Qualifying for ABA Therapy

Overview of ABA Therapy

Applied Behavior Analysis (ABA) is a medical intervention that works exceptionally well for children with autism or other developmental disabilities. ABA is considered an “evidence-based best practice treatment” by the US Surgeon General, American Psychological Association, American Academy of Pediatrics, and National Academy of Sciences.

ABA uses the scientific principles of learning and motivation to teach skills and reduce problem behaviors. Simply put, ABA uses enjoyable experiences and fun to get kids to learn the skills they need for a full life! Services may be provided in the home, community, or clinic and typically range from 5 to 25 hours per week of individualized treatment.

Step 1: Get an order

ABA treatment has been determined a medical necessity for autism spectrum disorder (ASD) and other developmental disabilities with proven effectiveness. To be eligible for ABA therapy through most insurance providers, a recognized COE must conduct a comprehensive evaluation and write an order for ABA therapy.

Note: Idaho Medicaid does not require evaluation by a Center of Excellence (COE).

A COE is any medical practice, psychology practice, multidisciplinary assessment team, or individual health care provider that has received the COE training authorized by the Washington State Health Care Authority (HCA) or has been determined by the HCA to be qualified to diagnose autism and write an order for ABA services. 

For a comprehensive list of COEs, visit Washington State Health Care Authority’s website, article Billers, providers, and partners.

The clinician will write a prescription stating that the patient demonstrated impairments in social interaction, social communication, and atypical behavior consistent with ASD; therefore, ABA services are reasonably expected to result in measurable improvements. The most recent prescription should not exceed two years.

NOTE: ABA treatment must be “ordered” by the clinician. Treatment that is “recommended” may not be insured.

Step 2: Choose a Provider

The next step is choosing an ABA provider. Not all providers are the same, so you will need to do your research! Your child’s prescription may include more than one treatment depending on their needs, such as speech therapy, occupational therapy, physical therapy, or other medical treatments. Keep in mind that some ABA providers offer more than one type of service.

Once you have chosen your provider, the clinician will send a letter ordering ABA services. The clinician will attach the prescription and DSM-5 Diagnostic Criteria for ASD. Upon receiving the order, the BCBA will verify with your insurance that they do cover ABA therapy.

Once verified, the provider will contact you to complete an intake with a Board Certified Behavior Analysts (BCBA). The BCBA will need to gather basic information on your child’s demographics, medical history, and family history.

Note: It is essential to bring a copy of your insurance card with you to the intake.

The BCBA will then receive authorization from the insurance provider to complete an initial assessment. Most authorizations allow 8 to 12 hours to complete the assessment. After your child’s assessment, the BCBA will notify you again once they have received a determination.

Step 3: Recieve Treatment

Following the assessment, the provider will send a highly individualized treatment plan to your insurance provider along with a request for treatment, including a breakdown of how many hours per week for each type of service.

After submitting the information, the BCBA will follow up with your insurance provider to confirm the information was received. If all information is correct and the authorization department has no questions, the BCBA will receive an approved authorization back within ten business days.

Once received, the BCBA will notify you that your child can begin treatment. Authorizations for ABA treatment range from 3 to 6 months. Don’t worry though, your BCBA will keep track of the expiration date, so you don’t have to! The BCBA may check in with you during this time to ensure no changes occurred with your insurance policy.

Note: If you change insurance providers, notify your BCBA to restart the process with the new insurance.

The BCBA will submit your child’s subsequent authorization request at least two weeks before the expiration date. If you have any questions about your child’s authorization, contact your ABA provider directly.

For more blog posts by SOAR Behavior Services, visit soarbehaviorwa.com/family-resources.