Autism Spectrum Disorder (ASD) Services

Applied Behavior Analysis (ABA) is a term used to describe a specific behavioral treatment approach for individuals diagnosed with an autism spectrum disorder (ASD). The goal of ABA is to teach new skills, increase behaviors that are wanted, and decrease those behaviors that are undesirable. There is an emphasis on parent training and involvement as part of the treatment. 

Other specialty providers may perform an ABA service if it falls within the scope of their license, such as psychiatrists and psychologists.

Highmark Blue Shield of Northeastern New York is compliant with the New York State mandate that requires insurance plans to cover these services, and other provisions under the Affordable Care Act and Parity Laws to ensure services are available. However, not all benefit plans cover these services. Verification of benefits under your insurance plan is necessary to see if these benefits are covered by calling the toll-free customer service number on the back of your member ID card. 

Once you have verified that these are covered benefits, there are some steps that need to be taken. ABA benefits must be authorized and meet medical necessity criteria.

1. A diagnosis of ASD is required. This diagnosis can be made by your physician (pediatrician or family practitioner) or a behavioral health specialist such as a psychiatrist or psychologist in their office by using certain screening tools.
   
   
2. Once the diagnosis has been made, or if there is already a diagnosis, a request for authorization of a Functional Behavioral Assessment (FBA) must be submitted. Your provider will submit the Comprehensive Evaluation or Functional Behavioral Assessment Request Form along with any screenings, clinical or medical documents, or assessments that have been completed. These forms are available on the provider portal of the Blue Shield website. The request will be reviewed for medical necessity and a determination (decision) will be made.*
   
   
3. If authorized, the FBA is administered by a qualified provider. It involves several interviews, observations, and review of clinical information and prior treatments that may have been received. It may take several visits and hours to complete. Once the provider has completed this assessment, they will submit the assessment summary that includes recommendations — Is ABA treatment recommended? What ABA services will be required? How frequent? — along with the Outpatient Applied Behavior Analysis Treatment Report Request Form to request authorization of the recommended ABA treatment services. This will be reviewed for medical necessity and a determination (decision) will made.*

*You will be notified of the decision; if the request is not approved, you will receive a written notification stating why the request was denied and instructions on what you can do.  

Certain devices or software dedicated to the production of speech or interpersonal communication may be eligible for coverage based on your benefit plan, certain criteria, and a comprehensive speech and language evaluation by a licensed speech and language pathologist. A prescription from a doctor is required for the device.

The speech and language evaluation must include documentation of the type of speech disorder and severity, the individual’s ability to use the device, that alternate communication means (sign language, gestures) are inadequate, treatment goals, and specific device or software needs along with the device name, provider, price, and codes. Software or apps that run on these devices may also be eligible for coverage.

Only devices or software dedicated to the production of speech or interpersonal communication are covered. Computers, iPads, and smart phones are NOT covered devices. 

You may call the toll-free customer service number on the back of your member ID card for assistance.

Customer service can verify if an ABA provider you are interested in is participating.

Non participating providers must submit an out-of-network/out-of-plan (OON/OOP) referral request as well as pre-authorization** for the service. Based on your benefit plan, you may not have the ability to use an OON/OOP provider, and your out of pocket cost-share may be much higher.

Blue Shield behavioral health case managers are also available to assist you in finding participating ABA providers.

**Request forms are available for providers on the website.