Applied Behavior Analysis (ABA) Policy Changes

REQUIREMENTS: 1. MONITOR FOR ANNOUNCEMENT: Billing team and providers must continuously monitor the DMAS provider portal (Provider Services Solution/PRSS) and Virginia Medicaid website for the announcement of the official effective date and updated DMAS Mental Health Services Manual guidance. CMS approval is a prerequisite before implementation. 2. BEFORE EFFECTIVE DATE (TBD): Update billing system to enforce the following rules: (a) Require documented ASD diagnosis prior to authorizing ABA services; (b) For members age 5 and younger, accept provisional ASD diagnosis using DMAS-designated protocol for up to one year; (c) Implement 20-hour per week cumulative limit per recipient on ABA services, with override capability for documented medical necessity under EPSDT guidelines. 3. UPDATE PRIOR AUTHORIZATION WORKFLOWS: Modify prior authorization processes within billing software and authorization request templates to screen for diagnosis requirements and enforce the 20-hour weekly limit. Coordinate with managed care organizations (Cardinal Care, Aetna Better Health of Virginia, Anthem HealthKeepers Plus, Humana Healthy Horizons, Sentara Community Plan, United Healthcare, and Acentra Health) regarding their specific authorization processes. 4. PROVIDER ENROLLMENT COMPLIANCE: Ensure all ABA provider and facility locations maintain current enrollment, contact information, and license information in PRSS. Unenrolled or non-current providers will have claims denied under federal rules. 5. DOCUMENTATION REQUIREMENTS: Prepare to implement enhanced ABA documentation requirements as specified by DMAS guidance (to be provided in future manual update). Coordinate with providers to ensure they capture and submit required documentation. 6. CLAIMS PAYMENT IMPACT: Beginning on the effective date (TBD), ABA claims exceeding 20 hours per week without documented medical necessity will be subject to denial. Claims for members without ASD or provisional ASD diagnosis will be denied. CONSEQUENCES OF INACTION: Failure to implement these controls will result in systematic claim denials for ABA services, disruption to behavioral health provider reimbursement, and potential compliance issues with managed care contracts.