Blue Care Network expanded benefits for autism spectrum disorder for BCN HMOSM(commercial) members in compliance with the state mandate signed into law April 18, 2012. Coverage was effective Oct. 15, 2012.
The mandate does not apply to self-funded employer groups or to government programs like Blue Cross Complete (Medicaid), MyBlue MedigapSM or BCN AdvantageSM. Providers should always check each member's benefits and eligibility before providing services. If the member has coverage for autism, it will be listed on the web-DENIS Medical Benefits screen under Mental Health Outpatient.
Autism provider resource materials
- Board-certified behavior analyst town hall presentation (PDF)
- Letter sent to all Blues-participating hospitals in Michigan (PDF)
- Letter of intent for AAEC designation (PDF)
- AAEC Evaluation Results Form (PDF)
Overview of autism coverage
Effective May 2014, Blue Cross Blue Shield of Michigan and Blue Care Network have been accepting only DSM-5 codes for the diagnosis of autism spectrum disorder, or ASD, in accordance with the American Psychiatric Association.
In DSM-5, Asperger’s disorder, pervasive developmental disorder, childhood disintegrative disorder and Rhett’s disorder are recognized as variants of ASD but are not individual diagnoses in and of themselves.
Covered benefits for children through the age of 18 (until the member's 19th birthday) include:
- Applied behavior analysis, a specialized treatment for ASD
- Physical therapy, speech therapy, occupational therapy as part of ASD treatment
- Nutritional counseling as part of ASD treatment, as individually needed
- Other mental health and medical services used to diagnose and treat autism, as individually needed
Applied behavior analysis limit removed in 2015
Effective Jan. 1, 2015, BCN removed the hourly limit for the treatment of autism using ABA but will continue to apply medical necessity criteria when authorizing these services. This will be effective for all non-grandfathered individual, small group and large group plans with effective dates beginning on or after January 1.
Psychiatric and psychological services are already without limits but are managed using medical necessity criteria.
Important information about billing for applied behavior analysis services
Providers should bill for ABA in units based on 15-minute increments. If a member received 4 1/2 hours of ABA treatment, for example, it should be billed as 18 units. When billing ABA services for BCN members, always use the HO modifier.
Applied behavior analysis requires AAEC evaluation and recommendation
For ABA treatment to be payable, the following must occur:
- A BCN-approved autism analysis evaluation center, or AAEC, participating with the member's health plan, is used to make or confirm a diagnosis of ASD for the member.
Note: If the member has a concern about obtaining an AAEC evaluation, please call BCN Behavioral Health at 1-800-482-5982.
- The treatment plan prepared by the AAEC must include a recommendation for ABA.
- The member must obtain care from a board-certified behavior analyst participating with the member's health plan.
- The board-certified behavior analyst must obtain prior approval from BCN before providing ABA services.
- For the purpose of approving ABA treatment, Blue Cross and BCN will accept a diagnosis of ASD if that diagnosis was made by an AAEC within three years of the date of request. This is true even if the AAEC had not yet been granted AAEC designation at the time of diagnosis. However, only those ABA services rendered on or after Oct. 15, 2012, are eligible for coverage.
- AAECs must submit the diagnosis and treatment recommendations to BCN using the AAEC Evaluation Results Form, which can be accessed in the provider resource materials section above. Follow the instructions at the top of the form.
Note: Board-certified behavior analysts may obtain a copy of the completed AAEC Evaluation Results Form from the member and submit it to BCN if the form is not already on file at BCN.
- Re-evaluation for ABA autism treatment services will not be required every three years, for all Blue Cross and BCN members. For more information, click here and scroll to the article on page 37.
Services other than applied behavior analysis
For covered autism services other than ABA, the following apply:
- Diagnosis — BCN members must use a health care provider participating with the member's health plan to diagnose ASD.
- BCN authorization requirements — BCN requires prior authorization for all behavioral health services, including all services for ASD, with the exception of nutritional counseling. All services must be provided by a participating provider.
Physical, occupational and speech therapy services
Autism-related physical, occupational and speech therapy services are subject to medical outpatient therapy deductible, copayment or coinsurance. Other outpatient autism-related services apply the primary care physician copayment and deductible when applicable.
PT/OT/ST visits may be unlimited for BCN members with an autism diagnosis. However, be sure to check each member's benefits, as self-funded groups have the option to customize their benefits, and may choose not to include unlimited PT/OT/ST visits for members with an autism diagnosis.
PT/OT/ST visits for most Blue Cross group members with an autism diagnosis are subject to visit limits specified by the member's plan.
Groups may choose to have different visit limits or no visit limits.
PT/ST/OT services, when performed for an autism diagnosis, are managed by BCN's Utilization Management department, not by eviCore healthcare. PT/ST/OT services managed as part of the autism benefit typically do not count toward the number of medical visits or day limit for these therapies. However, providers need to call to verify each member's benefits. This is because for some members, their autism benefits are managed as part of their medical benefits rather than as separate autism benefits.
A physician must write an order or prescription for therapy. For PT/ST/OT services managed under a member's autism benefits, neither the ordering physician nor the treating provider needs to submit an authorization request to BCN. A treatment plan does not need to be submitted for PT/ST/OT therapy services for autism unless these therapies are being reviewed for medical necessity.
Apply for AAEC designation
Blue Care Network and Blue Cross Blue Shield of Michigan are seeking facilities interested in earning the approved autism evaluation center designation. If your facility meets the criteria, you may complete and submit a letter of intent. The documents posted in the provider resource materials above provide more information.
Board-certified behavior analysts
Board-certified behavior analysts should enroll in the Blue Cross and BCN provider networks. Go to bcbsm.com/providers/enrollment and follow the prompts to find the enrollment form and agreements.
If a member's completed AAEC Evaluation Results Form is on file with BCN, the board-certified behavior analyst can obtain a copy from the member and submit it to BCN. Follow the directions at the top of the form.
For current billing and procedure code information pertinent to ABA, refer to the Applied Behavior Analysis Billing Guidelines and Procedure Codes document in the provider resource materials section above.
For additional information, review the board-certified behavior analyst town hall presentation, also available in the provider resource materials section above.
For more information, visit bcbsm.com/providers, log in to Provider Secured Services, click BCN Provider Publications and Resources and, finally, click Autism.
More information about the new state law on autism is available at www.mi.gov/autism.*