All PlansCoverageHigh impact
Treatment of Autism Spectrum Disorder (ASD)
Blue Cross & Blue Shield of Mississippi·MS · Psychiatry, Pediatrics, Family Medicine·Medical Policy
We identified it
Jun 20, 2026
Summary
This is a comprehensive new medical policy establishing coverage criteria for Applied Behavioral Analysis (ABA) treatment for Autism Spectrum Disorder. The policy defines specific requirements for ABA assessment, treatment plan development, and ongoing services with detailed CPT codes and certification requirements for providers.
Action Required
Immediately: Billing team must implement new ABA billing protocols requiring BCBA/BCBA-D certification verification for providers. Update system to enforce frequency limits: CPT 97151 (behavioral assessment) limited to once every 6 months, CPT 97152 and 0362T (follow-up assessments) limited to 3 hours every 6 months. Require standardized autism testing (CPT 96112, 96113) within 2 months of initial treatment. Verify all ABA claims include proper DSM-5 ASD diagnosis documentation and individualized treatment plans. Claims without proper certification or exceeding frequency limits will be denied.