April 2021

Applied Behavior Analysis May Be Covered for Some Medicaid Members with Autism Spectrum Disorder

Effective Nov. 1, 2020, the Illinois Department of Healthcare and Family Services (HFS) began covering Applied Behavior Analysis (ABA) services for children age 0 through 20 years old and diagnosed with an autism spectrum disorder. Blue Cross and Blue Shield of Illinois (BCBSIL) aligned with HFS for Blue Cross Community Health Plans^SM (BCCHP^SM) claims to administer this benefit.

According to HFS, ABA is the design, implementation, and evaluation of environmental modifications, using behavioral stimuli and consequences, to produce socially significant improvement in human behavior, including the use of direct observation, measurement, and functional analysis of the relationships between environment and behavior.¹

Per Public Act 101-10, treatment of autism spectrum disorder through applied behavior analysis shall be covered under the medical assistance program for children with a diagnosis of autism spectrum disorder when ordered by a physician licensed to practice medicine in all its branches and rendered by a licensed or certified health care professional with expertise in applied behavior analysis.

If you provide ABA services to Medicaid members, you must be registered in the HFS Illinois Medicaid Program Advanced Cloud Technology (IMPACT) system with the specialty or sub-specialty listed below:

Clinical Psychologist (Provider Type 87) – These providers MUST have a Board Certified Behavioral Analyst (BCBA) sub-specialty (Category of Service 118) in IMPACT.
Licensed Clinical Social Worker (Provider Type 86) – These providers MUST have a BCBA sub-specialty (Category of Service 118) in IMPACT.
Registered Behavior Technician (Provider Type 88) – These providers MUST have a Registered Behavior Technician specialty (Category of Service 119) in IMPACT.

We expect our systems to be ready to process and pay claims for ABA soon. Claims may reject or deny in the interim.

Reminders and Related Resources
As noted in our Medicaid Prior Authorization Requirements Summary, prior authorization through BCBSIL is required for ABA services. The BCBSIL prior authorization process may vary from HFS. Always check eligibility and benefits through the Availity^® Provider Portal or your preferred web vendor prior to rendering care and services to BCBSIL members. This step will confirm membership status, coverage details and prior authorization requirements. A Medicaid Prior Authorization Procedure Code List is posted for reference purposes.

To request prior authorization of ABA services for BCCHP members, you may use the Availity Authorizations tool. Also, complete and submit the following required forms to BCBSIL, according to the instructions on each form:

For more information, refer to the appropriate Provider Manual. If you have questions, email your Provider Network Consultant (PNC) or call 855-653-8126.

¹ HFS, Provider Notice Issued Oct. 30, 2020. https://www.illinois.gov/hfs/MedicalProviders/notices/Pages/prn201030c.aspx

Checking eligibility and/or benefit information and/or the fact that a service has been prior authorized 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. If you have questions, call the number on the member’s ID card.

Availity is a trademark of Availity, LLC, a separate company that operates a health information network to provide electronic information exchange services to medical professionals. Availity provides administrative services to BCBSIL. BCBSIL makes no endorsement, representations or warranties regarding any products or services provided by third party vendors such as Availity. If you have any questions about the products or services provided by such vendors, you should contact the vendor(s) directly.