11/15/2022
Blue Cross and Blue Shield of Texas (BCBSTX) implemented House Bill 3459 Prior Authorization (PA) Exemptions effective Oct. 1, 2022. As a result, Behavioral Health providers who were approved for an exemption, will not need to submit prior authorization requests for certain services such as ABA services for fully insured members and certain administrative Services only (ASO) groups.
Additional Changes to ABA Prior Authorizations
For providers who did not receive a HB3459 ABA PA exemption, we are also using claims data to improve access to care for our members and make the prior authorization process easier for you. Effective Sept. 1, 2022, in some instances, we eliminated the prior authorization requirement for certain ABA assessments for some commercial members.
Based on your specific claim history going forward, you may not have to request prior authorization for Current Procedural Terminology (CPT®) codes 97151 and 97152.* Prior authorization for these two codes still may be required, however, when:
- The member’s benefit plan specifically requires prior authorization of these codes.
- Use of these codes isn’t consistent with the presenting clinical issue, related medical policy or benefit plan design (in these cases, we’ll ask for more information).
- Claim analysis shows billing patterns that vary significantly from your peers.
Prior Authorization Verification
Providers can determine if they require prior authorization for codes 97151 and 97152 for their patient by calling the customer service number on the member ID card. Ask to speak to a behavioral health customer advocate.
For additional information about ABA criteria, or claims processes, please reference the BCBSTX Medical Policy Applied Behavior Analysis (ABA) for Autism Spectrum Disorder (ASD) Diagnosis and the BCBSTX Applied Behavioral Analysis Clinical Payment and Coding Policy on the Clinical Payment and Coding Policy page.
*Only CPT codes 97151 and 97152 are subject to this new ABA assessment prior authorization process.
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Checking eligibility and/or benefit information and/or obtaining prior authorization is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility, and the terms of the member’s certificate of coverage, including, but not limited to, exclusions and limitations applicable on the date services were rendered. If you have any questions, call the number on the member's ID card.