BT2026136: Minimum caregiver coaching and training requirements for ABA therapy clarified

Immediately effective: (1) Billing and clinical teams must update ABA therapy prior authorization submission procedures to include medical necessity justification for 12-18 hours of caregiver coaching and training (or additional hours if medically necessary). (2) Establish documentation protocols in billing system to capture and attach: specific barriers identified, anticipated duration of barriers, impact on caregiver participation, provider mitigation efforts, and formal barrier documentation (hospital records, court documents, proof of assistance program participation, etc.). (3) Create standardized checklist for providers to document all scheduling attempts, telehealth offers, alternative meeting locations, and attempts to engage alternative relevant caregivers. (4) Develop caregiver coaching and training improvement plan template for reauthorization requests that addresses identified barriers, actions taken, and strategies to increase participation. (5) Train billing team on case-by-case evaluation framework: qualifying barriers include caregiver availability/custody issues, serious medical circumstances, competing caregiving responsibilities, socioeconomic hardship, emergency events, and legal circumstances. (6) Update internal processes to prorate 12-hour minimum for authorization periods shorter than six months. (7) Establish workflow to flag reauthorization requests that do not meet minimum hours for inclusion of improvement plan and barrier documentation. Failure to comply will result in prior authorization denials and claim rejections.