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Applied Behavioral Analysis Benefit Preauthorization Requirement for PPO Members

Posted September 30, 2016

At Blue Cross and Blue Shield of Illinois (BCBSIL), we use benefit preauthorization requirements to help make sure that the service or drug being requested is medically necessary, as defined in the member’s certificate of coverage. Benefit preauthorization is one of the many things we are doing to help make the health care system work better, by focusing on improving health care delivery. We want our members to receive the best health outcomes for all of the dollars spent on their care. 

Effective Jan. 1, 2017, benefit preauthorization will be required for BCBSIL PPO members prior to receiving Applied Behavioral Analysis (ABA) services for the treatment of Autism Spectrum Disorder. Providers may request benefit preauthorization on behalf of members by calling the number on the member ID card. The call must be made at least one business day prior to the scheduling of the planned outpatient service. Our online benefit preauthorization tool iExchange® is not available for ABA preauthorization at this time. 

Eligible members must have a diagnosis of Autism Spectrum Disorder 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 by the servicing provider. After the first benefit preauthorization for ABA services, additional benefit preauthorization requests may require concurrent review to ensure the member continues to meet the medical necessity guidelines, under their benefit plan. 

As part of the benefit preauthorization process, submission of three forms – Diagnostic Physician/Specialist Evaluation, Provider Credentials Verification, Assessment Information and Initial Treatment Plan – will be required. These forms will be available on our Provider website. Additional information will be provided in upcoming issues of the Blue Review, as well as the News and Updates. If you have questions, contact your assigned Provider Network Consultant for assistance. 

As a reminder, checking member eligibility and benefits is an important first step, prior to every scheduled appointment. Eligibility and benefits 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. 

Please note that verification of eligibility and benefits, and the fact that a service or treatment has been preauthorized or predetermined for benefits, is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. Regardless of any benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.