Autism benefits for Blue Cross Blue Shield of Michigan 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 Medicare Plus BlueSM or Blue Cross Complete (Medicaid). Always check member benefits and eligibility.
For most Blue Cross commercial members, New Directions® Behavioral Health 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
- Blue Cross / New Directions Applied Behavior Analysis Medical Necessity Criteria (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
Blue Cross accepts only the current version of 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.
Blue Cross members receiving services other than applied behavior analysis to treat ASD do not need to receive the ASD diagnosis from an AAEC. Prior authorization is required only for applied behavior analysis services.
Applied behavior analysis requires AAEC evaluation and recommendation
For ABA treatment to be payable:
- A Blue Cross-approved autism 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 New Directions at 1-877-563-9347.
- The treatment plan prepared by the AAEC must include a recommendation for ABA.
- The member must obtain care from a licensed behavior analyst. The licensed behavior analyst must obtain authorization from Blue Cross before providing applied behavior analysis services.
- For the purpose of authorizing applied behavior analysis treatment, Blue Cross 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 Blue Cross using the AAEC Evaluation Results Form (PDF). This form must be submitted whether or not 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 Blue Cross, if the form isn’t already on file at Blue Cross.
- LBAs must submit the appropriate evaluation documents to Blue Cross 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
Blue Cross and BCN 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.
More information about the state law on autism is available at www.mi.gov/autism.*
New Directions Behavioral Health is an independent company that manages authorizations for behavioral health and autism services for Blue Cross Blue Shield of Michigan members who have commercial plans.
*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.