Autism benefits for Blue Care Network commercial members comply with Michigan-mandated benefits. The mandate does not apply to some self-funded employer groups or to Medicare Advantage or Medicare supplement plans, such as BCN AdvantageSM or MyBlue MedigapSM. Always check member benefits and eligibility.
For BCN commercial members, the BCN Behavioral Health department manages authorizations for autism-related services.
Autism provider resource materials
- Letter of intent for AAEC designation (PDF)
- AAEC Evaluation Results Form (PDF)
- AAEC evaluation and billing guidelines (PDF)
- Attestation form for psychologists interested in providing ABA (PDF)
- Documentation requirements for autism services (PDF)
- Behavioral health: For mental health and substance use disorders (PDF) - Includes information about care management and utilization management programs
Utilization management criteria
BCN Behavioral Health uses the utilization management criteria outlined below when making determinations on prior authorization requests for applied behavior analysis services for autism spectrum disorder:
- For dates of service on or after Oct. 1, 2022 - BCN uses InterQual® Applied Behavior Analysis Treatment criteria. To request a copy of the specific criteria used to make a determination on a member's case, call BCN Behavioral Health at 1-800-482-5982.
- For dates of service from Aug. 1, 2022, through Sept. 30, 2022 - BCN uses these local rules for Autism spectrum disorder / applied behavior analysis (PDF)
- For dates of service from Aug. 2, 2021, through July 31, 2022 - BCN uses these local rules for Autism spectrum disorder / applied behavior analysis (PDF)
Telehealth resources for autism
- Telemedicine medical policy - To view this document, go to the Medical Policy Router Search webpage on bcbsm.com, enter the name of the medical policy in the Policy/ Topic Keywork field and press Enter.
- Telehealth for behavioral health providers (PDF)
- ABA telemedicine guidelines for autism (PDF)
Overview of autism coverage
BCN accepts only the current version of the Diagnostic and Statistical Manual of Mental Disorders, or DSM, codes for the diagnosis of autism spectrum disorder, or ASD, in accordance with the American Psychiatric Association.
Asperger's syndrome, 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.
The following services are benefits for members with an ASD diagnosis:
- Applied behavior analysis, or ABA, a specialized treatment for ASD
- Physical therapy, occupational therapy and speech therapy as part of ASD treatment
- Nutritional counseling as part of ASD treatment
- Other mental health and medical services used to diagnose and treat autism, as individually needed
For dates of service on or after Jan. 1, 2022, the above services are benefits for members with an ASD diagnosis regardless of age. For dates of service before Jan. 1, 2022, some of the above services, such as ABA, are benefits for children with an ASD diagnosis only through the age of 18 (until the member’s 19th birthday). Always check member benefits and eligibility.
For autism services other than ABA, the following apply:
- Diagnosis - BCN members must use a health care provider who participates with the member's health plan to diagnose ASD.
- BCN authorization requirements - To determine which services require prior authorization, see BCN referral and authorization requirements (PDF) for details. All services must be provided by a participating provider.
Applied behavior analysis requires AAEC evaluation and recommendation
For ABA treatment to be payable:
- A BCN-approved autism analysis evaluation center, or AAEC, participating with the member's health plan, must 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 licensed behavior analyst participating with the member's health plan. The licensed behavior analyst must obtain prior approval from BCN before providing ABA services.
- For the purpose of authorizing ABA treatment, 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, provided the evaluation included a team evaluation using accepted screening and assessment tools that supported an ASD diagnosis.
- The AAEC must submit the diagnosis and treatment recommendations to BCN using the AAEC Evaluation Results Form. This form must be submitted whether or not a ASD is diagnosed. Follow the instructions at the top of the form.
Note: Licensed behavior analysts may obtain a copy of the completed AAEC Evaluation Results Form from the member and submit it to BCN if the form isn’t already on file at BCN.
- LBAs must submit the appropriate evaluation documents to BCN when requesting authorization for ABA services.
Note: To be reimbursed by Blue Cross or BCN, behavior analysts must be licensed by the state of Michigan. LBAs must also enroll in the Blue Cross and BCN provider networks. Go to bcbsm.com/providers/network and follow the prompts to find the enrollment form and agreements.
Apply for AAEC designation
BCN and Blue Cross 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 under “Autism provider resource materials” above provide more information.
Billing for autism services
Providers should bill for autism services using the process described in the Autism: Billing Guidelines and Procedure Codes document. When billing ABA services, always use the appropriate modifier.
Autism-related physical, occupational and speech therapy services and physical medicine services by chiropractors
Autism-related physical, occupational and speech therapy by therapists and physical medicine services by chiropractors 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.
A physician must write an order or prescription for therapy.
PT, OT and ST services by therapists and physical medicine services by chiropractors are managed as follows:
- For members 19 years of age or older, eviCore healthcare® manages these authorization requests. Submit requests to eviCore by logging in to our provider portal (availity.com*), clicking Payer Spaces on the menu bar, clicking the BCBSM and BCN logo, and then clicking the tile for eviCore in the Applications tab.
- For members under age 19, authorization isn’t required. Claims for these services pay without a referral or an authorization if they are billed by a BCN-contracted provider with a childhood autism diagnosis code - specifically, for diagnosis codes F84.0, F84.5, F84.8 and F84.9.
More information about the new state law on autism is available at www.mi.gov/autism.*
eviCore healthcare is an independent company that contracts with Blue Cross Blue Shield of Michigan and Blue Care Network to manage authorizations for select services.
*Clicking this link means that you're leaving the Blue Cross Blue Shield of Michigan and Blue Care Network website. While we recommend this site, we're not responsible for its content.