Yes, Kaiser Permanente provides coverage for ABA therapy to individuals diagnosed with autism or a developmental disability for which there is evidence that ABA therapy would be effective.
Not all Kaiser Permanente insurance plans cover ABA treatment. However, your coverage can be verified by contacting Kaiser Permanente of Washington Member Services toll-free at 1-888-901-4636.
Your family is required to provide a diagnosis of the member's autism spectrum disorder diagnosis or developmental disability.
There needs to be evidence that Applied Behavior Analysis (ABA) therapy is effective for your child. There also must be a referral for ABA treatment from a licensed health, mental health, or allied health provider.
A few examples of this would be a physician, psychologist, or a speech-language pathologist.
Your family's request for ABA therapy needs to be reviewed to determine whether they meet Kaiser Permanente's clinical review criteria.
Regardless of the patient's insurance plan, preauthorization is needed for the patient to receive coverage for ABA therapy.
Applied Behavior Analysis is delivered by providers who are contracted with Kaiser Permanente. However, if contracted providers aren't available, it's permitted for treatment to be delivered by non-contracted providers.
Despite this exception, all non-contracted providers must meet all state regulatory and licensure requirements. The authorization process is as follows:
A preauthorization request is generated to pre-approve an ABA assessment once a Kaiser Permanente member receives a referral for ABA therapy.
A pre-approval of the autism treatment is given after the member meets all clinical criteria.
An initial review of a referral is completed to determine whether the enrollee meets all eligibility criteria to receive ABA therapy. The criteria includes: diagnosis, coverage, presence of autistic behaviors that clearly have a significant impact on living.
An ABA assessment preauthorization is approved if the enrollee meets the criteria to receive ABA therapy.
Preauthorization requests can come from the members medical provider. This can either be their primary care physician, psychologist, or physician.
If the diagnosed member already has the formal documentation, the therapy provider is allowed to submit a preauthorization request with the diagnosis documents attached.
The CPT code will be included in the letter of approval for preauthorization of autism therapy services.
Initial assessments can be 6-10 hours long even though Kaiser Permanente doesn't issue a set number of hours for the initial assessment.
Any session that is longer than 10 hours will need to provide an additional clinical justification and hours utilization breakdown. In the references section, we will include a link to the Kaiser Permanente ABA PreAuthorization Request Template (Word).
Continued Treatment For Autism
After six months have passed, a progress report must be submitted by the ABA provider to determine whether the enrollee still meets criteria to receive ABA therapy. If the treatment plan is approved once Kaiser Permanente reviews it, an additional six months of ABA therapy is authorized.
Progress reports must be submitted 15 days before the end of the current authorization period.
Progress reports which are submitted after the 15 day due date could not be eligible for retro pay on claims which fall on days with no existing authorizations.
The ABA therapy provider must include a detailed explanation with the report.
The Kaiser Permanente report templates should be used for initial and continued care reports. It's important that these templates are used because failure to use them could result in submission of incomplete information which would delay the authorization process.
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