Evernorth^® Behavioral Health (Evernorth) is pleased to inform you of updated resources for the applied behavior analysis (ABA) level of care.

Prior authorization forms

The questions in the Applied Behavior Analysis Prior Authorization Form have been condensed and the form now contains a summary of the supporting clinical documentation to include for the medical necessity review. The form also now includes questions for network exception requests, allowing the Applied Behavior Analysis Initial Assessment Network Exception Request Form to be archived.

Please note, Evernorth is in the process of updating the Applied Behavior Analysis Prior Authorization Form to align with the changes noted above and a new version of the form will be made available in the coming weeks. For the most up-to-date prior authorization forms, visit the Behavioral Health Forms page on the Evernorth provider website (Provider.Evernorth.com).

Autism resource guide

Our autism resource guide is a comprehensive tool designed to help ease your administrative burden, so you can spend more time with your patients. We have made the following updates to ensure you have all the information you need in one place:

+ Changes throughout the guide – Updated style and language to comply with updated branding and style guidelines.

+ Contacting us – Updated the hours of availability for our Provider Services department and added details on how to use the Coverage Confirmation Grid.

+ Autism care management – Added information about how to request a care manager discussion and noted that the Applied Behavior Analysis Prior Authorization Form includes a summary of the supporting clinical documentation to include for the medical necessity review.

+ Billing information for applied behavior analysis – Added details on exceptions when only one provider can bill for a unit of time and removed information about the Current Procedural Terminology updates from 2019 and information related to Board Certified Assistant Behavior Analysts.

+ Website resources – Clarified that the Intensive Behavioral Interventions – (EN0499) coverage policy is used to render authorization determinations unless contractual requirements or federal or state law requires the use of other specifically identified clinical criteria; added information about the ability to request a care manager discussion; and outlined how to access the Applied Behavior Analysis Prior Authorization Form.

Coverage policy

We routinely review our coverage, reimbursement, and administrative policies for potential updates. In that review, we take into consideration one or more of the following: evidence-based medicine, professional society recommendations, Centers for Medicare & Medicaid Services guidance, industry standards, and our other existing policies.

As a result of a recent review, on January 15, 2025, the following updates were made to the Intensive Behavioral Interventions – (EN0499) coverage policy:

+ Changes throughout the coverage policy – Updated style and language to comply with updated branding and style guidelines.

+ Criteria for assessment – Updated information to reflect that the date on which the diagnosis was made should be the most recent date.

+ Criteria for initiation of treatment

• Updated the assessment criteria to include the areas of deficit details instead of results identified by the assessment tool.
• Added examples of autism spectrum diagnosis symptoms as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision.
• Clarified that quantitative baseline data dates should be from when the data was collected.
• Specified that the treatment plan/plan of care should include a clearly defined, measurable, individualized, and realistic transition plan instead of titration plan.
• Revised information about what to include for services to meet the definition of direct treatment/direct engagement regardless of location.
• Removed the information about multiple ABA providers needing to address substantially different skills.
• Added information about the time frame in which quantitative baseline data should be completed (i.e., within 60 days prior to the start of treatment with the severe behavior program).

+ Criteria for continued treatment – Added information about the time frame in which current data must be collected (i.e., no more than 60 days prior to the continued treatment start date).

Additional information If you have questions, please contact our Autism Care Coordinator team at 877.279.7603.