Washington Administrative Code
Title 182 - Health Care Authority
WASHINGTON APPLE HEALTH
Chapter 182-531A - Applied behavior analysis
Section 182-531A-1100 - Applied behavior analysis (ABA)-Prior authorization and recertification of ABA services
Universal Citation: WA Admin Code 182-531A-1100
Current through Register Vol. 24-18, September 15, 2024
(1) The medicaid agency requires prior authorization (PA) and recertification of the medical necessity of applied behavior analysis (ABA) services.
(2) Requirements for PA requests are described in WAC 182-531A-0700.
(3) The agency may reduce or deny services requested based on medical necessity (refer to subsection (5) of this section) when completing PA or recertification responsibilities.
(4) The following are requirements for recertification of ABA services:
(a)
Continued ABA services require the agency's authorization. Authorization is
granted in three-month increments, or longer at the agency's
discretion;
(b) The lead behavior
analysis therapist (LBAT) must request authorization for continuing services 15
calendar days prior to the expiration date of the current authorization. A
reevalua-tion and revised ABA therapy treatment plan documenting the client's
progress and showing measurable changes in the frequency, intensity, and
duration of the targeted behavior/symptoms addressed in the previously
authorized ABA therapy treatment plan must be submitted with this request.
Documentation must include:
(i) Projection of
eventual outcome;
(ii) Assessment
instruments;
(iii) Developmental
markers of readiness; and
(iv)
Evidence of coordination with providers.
(c) When completing recertification
responsibilities, the agency may request another evaluation from the COE to
obtain that provider's review and recommendation. This COE provider must review
the ABA therapy treatment plan, conduct a face-to-face visit with the client,
facilitate a multidisciplinary record review of the client's progress, hold a
family/caregiver conference, or request a second opinion before recommending
continued ABA services. Services will continue pending
recertification.
(d) When
completing recertification responsibilities, the agency may retroactively
authorize dates of service. Services will continue pending
recertification.
(5) Basis for denial or reduction of services includes, but is not limited to, the following:
(a) Lack of medical necessity, for
example:
(i) Failure to respond to ABA
services, even after trying different ABA techniques and approaches, if
applicable;
(ii) Absence of
harmful behaviors (e.g., physical aggression to self or others or property
destruction), if applicable; or
(iii) Absence of meaningful, measurable,
functional improvement changes or progress has plateaued without documentation
of significant interfering events (e.g., serious physical illness, major
family/care-giver disruption, change of residence), if applicable. For changes
to be meaningful they must be:
(A) Confirmed
through data;
(B) Documented in
charts and graphs;
(C) Durable over
time beyond the end of the actual treatment session; and
(D) Generalizable outside of the treatment
setting to the client's residence and the larger community within which the
client resides; or
(b) A demonstrated lack of engagement as
evidenced by the family/caregiver to:
(i) Keep
appointments;
(ii) Attend treatment
sessions;
(iii) Attend scheduled
family training sessions;
(iv)
Complete homework assignments; and
(v) Apply training as directed by the therapy
assistant or LBAT. Absences that are reasonably justified (e.g., illness) are
not considered a pattern.
Disclaimer: These regulations may not be the most recent version. Washington may have more current or accurate information. We make no warranties or guarantees about the accuracy, completeness, or adequacy of the information contained on this site or the information linked to on the state site. Please check official sources.
This site is protected by reCAPTCHA and the Google
Privacy Policy and
Terms of Service apply.
