Congratulations! You have chosen an ABA provider! You are excited for your child to begin services! You call the provider to set up an appointment but they tell you a prior authorization is required. At this point you might be asking yourself, “What does this mean for me?", "What is an authorization?", "Why do I need one of those?” Well fear not! We will answer every single one of those questions in this blog post.
What is a prior authorization?
A prior authorization is a process used by some health insurance companies to determine if they will cover a prescribed procedure, service, or medication. In the case of requesting ABA services, it is a decision by your health insurer that behavioral health services outlined in a treatment plan are medically necessary. This is sometimes called prior authorization, prior approval, or precertification.
1. Verify benefits
Choosing the right ABA provider for your family can be a difficult choice. Many families need to consider if the ABA provider is in network or out of network with their insurance carrier. Make sure to verify your benefits and ABA coverage information before signing up! It is important to know what ABA services will cost and what your insurance plan will cover.
Once you find a provider, you need to turn in all required documents (intake forms, copy of a diagnosis, referral, signed policies, copy of your insurance card, etc) to your chosen ABA provider. They will then begin the authorization process with your insurance carrier.
The most important part of this process is realizing that your ABA provider must acquire an authorization before providing any services to your child (including an assessment).
The only exception to this rule is if your plan is considered a "No Auth Plan." This means your insurance carrier does not require a prior authorization or preapproval for behavioral health services. An ABA provider can begin services and file the claims immediately. If this is the case for your family, there is no need to read the rest of this blog! We appreciate you making it this far. If your insurance plan requires an prior authorization, keep reading! We are here to help!
2. Assessment Authorization
When starting ABA services for the first time, an assessment authorization must be obtained. Typically, the ABA provider will need to complete a “Treatment Request Form” from the participating insurance provider. This form will be completed with information regarding your insurance policy, your child’s background details, the service location, the BCBA's credentials, and the services/codes requested. ABA providers request specific billing codes that allow the clinician a set amount of hours to work with a child to complete the assessment. These hours can range anywhere from two to ten, depending on your insurance. Once the treatment request form is completed, it is sent to the behavioral health division of the insurance company.
Although it would be great to obtain the assessment authorization the next day, that is almost never the case. And so the waiting game begins...Once the information has been sent to the insurance company, it can take anywhere from five to fifteen business days to obtain a mailed or faxed copy of the assessment authorization.
Once an insurance company approves the hours needed to complete the assessment, the BCBA may begin working with the child. Check out our podcast Piece of Hope to learn more about the Assessment Process!
4. Treatment Plan
“What happens once the assessment is complete?"
"Am I ready to begin services?”
Almost! Once the assessment is complete, the BCBA will begin to work on your child’s treatment plan. This is a document that helps outline the goals for the future, and the data taken during the time spent with your child. Once the treatment plan is complete, you will have a one on one meeting with the BCBA to review and discuss the future of your child’s care, as well as any concerns you might have. Once the treatment plan has been signed by the assessing BCBA and parents, your ABA provider can request an ongoing authorization.
5. Ongoing Authorization
An ongoing authorization is very similar to an assessment authorization. An ongoing authorization includes coverage for multiple hours over a six month period, verses the normal six or ten hours for an assessment. The difference is that obtaining an ongoing authorization can take more time. Insurance companies want to make sure that what they’re agreeing to cover, is actually needed. This is called “medical necessity”. I’m sure you’ve heard the saying, “Each child with Autism is unique”. Well this statement also applies to their level of care. When the BCBA finishes a treatment plan, they may suggest that one child receive eight hours of services a week, where as another child may receive forty hours a week.That varying range of services can also drive the amount of “push back” an insurance company will give when approving the request. In some instances, the insurance company will request extra documentation regarding your child's behaviors, their home life, and even an updated evaluation or diagnosis.
One of the biggest speed bumps in acquiring an authorization can happen when the insurance company require a peer review, also known as a “live review”. A live review consists of the BCBA completing a telephone review of your child’s treatment plan with a case manager at your insurance company. During this review they will discuss the assessment, the data recorded, and the overall plan of care. This process can tack on extra time to acquiring the authorization, because getting the BCBA and the case manager on the same schedule can be quite the task. The plus side to this process however, is once the live review is completed, your provider can acquire the authorization immediately over the phone. If a live review is not necessary, the process will take anywhere from five to twenty business days.
6. Begin Treatment
Once your insurance provider has approved services, the hard part is over, your child may begin ABA! You should receive a copy of the authorization in the mail from your insurance carrier. This piece of paper will outline how many hours a week your child is allowed to receive ABA. This ongoing authorization will last 6 months and then the process will need to be repeated.
The best thing to remember during the entire authorization process, is that each insurance company has different requirements. Your ABA provider will be working as quickly as possible to obtain those documents and get your services started. Although obtaining authorizations can be a long, drawn out process and stressful at times, it is the last step before opening the wonderful world of ABA to your child!