CommercialPrior AuthMedium impact
Applied Behavioral Analysis for Autism Spectrum Disorder or Pervasive Developmental Disorder (BSC3.01)
Blue Shield of California·CA · Pediatrics, Psychiatry, General Practice·Medical Policy
Effective date
May 1, 2026
We identified it
May 1, 2026
Summary
Blue Shield of California has updated their Applied Behavioral Analysis (ABA) policy for Autism Spectrum Disorder, effective May 1, 2026. The policy establishes comprehensive criteria for medical necessity, requires specific documentation and assessment protocols, mandates prior authorization for ABA services, and specifies supervision ratios of 1-2 hours per 10 hours of direct treatment.
Action Required
Before May 1, 2026: Billing team must ensure all ABA services require prior authorization from Blue Shield of California. Update billing workflows to include comprehensive assessment documentation, baseline behavior measurements, treatment goals, ongoing data analysis, caregiver training documentation, and transition/discharge planning. Verify supervision ratios of 1-2 hours per 10 hours of direct treatment are documented. Claims without proper prior authorization and documentation will be denied.