Cmprehensive Diagnstic Evaluatin (CDE) Guidelines t Access the Applied Behavir Analysis (ABA) Benefit May 5, 2017 Clinical infrmatin that utlines medical necessity is required t supprt the need fr initial and cntinuing ABA service preauthrizatins, including: - Cnfirmatin f an Autism Spectrum Disrder (ASD) diagnsis dcumented by ONE f the fllwing: CDE cmpleted within the last 3 years cnfirming an ASD diagnsis and a recmmendatin utlining the need fr ABA services written within the last 6 mnths by ne f the fllwing qualified health care prfessinals (QHCP): Pediatricians Develpmental Pediatricians Pediatric Neurlgists Child Psychiatrists Clinical Psychlgists Nurse Practitiners Neurpsychlgists
CDE cmpleted by an abve listed QHCP mre than 3 years ag accmpanied by a current Beacn Health Optins frm: Clinical Review fr ASD and ABA Diagnstic reprt cmpleted by a nn-qhcp (i.e., schl psychlgist r speech language pathlgist) within the last 3 years accmpanied by the Beacn Health Optins frm: Physician Cnfirmatin f ASD Diagnsis A CDE requires the fllwing elements: A parent/caregiver interview Direct bservatins f the participant utlining behavirs cnsistent with ASD per DSM-V criteria A descriptin f develpmental and psychscial histry f the participant Dcumentatin f current functining acrss majr dmains f develpment A statement identifying presenting diagnsis
Recmmended element f a CDE: Testing instruments and/r standardized assessment tls t arrive at a fully infrmed diagnsis Please use the fllwing charts which utline what dcuments are required t submit fr an ABA assessment request as well as a cncurrent ABA service request. Length f time since mst current CDE cmpleted 0-3 years Parent/Caregiver: Requesting Access t ABA Services ABA Prvider: Initiating ABA Assessment Request Submissin requirements t Beacn Health Optins Mst current Cmprehensive Diagnstic Evaluatin (CDE) ASD Diagnstic Cnfirmatin and ABA Recmmendatin Checklist Nt Applicable 3.1 + years Length f time since ABA recmmendatin by QHCP Submissin requirements t Beacn Health Optins 0-6 mnths Submit ABA recmmendatin 7 + mnths An updated ABA recmmendatin by a QHCP is required Length f time since mst current CDE r ASD Diagnstic Cnfirmatin cmpleted 0-3 years ABA Prvider: Cncurrent ABA Service Requests Submissin requirements t Beacn Health Optins Cmprehensive Diagnstic Evaluatin (CDE) Nt Required ASD Diagnstic Cnfirmatin and ABA Recmmendatin Checklist Nt Required 3.1+ years Nt Applicable (CDE n file is ut f date)
Attached t this Prvider Alert, yu will find the dcuments necessary fr submissin t Beacn Health Optins fr diagnsis cnfirmatin. These dcuments make up the minimum requirements t be included with any initial authrizatin request fr an ABA assessment. The Parent/Caregiver Checklist is prvided as a resurce fr families t use when cllecting the necessary dcuments. Prviders are respnsible fr cllecting and submitting the necessary dcuments alng with the request fr an ABA assessment and/r cntinued ABA services. Hwever, all dcumentatin regarding diagnsis cnfirmatin will remain subject t clinical review by Beacn Health Optins fr determinatin f eligibility.
ACCESSING APPLIED BEHAVI ANALYSIS (ABA) BENEFIT: PARENT/CAREGIVER DOCUMENT CHECKLIST Fllwing are the qualified health care prfessinals (QHCP) that are apprved under the Maryland Medicaid ABA benefit t cmplete a Cmprehensive Diagnstic Evaluatin (CDE) if they have the requisite training and experience t diagnse Autism Spectrum Disrder (ASD). Develpmental Pediatricians Pediatric Neurlgists Child Psychiatrists Clinical Psychlgists Nurse Practitiners Neurpsychlgists Pediatricians Outlined belw are the requirements t access the ABA benefit: ONE f the fllwing: Cmprehensive diagnstic evaluatin cmpleted by a (QHCP) dated within past 3 years; Diagnstic evaluatin cmprised f 1) diagnstic reprt cmpleted by a nn-qhcp (e.g. schl psychlgist, speech language pathlgist) accmpanied by 2) Physician Cnfirmatin f Autism Spectrum Disrder Diagnsis frm bth dated with in the past 3 years; Cmprehensive diagnstic evaluatin cmpleted mre than 3 years ag accmpanied by a current Clinical Review fr Autism Spectrum Disrder and Applied Behavir Analysis frm ABA Recmmendatin cmpleted by an abve listed Qualified Health Care Prfessinal dated within the past 6 mnths Submit dcuments via E-Mail r Fax: E-Mail: abaservices@beacnhealthptins.cm Fax: 1-877-502-1044 (Attn: ABA Services) If yu have any questins regarding the requirements t access the ABA benefit, please cntact an ABA Care Crdinatr thrugh Beacn Health Optins Custmer Service at 1-800-888-1965 Mnday Friday 8:00 a.m. 6:00 p.m.
5/1/2017 Clinical Review fr Autism Spectrum Disrder and Applied Behavir Analysis Please cmplete the fllwing checklist t cnfirm whether yur patient cntinues t meet criteria fr an Autism Spectrum Disrder and requires ABA services. This checklist shuld be used when it has been 3 years r mre since the date that the patient s mst recent Cmprehensive Diagnstic Evaluatin was perfrmed. Name f Medicaid Participant Date f Birth Please cmplete the fllwing: I am a develpmental pediatrician, pediatrician, pediatric neurlgist, child psychiatrist, clinical psychlgist, neurpsychlgist, r a nurse practitiner with training and experience t diagnse Autism Spectrum Disrders (ASD). Check ne: YES NO N/A I have cmpleted a face-t-face evaluatin with this patient and his/her parent r caregiver within the past 6 mnths. Date f evaluatin *Please attach a cpy f the mst recent evaluatin and any ther relevant recrds. Based n my histry, direct bservatin f the patient, and review f any relevant recrds, he/she cntinues t meet criteria fr a diagnsis f Autism Spectrum Disrder (ASD). If this patient has been receiving Applied Behavir Analysis (ABA) services, I have reviewed his/her prgress and respnse t interventin. This patient has scial cmmunicatin deficits and/r maladaptive behavirs directly attributable t ASD fr which ABA is a medically necessary interventin. Please list: I recmmend that this patient receive ABA services. Please prvide any additinal infrmatin that yu deem relevant t this patient s diagnsis and need fr ABA services: I attest that I am the qualified health care prfessinal prviding care fr this Medicaid participant and that the medical necessity infrmatin cntained in this dcument is true, accurate and cmplete, and t the best f my knwledge. I understand that any falsificatin, missin, r cncealment f material fact may subject me t civil r criminal liability. Name Signature Date
5/1/2017 COMPREHENSIVE DIAGNOSTIC EVALUATION: COMPLETED BY NON-QUALIFIED HEALTH CARE PROFESSIONAL REQUIRING PHYSICIAN CONSULTATION Children diagnsed with ASD thrugh a diagnstic evaluatin perfrmed by a nn-qualified health care prfessinal (e.g., schl psychlgist, certified schl psychlgist, speech language pathlgist) will require a physician t cnfirm the diagnsis by cmpleting the Physician Cnfirmatin f Autism Spectrum Disrder Diagnsis in additin t submitting the diagnstic evaluatin cmpleted by the nn-qualified health care prfessinal. Physician Cnfirmatin f Autism Spectrum Disrder Diagnsis Please cmplete the fllwing steps t cnfirm a diagnsis f Autism Spectrum Disrder fr yur patient upn reviewing a diagnstic evaluatin cmpleted by a nn-qualified health care prfessinal (e.g., schl psychlgist). Step 1: The fllwing are the diagnstic criteria fr Autism Spectrum Disrder. Please check the bxes t cnfirm whether yur patient meets the fllwing criteria: N N N N Persistent deficits in scial cmmunicatin and scial interactin acrss multiple cntexts, as manifested by the fllwing, currently r by histry (must have all 3): 1. Deficits in scial-emtinal reciprcity, ranging, fr example, frm abnrmal scial apprach and failure f nrmal back-and-frth cnversatin; t reduced sharing f interests, emtins, r affect; t failure t initiate r respnd t scial interactins. 2. Deficits in nnverbal cmmunicative behavirs used fr scial interactin, ranging, fr example, frm prly integrated verbal and nnverbal cmmunicatin; t abnrmalities in eye cntact and bdy language r deficits in understanding and use f gestures; t a ttal lack f facial expressins and nnverbal cmmunicatin. 3. Deficits in develping, maintaining, and understand relatinships, ranging, fr example, frm difficulties adjusting behavir t suit varius scial cntexts; t difficulties in sharing imaginative play r in making friends; t absence f interest in peers. Restricted, repetitive patterns f behavir, interests, r activities, as manifested by the fllwing, currently r by histry (must have at least 2): 1. Steretyped r repetitive mtr mvements, use f bjects, r speech (e.g., simple mtr steretypes, lining up tys r flipping bjects, echlalia, idisyncratic phrases). 2. Insistence n sameness, inflexible adherence t rutines, r ritualized patterns f verbal r nnverbal behavir (e.g., extreme distress at small changes, difficulties with transitins, rigid thinking patterns, greeting rituals, need t take same rute r eat same fd every day). 3. Highly restricted, fixated interests that are abnrmal in intensity r fcus (e.g., strng attachment t r preccupatin with unusual bjects, excessively circumscribed r perseverative interests). 4. Hyper- r hypreactivity t sensry input r unusual interest in sensry aspects f the envirnment (e.g. apparent indifference t pain/temperature, adverse respnse t specific sunds r textures, excessive smelling r tuching f bjects, visual fascinatin with lights r mvement). These disturbances are nt better explained by intellectual disability r glbal develpmental delay. Intellectual disability and Autism Spectrum Disrder frequently c-ccur; t make cmrbid diagnses f Autism Spectrum Disrder and intellectual disability, scial cmmunicatin shuld be belw that expected fr general develpmental level. Symptms cause clinically significant impairment in scial, ccupatinal, r ther imprtant areas f current functining. This patient meets criteria fr a diagnsis f Autism Spectrum Disrder. Step 2: Please attach a signed written statement n ffice letterhead that includes the fllwing: Examples specific t yur patient that supprt each f yur respnses abve. Supprting evidence may cme frm histry (parent/caregiver interview) and direct bservatin as well as diagnstic evaluatins cmpleted by nn-qualified health care prfessinals. Please attach any recrds that supprt yur respnses. If applicable, a written recmmendatin fr Applied Behaviral Analysis (ABA) services.