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Behavioral Health Treatment for Autism Spectrum Disorder or Pervasive Developmental Disorder (BSC3.01)
Effective date
Dec 1, 2025
Identified
Nov 1, 2025
Summary
Blue Shield of California medical policy BSC3.01 covers outpatient behavioral health treatment, including applied behavior analysis (ABA), for autism spectrum disorder or pervasive developmental disorder when it is medically necessary. Blue Shield covers BHT/ABA when it is state mandated or when it is specifically included in a member's benefit plan. Respite, day care, educational services, and reimbursing a parent for participating in treatment are generally not covered benefits.
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What to do
Action · 7 steps
01Already effective December 1, 2025: Billing team: Confirm that outpatient BHT/ABA has prior authorization from Blue Shield's mental health service administrator (MHSA), and that home-based services are obtained from participating providers.
02Initial assessment requests need the total hours or units for each CPT code to be billed, a list of standardized assessments that will be used, and, if the total time is more than 20 hours, a detailed explanation supporting the additional time.
03Initial ABA care needs a diagnosis by a licensed, qualified health care provider, documented baseline skills and problems, standardized assessments, an individualized treatment plan that shows collaboration with family and caregivers, and discharge planning.
04Continued care needs an initial assessment or reassessment within the prior 12 months, a comparison of baseline and current data, an updated treatment plan, and requested hours of service by CPT code.
05Supervision hours should be no more than 2 hours for every 10 hours of direct service, unless the record supports a higher ratio as medically necessary.
06Clinical documentation for review should include the type and degree of behaviors needing treatment, the functional assessment, prior treatment plans and response, the proposed treatment plan with goals, and the most current IEP or ISP if applicable.
07Post-service, include results or reports of tests performed and procedure reports.
Codes mentioned
9715197152971539715497155971569715797158G9012H0031H0032H2014H2019S5108S5110
Original notice
Behavioral Health Treatment for Autism Spectrum Disorder or Pervasive Developmental Disorder (BSC3.01)
blueshieldca.com · Always check the source before changing claims.
Related changes
See all Blue Shield of California changes →Applied Behavior Analysis for Autism Spectrum Disorder or Pervasive Developmental Disorder (BSC3.01)MediumEffective Aug 1, 2026 · Medical PolicyApplied Behavioral Analysis for Autism Spectrum Disorder or Pervasive Developmental Disorder (BSC3.01)MediumEffective Aug 1, 2026 · Medical PolicyBrowse every Blue Shield of California change in the policy list