1. By: Christina Martin, M.S., CCC-SLP, BCBA
My Insurance Covers ABA: Now What? Medical Necessity, Authorization, and Appeals
By: Christina Martin, M.S., CCC-SLP, BCBA

2. Discussing treatment documentation and insurance is not
DISCLAIMER
Discussing treatment documentation and insurance is not
Not
Sexy
SEXY

3. DISCLAIMER
This content is for informational purposes only and it is intended to be a substitute for professional medical or legal advice for your specific situation.
not

4. Presentation Outline Medical Necessity Guidelines Authorizations
Appeals

5. Medical Necessity Guidelines

6. Medical Necessity Guidelines
There is no substitute for parent activism.
The provider can help, but they can’t fight insurance like the policy holder can because providers don’t pay the premiums.
Become educated about your specific policy.

7. Medical Necessity Guidelines
Per CMS, the definition of “Medically Necessary” is for services or supplies that:
are proper and needed for the diagnosis or treatment of your medical condition,
are provided for the diagnosis, direct care, and treatment of your medical condition,
meet the standards of good medical practice in the local area,
and are not mainly for the convenience of you or your doctor.
CMS.gov. (2017) Glossary. Retrieved from

8. Medical Necessity Guidelines
Each insurance carrier has created specific guidelines to determine the medical necessity of ABA therapy to treat an autism spectrum disorder.
Not all guidelines are alike.
Not all guidelines follow state mandates or The Mental Health Parity and Addiction Equity Act (MHPAEA).

9. Medical Necessity Guidelines

10. Medical Necessity Guidelines
Diagnosis

11. Medical Necessity Guidelines
Diagnosis

12. Medical Necessity Guidelines
Dosage
No specific dosage limitations listed

13. Medical Necessity Guidelines
Dosage

14. Medical Necessity Guidelines
Place of Service
No specific exclusions listed

15. Medical Necessity Guidelines
Place of Service

16. Medical Necessity Guidelines
Parent Participation

17. Medical Necessity Guidelines
Parent Participation

18. Medical Necessity Guidelines
Treatment Goals

19. Medical Necessity Guidelines
Treatment Goals

20. Authorizations

21. Authorizations Initial Evaluation Authorization
Request before the initial evaluation is conducted
Typically provide diagnostic information
Initial Evaluation Authorization
Request after the initial evaluation is conducted
Treatment Plan to document medical necessity
Initial Treatment Authorization
Request before the current authorization period expires
Treatment Plan to show progress and document medical necessity if services are still needed
Concurrent Treatment Authorization

22. Authorizations
Get your “docs” in a row

23. Authorizations Determine if authorization is required.
This should be part of the benefit check.
Any specific forms needed?
For example, if authorization is required, BCBS and Magellan require a specific form with each request.
What documentation must be sent?
Examples include: Diagnosis report, letter of medical necessity, physician referral/prescription, treatment plan
Is a live review required?
For example, if authorization is required, Cigna and Optum require a live review with every request

24. Denials will still happen
Overview of EFL
Even with all of this information . . .
Denials will still happen

25. Appeals

26. Appeals
Denial- Initial
May 13, 2016

27. Appeals
Denial- Appeal
July 13, 2016

28. Appeals
Denial- Overturned
September 1, 2016

29. Appeals
Denial- Initial
June 18, 2015

30. Appeals
Denial- Appeal
July 23, 2015

31. Denial- IOR Overturned
Appeals
Denial- IOR Overturned
September 29, 2015

32. Appeals
Denial- Initial
January 4, 2016

33. Denial- 1st Level Appeal
Appeals
Denial- 1st Level Appeal
January 20, 2016

34. Denial- 2nd Level Appeal
Appeals
Denial- 2nd Level Appeal
February 25, 2016

35. Denial- IOR Overturned
Appeals
Denial- IOR Overturned
May 2, 2016

36. Questions

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