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New Preauthorization Requirement for Applied Behavior Analysis for BCBSTX Members Enrolled in Blue Choice PPOSM

September 28, 2016

Effective January 1, 2017, there will be a requirement for a preauthorization for Applied Behavior Analysis (ABA) for the treatment of Autism Spectrum Disorder for Blue Cross and Blue Shield of Texas (BCBSTX) members enrolled in Blue Choice PPOSM. Preauthorization for these services is processed through Behavioral Health Medical Management Review, by calling the number on the back of the member's ID card.

The updated Blue Choice PPOSM Preauthorization Requirements List will be located on the bcbstx.com/provider website General Reimbursement Information under the Standards and Requirements menu.

At BCBSTX, we use preauthorization requirements to help make sure that the service or drug being requested is medically necessary and appropriate, follows up-to-date medical recommendations, is the most economical treatment, is not being duplicated and is actually helping.

This is one of many things we are doing to make the health care system work better, by focusing on improving health care delivery as well as finding solutions to aid in reducing unnecessary health care costs for everyone. We want our members to receive the best health outcomes for all of the dollars spent on their care.

We will be providing additional information in the coming months on the BCBSTX Provider website at bcbstx.com/provider in later Blue Review issues including:

  • Preauthorization forms: Diagnostic Physician/Specialist Evaluation, Provider Credentials Verification, and Assessment Info & Initial Treatment Plan.

Reminders:

  • The member must have an Autism Spectrum Disorder diagnosis from a qualified diagnostician.
  • The ABA service provider must have the credentials necessary to conduct ABA services.
  • An initial functional assessment, including a treatment plan that identifies any deficient skills and the appropriate interventions, must be completed.
  • After the first authorization for ABA services, additional authorizations may require concurrent review to ensure the member continues to meet the medical necessity guidelines. 
  • iExchange® is not available for ABA preauthorization or behavioral health at this time, therefore please call the number on the back of the member's ID card for ABA preauthorization requests.

Member eligibility and benefits should be checked prior to every scheduled appointment. Eligibility and benefit quotes include membership status, coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts. It is strongly recommended that providers ask to see the member's ID card for current information and a photo ID to guard against medical identity theft. When services may not be covered, members should be notified that they may be billed directly.

If you have any questions or if you need additional information, please contact your BCBSTX Network Management Representative