Autism

Blue Cross Blue Shield of Michigan's autism benefits comply with Michigan-mandated coverage. The mandate does not apply to some self-funded employer groups and government programs. 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

Telehealth resources for autism

Overview of autism coverage

Blue Cross accepts only the current version of DSM codes for the diagnosis of autism spectrum disorder, or ASD, in accordance with the American Psychiatric Association.

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 with an autism spectrum diagnosis 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
  • Other mental health benefits to diagnose and treat autism
  • Other medical services used to diagnose and treat autism

Applied behavior analysis requires AAEC evaluation and recommendation

For applied behavior analysis treatment to be payable:

  • A Blue Cross-approved autism evaluation center, or AAEC, participating with the member’s health plan, makes or confirms a diagnosis of autism spectrum disorder 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 applied behavior analysis.
  • 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. This form must be submitted whether or not an ASD is diagnosed. Follow the instructions at the top of the form.

LBAs are responsible for submitting the appropriate evaluation documents to Blue Cross when requesting authorization for ABA services.

If a member's completed AAEC Evaluation Results Form is on file, the licensed behavior analyst can obtain a copy from the member and submit it. Follow the directions at the top of the form.

Licensed behavior analysts

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/enrollment and follow the prompts to find the enrollment form and agreements.

Billing for autism services

Providers should bill for autism using the process described in the Autism: Billing Guidelines and Procedure Codes document. When billing ABA services, always use the appropriate modifier.

Services other than applied behavior analysis

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.

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.

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 Licensed behavior analysts in the provider resource materials above provide more information.

More Information

For more information, visit bcbsm.com/providers, log in to Provider Secured Services, click BCBSM Provider Publications and Resources, click Clinical Criteria and Resources and, finally, click Autism.

More information about the new state law on autism is available at www.mi.gov/autism.**

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