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Autism Care Demonstration: Authorization Changes

Applied behavior analysis (ABA) providers and beneficiaries can request certain changes to current (valid) authorizations. Health Net Federal Services, LLC (HNFS) cannot make changes to expired authorizations.

Unit Modifications

In order to request a change to the number of units authorized by HNFS, providers must submit a new request for ongoing services. If approved, HNFS will update the existing authorization.

This new request must:

  • Include an updated treatment plan that documents the reason for the change and any applicable modifications to the beneficiary's goals.
  • Specify the requested units for all CPT® codes.
  • Match what is document in the treatment plan. 

Unit modifications may be approved when there is a significant change in the clinical status of the beneficiary resulting in a modification to the treatment plan and recommended units. These may include but are not limited to: 

  • the number of hours the beneficiary is receiving
  • the number of behavior excesses requiring management of the Behavior Intervention Plan (BIP)
  • the acquisition rate of the beneficiary
  • frequency and rate of modifications to maintain progress
  • the frequency needed to demonstrate modifications to the behavioral technician or parents
  • the complexity of the program requiring modifications
  • the level of generalization of mastered skills
  • the engagement and availability of the family 

Second Opinion

  • Beneficiaries or the family may request a second initial assessment from a different ABA provider to obtain another clinical recommendation or plan of care.

  • Second opinion assessments follow the same referral, access to care, treatment plan, outcome measure, and process requirements as an initial assessment. A new referral is not required for second opinions if within the two-year timeline.

  • The second opinion assessment can be completed by a different ABA provider but only one ABA provider may be authorized to provide treatment at a time.

  • When a ABA supervisor seeks consultation from another authorized ABA supervisor, the primary ABA supervisor will remain responsible for the treatment plan and is the sole provider authorized to bill for ABA services.

Provider Changes

In the event a beneficiary would like to change ABA providers, he or she should contact our ACD customer service line and request a change of ABA providers.

  • HNFS will gather additional information and assist the beneficiary in facilitating the change based on the reasons and availability of other ABA providers. 
  • If the beneficiary has an active referral within the current two-year period, a new referral is not required for provider changes. 
  • Ongoing care from two ABA providers is not permitted. 

Moving

Regional contractors can help beneficiaries with the transfer of ABA services across regions when moving.

Moving from West (HNFS) to East (Humana Military):

  • Beneficiaries can contact HNFS’ ACD customer service line to notify HNFS of their move date and request ABA-related documents previously submitted to HNFS be transferred to Humana Military. HNFS will transfer the documents, including a copy of the ABA therapy referral, the treatment plan and related assessments within 10 business days of the request. 
  • Beneficiaries assigned an Autism Services Navigator (ASN) will remain eligible for an ASN as long as they continue to meet eligibility requirements. ASNs will assist in care coordination during the transition.
  • Beneficiaries not assigned an ASN may be eligible for case management services to assist in the process. Case management nominations can be made online or via the ACD customer service line.
  • Contact Humana Military for more information about receiving ABA services in the East.

Moving from East (Humana Military) to West (HNFS):

  • Beneficiaries can contact Humana Military to notify Humana of their move date and request ABA-related documents previously submitted to Humana Military be transferred to HNFS. Humana Military will transfer the documents, including a copy of the ABA therapy referral, the treatment plan and related assessments within 10 business days of the request. 
  • Beneficiaries assigned an Autism Services Navigator (ASN) will remain eligible for an ASN as long as they continue to meet eligibility requirements. ASNs will assist in care coordination during the transition.
  • After a beneficiary’s enrollment has been transferred to the West, he/she can call HNFS to request an initial ABA assessment. Beneficiaries should let HNFS know whether they have already requested the ABA document transfer from Humana Military. 
  • HNFS will honor valid Humana Military referrals in order to authorize initial assessments while ABA services are being established with West region providers. All beneficiaries who transfer from the East Region must receive a new initial assessment and meet all ACD requirements prior to approval of ongoing care. (Beneficiaries must show as eligible in the West Region before HNFS can authorize services.)

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