Autism Spectrum Disorder (ASD) Services

BlueCross BlueShield WNY complies with the New York State Autism Mandate, Affordable Care Act and Federal Parity provisions requiring health  plans to provide specific  coverage for Autism Spectrum Disorders (ASD), including ABA ( Applied Behavior Analysis) and ACD ( Assistive Communication Devices).  

Many, but not all benefit plans cover these services.

Verification of benefits is necessary to see if these benefits are covered by calling the toll-free provider service phone number on the back of your patients ID card. 

Applied Behavior Analysis and Assistive Communication Devices require pre-authorization and medical necessity review. 

How do I obtain Pre-Authorization? 

Once you have verified that these are covered benefits, there are some steps that need to be taken.

 

1.     A diagnosis of Autism Spectrum Disorder is required. This diagnosis can be made by a physician (pediatrician or family practitioner), or Behavioral Health Specialists such as a Psychiatrist, or Psychologist in their office by using certain screening tools.

 

2.     Once the diagnosis has been made, or if a diagnosis already has already been established, an authorization request for Functional Behavior Assessment (FBA) must be submitted. The Comprehensive Evaluation or Functional Behavior Assessment Request Form along with any screenings, clinical or medical documents, or any assessments can be FAXED to the BH UM department fax number located on the form.

      These forms are available on the provider portal of the BCBSWNY website.

      The request will be reviewed for medical necessity and a determination (decision) will be made.*  

 

3.     If authorized, the FBA is administered by a qualified provider. It involves several interviews, observations, and a review of clinical information and prior treatments that may have been received. It may take several visits, and hours to complete. Once the provider has completed this assessment, they will submit the assessment summary that includes recommendations- is ABA treatment recommended? What ABA services will be required? How frequent? , along with the Outpatient Applied Behavior Analysis Treatment Report Request Form. The ABA request form along with the FBA assessment can be FAXED to the BH UM department fax number located on the form.

      These forms are available on the provider portal of the BCBSWNY website.

      The request will be reviewed for medical necessity and a determination (decision) will be made.* 

 

 

*You will be notified of the decision, if the request is not approved, you will receive a written notification stating why the request was denied and instructions on what you can do. 

 

Other Important Information 

·         ABA services are only available when there is a Diagnosis of Autism Spectrum Disorder

·         Providers outside of our service area, or if you are not contracted to provide these services should call the toll-free provider service phone number on the back of your patient’s ID card to find out the necessary steps to request authorization. Based on the patient’s benefit plan there may not be coverage for utilizing out of network providers, and additional out of pocket costs may apply.

·         ABA benefits are authorized for six month durations. Progress and treatment plan updates must be reviewed every six months for authorization of continued services. A request form, Outpatient Applied Behavior Analysis Treatment Report, to continue ABA services is available on the provider portal of the BCBSWNY website

·         ABA benefits are subject to co-pays and deductibles per the member benefit plan.

·         ABA services are excluded from coverage when they are provided as part of an individualized Education or Service Plan such as :

    -       Article 89 of the Education Law

    -       Section 2545 of the Public Health Law

    -       Office of Persons with Developmental Disabilities Regulation.

·         Parents are required to be active participants in the ABA treatment services. 

Assistive Communication Devices (ACD)

Certain devices or software dedicated to the production of speech or interpersonal communication may be eligible for coverage based on your patient’s benefit plan, a comprehensive speech and language evaluation by a licensed speech and language pathologist, and a prescription for the device from a physician is required.

The speech and language evaluation must include documentation of the type of speech disorder and severity, the individual’s ability to use the device, alternate communication means (sign language, gestures) are inadequate, treatment goals, and specific device/software needs along with the device name, provider, price and codes. Software or apps that run on these devices may also be eligible for coverage.

 

Only devices, or software dedicated to the production of speech or interpersonal communication are covered. Computers, iPads, smart phones are NOT covered devices. 

Other Services 

·         Therapy services - Physical Therapy, Occupational and Speech therapy may also be available under your patient’s medical benefits. These services do not require any additional or special process for the diagnosis of ASD. Limitations and out of pocket costs may apply. Call the toll-free provider service phone number on the back of your patients ID card.

·         Mental Health services- Mental Health services provided by mental health specialists do not require any special process for the diagnosis of ASD. Limitations and out of pocket costs may apply. Call the toll-free provider service phone number on the back of your patients ID card.  

Need Assistance?

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Provider Services & Billing
1-800-471-4685

 

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Crisis Services
716-834-3131

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