Current through Register Vol. 54, No. 44, November 2, 2024
(a) Payment will be made to a licensed IBHS
agency for ABA services if the following conditions are met:
(1) There is a written order for ABA services
based on a face-to-face interaction with the child, youth or young adult that
meets the following:
(i) Written within 12
months prior to the initiation of ABA services.
(ii) Written by a licensed physician,
licensed psychologist, certified registered nurse practitioner or other
licensed professional whose scope of practice includes the diagnosis and
treatment of behavioral health disorders and the prescribing of behavioral
health services, including IBHS.
(iii) Includes a behavioral health disorder
diagnosis listed in the most recent edition of the DSM or ICD.
(iv) Orders ABA services for the child, youth
or young adult and includes the following:
(A)
The clinical information to support the medical necessity of each ABA service
ordered.
(B) The maximum number of
hours of each ABA service per month.
(C) The settings where ABA services may be
provided.
(D) The measurable
improvements in targeted behaviors or skill deficits that indicate when
services may be reduced, changed or terminated.
(2) A face-to-face assessment has been
completed by an individual qualified to provide behavior analytic services or
behavior consultation-ABA services within 30 days of the initiation of ABA
services and prior to completing the ITP in accordance with §
5240.85 (relating to assessment)
or a face-to-face assessment has been reviewed and updated within 12 months of
the previous face-to-face assessment.
(3) The assessment and all updates have been
signed by the staff person who completed the assessment.
(4) An ITP based upon the assessment and the
written order for ABA services has been completed within 45 days after the
initiation of ABA services in accordance with §
5240.86 (relating to individual
treatment plan) or an ITP has been reviewed and updated within 6 months of the
previous ITP.
(5) The ITP and all
updates have been reviewed and signed by the youth, young adult, or parent or
legal guardian of the child or youth, the staff person who completed the ITP
and an individual who meets the qualifications of a clinical director in §
5240.81 (relating to staff
qualifications for ABA services).
(6) For continued ABA services, a child,
youth or young adult shall have an order written within 12 months of the
initiation of the continued services that complies with subsection
(a)(1)(ii)-(iv).
(b)
Payment will be made to a licensed IBHS agency for ABA services for up to 75
days after initiation of services, if an ITP has not yet been completed but
there is a written order for services that complies with subsection (a)(1) and
there is a treatment plan for the ABA services provided.
This section cited in 55 Pa. Code §
1155.35 (relating to payment
conditions for EBT delivered through individual services, ABA services or group
services); 55 Pa. Code §
1155.37 (relating to limitations);
55 Pa. Code §
5240.41 (relating to individual
records); 55 Pa. Code §
5240.84 (relating to ABA services
initiation requirements); and 55 Pa. Code §
5240.86 (relating to individual
treatment plan).
