Prior Authorization for Adaptive Behavioral Treatment for Autism

Effective January 1, 2022, Blue Cross and Blue Shield of North Carolina (Blue Cross NC) will require prior authorization for Adaptive Behavioral Treatment (ABT) for ALL Commercial products/plans that provide benefits for this therapy. ABT refers to behavioral and developmental interventions that can reduce challenges due to Autism Spectrum Disorder (ASD). ABT can include services such as Applied Behavior Analysis (ABA) and interventions for ASD can include screening, diagnosis and treatment.  

Please also note, effective January 1, 2022, Blue Cross NC will be in-sourcing Behavioral Health Utilization and Case Management for the State Health Plan, presently conducted by Beacon Health Options.  

Obtaining prior authorization effective January 1, 2022

• No prior authorization is required for the initial evaluation to determine if ABT services are warranted. 
  
• However, to request services after conducting the initial evaluation, a medical necessity review will be required. The following actions will need to be taken:  
  • Submission of request for services via the Adaptive Behavioral Treatment for Autism Spectrum Disorder/Applied Behavioral Analysis (ABA/ABT) form (PDF), including documentation of proposed treatment plan in adherence with the criteria outlined in the Blue Cross NC Adaptive Behavioral Treatment Corporate Medical Policy (PDF).
  • Verification of provider credentials 
  • Verification of units for control 
• Conduct authorization extension requests after 6 months to continue to verify medical necessity. 

Process for providers currently servicing members 

• Submissions for prior authorization for dates of service January 1, 2022 may be submitted to Blue Cross NC for review in advance, upon confirmation of member benefits and eligibility for 2022 (this is usually available in mid-November to early December) 
  
  • Additional details will be forthcoming for providers with multiple members for requesting prior authorization.  
• Providers are encouraged to utilize the Blue e Authorization Portal to submit requests electronically, including attaching the form for prior authorization review.   
  • Providers who do not have a Blue e account will need to complete an Interactive Network Agreement. 
  • Providers who have a Blue e account but do not have the correct access need to complete a User Maintenance form.
• In-network providers who provide autism treatment services in accordance with Blue Cross NC medical policy guidelines will be eligible for inclusion in a supplemental listing of providers within our Provider Directory. Additional details will be forthcoming.