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Applied Behavioral Analysis Benefit Preauthorization Requirement

November 18, 2016

Blue Cross and Blue Shield of New Mexico uses benefit preauthorization requirements to ensure the service or drug being requested is medically necessary, as defined in the member’s certificate of coverage. Benefit preauthorization is one of the many things we are doing to help make the health care system work better, by focusing on improving health care delivery. We want our members to receive the best health outcomes for all of the dollars spent on their care.

Effective Jan. 1, 2017, BCBSNM will require benefit preauthorization for members prior to receiving Applied Behavioral Analysis (ABA) services for the treatment of Autism Spectrum Disorder for the following benefit plans:

  • All retail plans
  • All fully insured small and large commercial groups

Providers may request benefit preauthorization on behalf of members by calling the number on the back of the member’s ID card. The call must be made at least one business day prior to the scheduling of the planned outpatient service. Our online benefit preauthorization tool iExchange® is not available for ABA preauthorization at this time.

Eligible members must have a diagnosis of Autism Spectrum Disorder from a qualified diagnostician. The ABA service provider must have the credentials necessary to conduct ABA services. An initial functional assessment, including a treatment plan that identifies any deficient skills and the appropriate interventions, must be completed by the servicing provider. After the first benefit preauthorization for ABA services, additional benefit preauthorization requests may require concurrent review to ensure the member continues to meet the medical necessity guidelines, under their benefit plan.

As part of the benefit preauthorization process, submission of the following three forms will be required:

  • Diagnostic Physician/Specialist Evaluation
  • Provider Credentials Verification
  • Assessment Information and Initial Treatment Plan

These forms will be available on our Provider website. Additional information will be provided in upcoming issues of the Blue Review, as well as the News and Updates. If you have questions, contact your assigned Provider Network Representative PDF Document for assistance.

As a reminder, checking member eligibility and benefits is an important first step, prior to every scheduled appointment. Eligibility and benefits quotes include membership status, coverage status and other important information, such as applicable copayment, coinsurance and deductible amounts. It is strongly recommended that providers ask to see the member’s ID card for current information and a photo ID to guard against medical identity theft. When services may not be covered, members should be notified that they may be billed directly.

Please note that verification of eligibility and benefits, and the fact that a service or treatment has been preauthorized or predetermined for benefits, is not a guarantee of payment. Benefits will be determined once a claim is received and will be based upon, among other things, the member’s eligibility and the terms of the member’s certificate of coverage applicable on the date services were rendered. Regardless of any benefit determination, the final decision regarding any treatment or service is between the patient and the health care provider.