Blue Review
A Provider Publication

October 2022

We’re Reducing Prior Authorization Requirements for Certain Applied Behavioral Analysis (ABA) Codes for Some Commercial Members

Blue Cross and Blue Shield of Illinois (BCBSIL) is using claims data to improve access to care for our members and make the prior authorization process easier for you. Effective Sept. 1, 2022, we eliminated the prior authorization requirement for certain ABA assessments for some commercial members, in some instances.

What’s Different
Based on your specific claim history, going forward, you may not have to request prior authorization for Current Procedural Terminology (CPT®) codes 97151 and 97152.* Prior authorization for these two codes still may be required, however, when:

  • The member’s benefit plan specifically requires prior authorization of these codes.
  • Use of these codes isn’t consistent with the presenting clinical issue, related medical policy or benefit plan design (in these cases, we’ll ask for more information).
  • Claim analysis shows billing patterns that vary significantly from your peers.

Prior Authorization Verification
To find out if prior authorization for codes 97151 and 97152 is required for your patient, call the customer service number on the member’s BCBSIL ID card. Ask to speak to a behavioral health customer advocate. Refer to the Behavioral Health Program section of our Provider website for other reminders and resources.

Medical Policy and Billing Guidelines
For more information, please refer to BCBSIL’s Medical Policy PSY301.021, Applied Behavior Analysis (ABA) for Autism Spectrum Disorder (ASD) Diagnosis. Although medical policies can be used as a guide, providers serving HMO members should refer to the HMO Scope of Benefits in the BCBSIL Provider Manual, located in the Standards and Requirements section of our website. Also see our Clinical Payment and Coding Policies (CPCPs) for CPCP011, Applied Behavioral Analysis.

*Only CPT codes 97151 and 97152 are subject to this new ABA assessment prior authorization process.

This information doesn’t apply to behavioral health services provided to any of our government programs (Medicare Advantage or Illinois Medicaid) members.

All behavioral health benefits are subject to the terms and conditions as listed in the member’s benefit plan The Behavioral Health program is available only to those members whose health plans include behavioral health benefits through BCBSIL. Some members may not have outpatient behavioral health management. All behavioral health benefits are subject to the terms and conditions as listed in the member’s benefit plan.

CPT Copyright 2021 American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

Checking eligibility and/or benefit information and/or obtaining prior authorization 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, including, but not limited to, exclusions and limitations applicable on the date services were rendered. If you have any questions, call the number on the member's ID card.