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Upcoming Policies effective January 4, 2027
Act
by Jan 4, 2027
Effective date
Jan 4, 2027
Identified
Nov 3, 2026
Summary
Blue Cross Minnesota revised its medical policy for Applied Behavior Analysis (ABA) assessment and early intensive behavioral intervention for autism spectrum disorder, effective January 4, 2027. The policy establishes new clinical criteria for medical necessity, including required diagnostic and adaptive behavioral assessments, functional behavioral assessment completion, treatment plan specifications, supervision ratios, and ongoing authorization requirements with validated assessment tool documentation every 6 months.
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What to do
by Jan 4, 2027 · 5 steps
01Billing team must obtain prior authorization before submitting claims for ABA assessment and initiation of ABA care for autism spectrum disorder.
02Update charge entry and prior authorization tracking to require documentation of: (1) validated diagnostic assessment (ADOS-2, ADI-R, or CARS-2) completed within 24 months; (2) adaptive behavioral assessment (Vineland, ABAS, DAYC-2, or DP-4 depending on age) within 12 months; (3) functional behavioral assessment with dated baseline completed within 12 months by BCBA, BCBA-D, licensed psychologist, or licensed physician; (4) detailed treatment plan with specific measurable goals, targeted skill deficits and behaviors, hours justification, caregiver goals, school documentation (daily/weekly schedule and IEP if applicable), adjunctive treatment schedule, discharge criteria, and supervising clinician rationale; (5) evidence that supervision meets minimum 2 hours per 10 hours direct treatment.
03Tell providers and clinical staff that ABA services require demonstration that target behaviors meet at least one criterion: poses significant harm risk (with specified behavioral examples) OR significantly impedes adaptive functioning/community participation (with specified functional examples).
04For ongoing authorization, claims must include updated treatment plan and caregiver/school reports every 6 months with validated adaptive functioning assessment (Vineland or ABAS) showing improvement from baseline or documentation addressing lack of progress, current hospitalizations, medications, diagnoses, updated school attendance information, and adjunctive treatment schedule.
05Claims submitted without meeting these documentation and prior authorization requirements will be denied.
Original notice
Upcoming Policies effective January 4, 2027
bluecrossmn.widen.net · Always check the source before changing claims.