Current through Vol. 42, No. 1, September 16, 2024
Eligible providers must submit an initial prior
authorization request to the Oklahoma Health Care Authority (OHCA) or its
designated agent. Prior authorization requests shall be granted up to six (6)
months of ABA treatment services at one (1) time unless a longer duration of
treatment is clinically indicated. The number of hours authorized may differ
from the hours requested on the prior authorization request based on the review
by an OHCA reviewer and/or physician. If the member's condition necessitates a
change in the treatment plan, the provider must request a new prior
authorization. The prior authorization request must meet the following
SoonerCare criteria for ABA services.
(1) The criteria include a comprehensive
behavioral assessment, FBA, and other supporting assessment(s) outlining the
maladaptive behaviors consistent with the diagnosis of ASD and its associated
comorbidities. In addition to completing the initial request form, providers
will be required to submit documentation that will consist of the following:
(A) Information about relevant medical
status, prior assessment results, response to prior treatment, and other
relevant information gathered from review of records and past
assessments.
(B) Information
gathered from interview of family and/or caregivers, rating scales, and social
validity measures to assess perceptions of the client's skill deficits and
behavioral excesses, and the extent to which these deficits impede the daily
life of the member and the family.
(C) Direct assessment and observation,
including any data related to the identified problem behavior. The analysis of
such data serves as the primary basis for identifying pretreatment levels of
functioning, developing, and adapting treatment protocols, and evaluating
response to treatment and progress towards goals.
(D) Functional assessment of problem behavior
that includes antecedent factors, skill deficits, and consequences contributing
to the problem behavior. The treatment plan should address all three (3) areas,
including antecedent interventions, teaching replacement skills, and
modification of consequences. Other supporting assessments may be additionally
submitted for review.
(2)
The prior authorization for ABA treatment will be time limited for up to thirty
(30) hours per week unless other hours are deemed medically necessary and
authorized through a prior authorization request and must:
(A) Be a one-on-one encounter (face to face
between the member and ABA provider) except in the case of family adaptive
treatment guidance;
(B) Be
child-centered and based upon individualized goals that are strengths-specific,
family focused, and community based;
(C) Be culturally competent and the least
intrusive as possible;
(D) Clearly
define in measurable and objective terms the intervention plan so it can
address specific target behaviors. The intervention plan should be clearly
linked to the function of the maladaptive behavior and include antecedent
interventions, replacement skills to be taught, and modification of
consequences. Additional goals may be identified that are related to the core
deficits of ASD and are prioritized based on current research and social
significance for the individual.
(E) Record the frequency, rate, symptom
intensity/duration, or other objective measures of baseline levels;
(F) Set quantifiable criteria for
progress;
(G) Establish and record
behavioral intervention techniques that are appropriate to target behaviors.
The detailed treatment plan utilizes reinforcement and other behavioral
principles and excludes the use of methods or techniques that lack consensus
about their effectiveness based on evidence in peer-reviewed
publications;
(H) Specify
strategies for generalization of learned skills beyond the clinical settings
such as in the home or other community settings;
(I) Document planning for transition through
the continuum of interventions, services, and settings, as well as discharge
criteria. Treatment (behavioral training) will be individualized, and
documentation will support the identified atypical or disruptive
behavior.
(J) Include
parent(s)/legal guardian(s) in behavioral training techniques so that they can
practice additional hours of intervention on their own. The treatment plan is
expected to achieve the parent(s)/legal guardian(s) ability to successfully
reinforce the established plan of care and support generalization of skills in
the home and community settings. Frequency of parental involvement will be
determined by the treatment provider and listed on the treatment
plan;
(K) Document parent(s)/legal
guardian(s) participation in the training of behavioral techniques in the
member's medical record. Parent(s)/legal guardian(s)' participation is critical
to the generalization of treatment goals to the member's environment;
and
(L) Ensure that recommended ABA
services do not duplicate, or replicate services received in a member's primary
academic education setting or provided within an Individualized Education Plan
(IEP), Individualized Service Plan (ISP), or any other individual plan of care.
Documentation may be requested by the OHCA to support coordination of services
with other providers and to prevent overlap and duplication of services
including those in school settings.
