counties)Salish (Clallam, Jefferson, and Kitsap counties)Thurston-Mason (Mason and Thurston counties)These last three regions have plan changes, with only Amerigroup, Molina, and UnitedHealthcare remaining. There are changes to the plans available in these last three regions. Theonly plans that will be in these regions are Amerigroup, Molina, and United Healthcare. If aclient is currently enrolled in one of these health plans, their health plan will not change.Clients have a variety of options to change their plan: Available to clients with a Washington Healthplanfinder account:Go to Washington HealthPlanFinder website. Available to all Apple Health clients: Visit the ProviderOne Client Portal website: Call Apple Health Customer Service at 1-800-562-3022. The automated system isavailable 24/7. Request a change online at ProviderOne Contact Us (this will generate an email toApple Health Customer Service). Select the topic “Enroll/Change Health Plans.”For online information, direct clients to HCA’s Apple Health Managed Care webpage.13
Applied Behavior Analysis (ABA) Programfor Clients Age 20 and YoungerClients who are not enrolled in an agency-contractedmanaged care plan for physical health servicesSome Medicaid clients do not meet the qualifications for managed care enrollment. These clientsare eligible for services under the FFS Medicaid program. In this situation, each IntegratedManaged Care (IMC) plan will have Behavioral Health Services Only (BHSO) plans availablefor Apple Health clients who are not in managed care. The BHSO covers only behavioral healthtreatment for those clients. Clients who are not enrolled in an agency-contracted managed careplan are automatically enrolled in a BHSO, with the exception of American Indian/Alaska Nativeclients. Some examples of populations that may be exempt from enrolling into a managed careplan are Medicare dual-eligible, American Indian/Alaska Native, Adoption support and FosterCare alumni.Integrated managed care (IMC)Clients qualified for managed care enrollment and living in integrated managed care (IMC)regions will receive all physical health services, mental health services, and substance usedisorder treatment through their agency-contracted managed care organization (MCO).American Indian/Alaska Native (AI/AN) clients have two options for AppleHealth coverage: Apple Health Managed Care; orApple Health coverage without a managed care plan (also referred to asfee-for-service [FFS]).If a client does not choose an MCO, they will be automatically enrolled intoApple Health FFS for all their health care services, including comprehensivebehavioral health services. See the agency’s American Indian/Alaska Nativewebpage.For more information about the services available under the FFS program, see theagency’s Mental Health Services Billing Guide and the Substance Use DisorderBilling Guide.For full details on integrated managed care, see the agency’s Apple Health managed carewebpage and scroll down to “Changes to Apple Health managed care.”14
Applied Behavior Analysis (ABA) Programfor Clients Age 20 and YoungerIntegrated managed care regionsClients residing in integrated managed care regions and who are eligible for managed careenrollment must choose an available MCO in their region. Details, including information aboutmental health crisis services, are located on the agency’s Apple Health managed care webpage.RegionGreat RiversSalishThurston-MasonNorth SoundGreater ColumbiaKingPierceSpokaneNorth CentralSouthwestCountiesCowlitz, Grays Harbor,Lewis, Pacific, andWahkiakumClallam, Jefferson, KitsapThurston, MasonIsland, San Juan, Skagit,Snohomish, and WhatcomAsotin, Benton, Columbia,Franklin, Garfield, Kittitas,Walla Walla, Yakima, andWhitmanKingPierceAdams, Ferry, Lincoln, PendOreille, Spokane, and StevenscountiesGrant, Chelan, Douglas, andOkanoganClark, Skamania, andKlickitat15Effective DateJanuary 1, 2020January 1, 2020January 1, 2020July 1, 2019January 1, 2019January 1, 2019January 1, 2019January 1, 2019January 1, 2018January 1, 2019 (Okanogan)April 2016January 1, 2019 (Klickitat)
Applied Behavior Analysis (ABA) Programfor Clients Age 20 and YoungerIntegrated Apple Health Foster Care (AHFC)Children and young adults in the Foster Care, Adoption Support and Alumni programs who areenrolled in Coordinated Care of Washington’s (CCW) Apple Health Foster Care program receiveboth medical and behavioral health services from CCW.Clients under this program are: Under the age of 21 who are in foster care (out of home placement)Under the age of 21 who are receiving adoption supportAge 18-21 years old in extended foster careAge 18 to 26 years old who aged out of foster care on or after their 18th birthday (alumni)These clients are identified in ProviderOne as“Coordinated Care Healthy Options Foster Care.”The Apple Health Customer Services staff can answer general questions about this program. Forspecific questions about Adoption Support, Foster Care or Alumni clients, contact the agency’sFoster Care Medical Team at 1-800-562-3022, Ext. 15480.Fee-for-service Apple Health Foster CareChildren and young adults in the fee-for-service Apple Health Foster Care, Adoption Support andAlumni programs receive behavioral health services through the regional Behavioral HealthServices Organization (BHSO). For details, see the agency’s Mental Health Services BillingGuide, under How do providers identify the correct payer?16
Applied Behavior Analysis (ABA) Programfor Clients Age 20 and YoungerProvider EligibilityWAC 182-531A-0800Who may provide services under the appliedbehavior analysis (ABA) program?Two types of providers deliver services under the ABA program: Centers of Excellence (COE) Applied behavior analysis (ABA) therapy service providersWhat is a Center of Excellence (COE)?A COE is a hospital, medical center, or other health care provider that meets or exceedsstandards set by the agency for specific treatments or specialty care. In this program, a COEperforms the clinical diagnostic evaluation to determine whether ABA services are appropriatefor an individual child. The COE provides the required diagnostic documentation, evidence ofmedical necessity, and an order for ABA services to the agency or the managed care organization(MCO).What are the qualifications for a COE?All COE providers
Washington Apple Health (Medicaid) Applied Behavioral Analysis (ABA) Program Billing Guide (For clients age 20 and younger) January 1, 2020 . Every effort has been made to ensure this guide's accuracy.
