Florida Agency for Health Care Administration

Better Health Care for All Floridians

 

FLORIDA MEDICAID
A Division of the Agency for Health Care Administration

Florida Medicaid Health Care Alert
January 2014


Provider Type(s): 07, 16, 25, 26, 67, 68, 70, 71, 72, 77, 91

Revised Alert for Developmental Disabilities Home and Community Medicaid Waiver Providers:  Medicaid Coverage and Prior Authorization of Applied Behavior Analysis for Children Under 21 with Autism Spectrum Disorder

This alert includes information for Developmental Disabilities Home and Community Medicaid waiver providers. Information for other qualified provider types can be found in the applicable provider alert. This revised alert supersedes the information specific to Developmental Disabilities Home and Community Medicaid waiver providers in previous alerts posted on 4/2/12, 4/17/12, 5/17/12, 6/15/12, 7/6/12, and 9/6/12.

This alert describes provider qualifications, recipient eligibility criteria, the prior authorization request process, service codes and reimbursement rates, the billing process, place of service codes, and instructions for managed care plans. These services require prior authorization.

Provider Qualifications:

ABA services described in this alert must be rendered by Certified behavior analyst (CBA) and certified associate behavior assistant (CABA) providers who meet the qualifications outlined in 65G-4.003 of the Florida Administrative Code, are enrolled as Medicaid waiver providers through the Developmental Disabilities Home and Community Medicaid waiver programs and have received prior authorization from Medicaid for the service.

Recipient Eligibility Criteria:

Qualified treating practitioners may render medically necessary ABA to children under 21 years old having any of the following ICD-9 diagnosis codes:  299, 299.0, 299.00, 299.01, 299.1, 299.10, 299.11, 299.8, 299.80, 299.81, 299.9, 299.90, or 299.91.

Prior Authorization Request Process:

ABA services must be prior approved by Medicaid.  If a physician determines that a Medicaid eligible child diagnosed with an autism spectrum disorder needs Applied Behavior Analysis (ABA), the provider must submit a request to the Medicaid area office. The following information must be included:

  1. Recipient name, date of birth, Medicaid ID, and current mailing address.
  2. Requesting provider name, national provider identifier, address, and telephone and fax numbers.
  3. Diagnosis of recipient and diagnosis code.
  4. If already assessed, expected duration of ABA treatment.
  5. The primary focus of ABA treatment.
  6. Medical records that document the diagnosis of autism spectrum disorder.

An optional form for this purpose is available online at the Child Health Check-Up web page. This optional prior authorization form has been revised effective January 10, 2014.Prior authorization documentation as described above must be submitted to the recipient’s Medicaid area office. Contact information for the area offices can be found on the Public Provider Web Portal.

Service Codes and Reimbursement Rates:

Instructions for Developmental Disability Waiver Providers
to Bill Fee-For-Service for Non-Waiver Recipients

ABA services must be prior approved by Medicaid. Providers should consult the Medicaid Developmental Disabilities Waiver Services Coverage and Limitations Handbook for provider qualifications and documentation requirements (requirements for review of documentation by a Local Review Committee and submission of documentation to the waiver support coordinator do not apply). Billing for ABA services in a group setting is not allowable. A total of up to 160 quarter-hour units per week of combined service may be authorized. Eligible service codes and rates of reimbursement for Applied Behavior Analysis services are:

Description of
Service

Procedure
Code

Modifier
1

Modifier
2

Rate

Limits

Assessment Services
Behavior Analysis Assessment for Autism

H2020

UD

$299.85 per assessment

One assessment per state fiscal year

Treatment Services
Behavior Analysis Level 1 for Autism

H2019

UD

HP

$19.05 per quarter hour

Maximum combined daily limit of up to 32 quarter-hour units
Maximum combined weekly limit up to 160 quarter-hour units of all treatment services

Behavior Analysis Level 2 for Autism

H2019

UD

HO

$16.64 per quarter hour

Behavior Analysis Level 3 for Autism

H2019

UD

HN

$10.35 per quarter hour

Behavior Assistant Services for Autism

H2019

UD

HM

$4.31 per quarter hour

 Instructions for Developmental Disability Waiver Providers
for Waiver Recipients

Scenario Coverage
Existing DD waiver recipient receives ABA waiver services APD continues to cover these ABA hours through the waiver.
Existing DD waiver recipient receives ABA waiver services but requests an increase in services APD reviews the request to determine if additional hours are medically necessary. If yes, then APD will cover the additional hours through the waiver. If no, then the recipient may request authorization to receive ABA through the state plan.
Existing DD waiver recipient, who does not receive ABA services, requests ABA APD reviews the request to determine if additional hours are medically necessary. If yes, then APD will cover the service through the waiver. If no, then the recipient may request authorization to receive ABA through the state plan.
Individual on the DD waiver waiting list who is Medicaid eligible applies for the waiver through the crisis process. ABA is one of the identified service needs. APD will refer the individual to the ABA state plan authorization process for coverage of ABA.
Individual on the DD waiver waiting list who is Medicaid eligible and requests ABA services. APD will refer the individual to the ABA state plan authorization process for coverage of ABA.

Billing Process:

To bill for the services, providers must submit claims in accordance with the Provider Reimbursement Handbook, CMS-1500 located on the Provider Handbook page of the Public Provider Web Portal. All claims for ABA services for children with autism spectrum disorders must be billed fee-for-service, even for those recipients enrolled in a Medicaid managed care plan. When billing for services for treatment of autism spectrum disorders, the claim must include one of the following primary diagnoses: 299, 299.0, 299.00, 299.01, 299.1, 299.10, 299.11, 299.8, 299.80, 299.81, 299.9, 299.90, or 299.91. Enter “1” for the diagnosis code reference number (pointer) to relate the procedures performed to the primary diagnosis.

Billing is allowed for dates of service beginning with the date of prior authorization.

DO NOT SEND any attachments or medical records to the Medicaid fiscal agent with the CMS-1500 claim form. Regardless of place or dates of service, attachments for Applied Behavior Analysis are not required. All CMS-1500 claims for Applied Behavior Analysis services for children with autism spectrum disorders will be processed per these instructions.

Place of Service Codes:

Services must be billed using the correct place of service code for the location of the service provided. These services may be provided in the provider’s office, the recipient’s place of residence or anywhere in the community. However, in all cases, behavior analysis services must also be provided in the setting(s) relevant to the behavior problems being addressed.

The following place of service codes should be used by DD Waiver Providers when submitting claims (see page 2-22 of the Developmental Disabilities Waiver Services Coverage and Limitations Handbook):

11 – Office
12 – Home
13 – Assisted Living Facility
14 – Group Home
49 – Independent Clinic
53 – Community Mental Health Center
99 – Other Place of Service

Place of service code “99 – Other Place of Service” is not acceptable except for unusual circumstances that are documented in the recipient’s treatment or service plan, or in the recipient’s treatment notes.Medicaid will monitor providers who frequently utilize place of service code 99.

Instructions for Managed Care Plans:

Managed care plans are not currently required to authorize or cover Applied Behavior Analysis Services for the treatment of autism spectrum disorders. If a child enrolled in a Medicaid managed care plan requires ABA services, the plan may refer the recipient to any of the identified qualifying providers to receive the service under Medicaid fee-for-service. Alternatively, the managed care plan may refer the recipient to the Medicaid area office for assistance with finding a qualified provider. Managed care plans must share information on how to access ABA services with their contracted community behavioral health and physician providers.

Other Key Information:

For questions, contact your local Medicaid area office. Contact information for the area offices can be found on the Public Provider Web Portal.

 


 

LINKS

Florida Medicaid Web Portal | Florida Medicaid Health Information Network | Florida Medicaid HIPAA Information | HIPAA Transactions & Code Sets Standard | National Provider Identifier Standard (NPI) | Florida Medicaid EHR Incentive Program | FloridaHealthFinder.gov


QUESTIONS ABOUT FLORIDA MEDICAID?

Please direct questions about Medicaid policies to your local Medicaid area office. The Medicaid area offices’ addresses and phone numbers are available on the Area Offices Web page.


ALERTS INFORMATION

The Florida Medicaid program has created an e-mail alert system to supplement the present method of receiving Provider Alerts information and to alert registered subscribers of “late-breaking” health care information. An e-mail will be delivered to your mailbox when Medicaid policy clarifications or other health care information is available that is appropriate for your selected area and provider type.

Visit the Florida Medicaid’s Health Care Alerts page to subscribe now. You may unsubscribe or update your subscription at any time by clicking on the “Manage your subscription” icon in the footer of each e-mail. Other questions regarding the e-mail alert system can be sent to the Florida Medicaid Alerts Administrator.

 

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