Department Policy material is updated periodically, and it is the responsibility of the users to ensure that the policy they are researching or applying has the correct effective date for their circumstances.
This edition has three search options.
Prior manuals may be located through the provider website archives.
Updated 09/23/2022
To print this manual, right click your mouse and choose "Print". Printing the manual material found at this website for long-term use is not advisable. Department Policy material is updated periodically, and it is the responsibility of the users to check and make sure that the policy they are researching or applying has the correct effective date for their circumstances.
09/23/2022
07/26/2022
Updated age limit in Initial Eligibility section of Eligibility Chapter and SED section of Clinical Guidelines Chapter.
02/01/2022
Montana Medicaid Applied Behavior Analysis (ABA) Services Manual created in HTML format to meet 508 Accessibility Standards.
For a list of contacts and websites see the Applied Behavior Analysis Services webpage.
For information on the certification types listed below, access the Behavior Analyst Certification Board website at https://bacb.com.
The website is https://medicaidprovider.mt.gov and the following information is available:
This manual includes information for Applied Behavior Analysis Providers.
Notification of manual updates are provided through provider notices and web postings. Refer to “Recent Website Posts” on the bottom of the Home page of the Provider Information Website.
Older versions of the manual may be found through the Archive page on the Provider Information Website.
Printing the manual material found at this website for long-term use is not advisable. Department policy material is updated periodically, and it is the responsibility of the users to ensure that the policy they are researching or applying has the correct effective date for their circumstances.
Providers must be familiar with all current rules and regulations governing the Montana Medicaid program. Provider manuals are to assist providers in billing Medicaid; they do not contain all Medicaid rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. If a manual conflicts with a rule, the rule always prevails. Paper copies of rules are available through the Secretary of State's office. Choose ARM, Contact Us, and Purchasing ARM in Print at https://sosmt.gov/arm/ordering/.
The Department is committed to paying Medicaid providers’ claims as quickly as possible. Medicaid claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were billed appropriately. Although the claim processing system can detect and deny some erroneous claims, there are many erroneous claims that it cannot detect. Therefore, payment of a claim does not mean the service was correctly billed or the payment made to the provider was correct. If a claim is paid and the Department later discovers that the service was incorrectly billed or paid, or the claim was erroneous in another way, the Department is required by Federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of the Department or provider error or other cause. (42 CFR Part 455)
ABA Applied Behavior Analysis
ASD Autism Spectrum Disorder
BIA Behavior Identification Assessment
BCBA Board Certified Behavior Analyst
BCBA-D Board Certified Behavior Analyst-Doctoral
BCaBA Board Certified Assistant Behavior Analyst
DD Developmental Disability
RBT Registered Behavior Technician
SED Serious Emotional Disturbance
Applied Behavior Analysis (ABA)
A type of therapy that applies human behavior principles to improve a member’s adaptive functioning and reduce problem behaviors due to a psychiatric and/or behavioral condition.
Autism Spectrum Disorder (ASD)
Condition as defined in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM®) of the American Psychiatric Association.
Behavior Identification Assessment (BIA)
A developmentally appropriate assessment that identifies strengths and weaknesses across domains and potential barriers to progress.
Board Certified Behavior Analyst® (BCBA®)
An individual with a graduate-level certification in behavior analysis. Professionals certified at the BCBA level are independent practitioners who provide applied behavior analysis services.
Board Certified Behavior Analyst-Doctoral® (BCBA-D®)
A BCBA who has earned their Ph.D., in addition to their master’s and bachelor’s degrees.
Board Certified Assistant Behavior Analyst® (BCaBA®)
An individual with an undergraduate-level certification in behavior analysis. Professionals certified at the BCaBA level provide behavior analysis services under the supervision of a BCBA.
Department, the
The Montana Department of Public Health and Human Services (DPHHS).
Developmental Disability (DD)
Disabilities defined in 53-20-202(3), MCA.
Diagnostic Evaluation
An evaluation that is performed by a qualified healthcare professional with expertise in the diagnostic area and that establishes the qualifying diagnosis.
DD Eligible
A member found eligible for the receipt of state-sponsored developmental disabilities services as per ARM 37.34.201.
Eligibility Criteria
ABA services criteria the Department authorizes, which are found in this Montana Medicaid Applied Behavior Analysis Services Manual.
Expertise in the Diagnostic Area
For the purposes of Montana Medicaid, ABA services refers to one of the following qualified healthcare professionals:
a. Child and adolescent psychiatrist;
b. General psychiatrist with adequate child and adolescent experience;
c. Psychiatric mental health nurse practitioner with adequate child and adolescent experience;
d. Developmental pediatrician; or
e. Neuropsychologist or psychologist.
Functional Impairment Criteria
The criteria listed and defined in the Clinical Guidelines chapter of this manual.
Intermediate Professional
A graduate student who has completed basic coursework requirements for Behavior Analyst Certification Board® (BACB®) certification and is in the process of completing the experience portion of the eligibility requirements as delineated in the Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers Second Edition issued by the BACB and/or the Council of Autism Service Providers.
Member
A person enrolled in Montana Medicaid who is eligible to receive those services.
Provisional Qualifying Diagnosis
A member’s diagnosis that qualifies the member for initiation of ABA services but that has not yet been confirmed by a qualified healthcare professional with expertise in the diagnostic area. The diagnosis must meet Functional Impairment Criteria and be:
a. SED; or
b. ASD; or
c. DD Eligible.
Qualified Healthcare Professional
A physician, nurse practitioner, or psychologist.
Qualifying Diagnosis
A member’s diagnosis established by a qualified healthcare professional with expertise in the diagnostic area, through a diagnostic evaluation. The diagnosis must meet functional impairment criteria and be:
a. SED; or
b. ASD; or
c. DD Eligible.
Registered Behavior Technician (RBT)
An individual with a paraprofessional certification in behavior analysis. RBTs assist in delivering behavior analysis services and practice under the direction and close supervision of a BCBA. The supervising BCBA is responsible for all work RBTs perform.
Serious Emotional Disturbance (SED)
For the purposes of the program of ABA services authorized by the Department, an emotional disturbance as defined in the Clinical Guidelines chapter of this manual.
Treatment Plan
An individualized written document that has been developed from the BIA and contains all the critical features listed in the Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers Second Edition issued by the Behavior Analyst Certification Board, Inc.® (BACB®) and/or Council of Autism Service Providers.
Unit of Service
15 minutes of treatment service.
Montana Medicaid Applied Behavior Analysis (ABA) services administered by the Department may be provided to a member under the following required conditions:
Any physician, licensed mental health professional, or other qualified healthcare professional may refer a member for the initiation of ABA services under a provisional qualifying diagnosis. However, the Department may only determine a member to be eligible for receipt of continued ABA services after the initial 180 calendar days or the initial authorized units of service are exhausted if:
The medical necessity review and authorization process for continued eligibility and receipt of ABA services will occur every 180 calendar days or when the initial or subsequent authorized units of service are exhausted.
The Department may also review the medical necessity of services or items at any time, either before or after payment, in accordance with the provisions of ARM 37.85.410. If the Department determines that services or items were not medically necessary or otherwise in compliance with applicable requirements, the Department may deny payment or may recover any overpayment in accordance with applicable requirements.
The following clinical guidelines must be employed for each covered Montana Medicaid Applied Behavior Analysis (ABA) service:
Members with a primary Developmental Disability (DD) diagnosis must be determined eligible for services administered by the Developmental Disabilities Program. Members must also meet Functional Impairment Criteria listed in this section.
Neurodevelopmental Disorders
• Attention Deficit/Hyperactivity Disorder (if accompanied by another SED diagnosis)
• Other Specified Neurodevelopmental Disorder
Schizophrenia Spectrum and Other Psychotic Disorders
• Schizophreniform Disorder
• Schizophrenia
• Schizoaffective Disorder, Bipolar Type
• Schizoaffective Disorder, Depressive Type
• Other Specified Schizophrenia Spectrum and other Psychotic Disorder
Bipolar and Related Disorders
• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymic Disorder
• Other Specified Bipolar and Related Disorder
Depressive Disorders
• Disruptive Mood Dysregulation Disorder
• Major Depressive Disorder, Single Episode
• Major Depressive Disorder, Recurrent Episode
• Persistent Depressive Disorder (Dysthymia)
• Other Specified Depressive Disorder
Anxiety Disorders
• Separation Anxiety Disorder
• Panic Disorder
• Generalized Anxiety Disorder
• Other Specified Anxiety Disorder
Obsessive-Compulsive and Related Disorders
• Obsessive-Compulsive Disorder
• Hoarding Disorder
• Excoriation Disorder
• Other Specified Obsessive-Compulsive and Related Disorder
Dissociative Disorders
• Dissociative Identity Disorder
• Other Specified Dissociative Disorders
Trauma- and Stressor-Related Disorders
• Reactive Attachment Disorder
• Disinhibited Social Engagement Disorder
• Posttraumatic Stress Disorder
• Other Specified Trauma- and Stressor-Related Disorder
Somatic Symptom and Related Disorders
• Somatic Symptom Disorder
• Conversion Disorder
• Other Specified Somatic Symptom and Related Disorder
Feeding and Eating Disorders
• Anorexia Nervosa
• Bulimia Nervosa
• Binge Eating Disorder
• Other Specified Feeding or Eating Disorder
Gender Dysphoria
• Gender Dysphoria
• Other Specified Gender Dysphoria
Disruptive, Impulse-Control, and Conduct Disorders
• Oppositional Defiant Disorder
• Intermittent Explosive Disorder
• Other Specified Disruptive and Impulse-Control Disorder
Members referred for ABA services under a provisional qualifying diagnosis or subsequently established qualifying diagnosis (SED, ASD, or DD eligible) must consistently demonstrate active symptomatology which is clearly documented by the BCBA. Active symptomology means substantial impairment in functioning for at least 180 calendar days or that is reasonably predicted to last at least 180 calendar days, as manifested by two (2) or more of the following:
This chapter provides covered service information that applies specifically to services performed by BCBAs, BCBA-Ds, RBTs, and BCaBAs. Like all healthcare services received by Medicaid members, services rendered by these providers must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers Manual.
Services are covered only when they are within the scope of the provider’s license. As a condition of participation in the Montana Medicaid program, all providers must comply with all applicable state and federal statutes, rules, and regulations.
Medicaid ABA services must be deemed medically necessary and meet the eligibility criteria as established by the Department and as defined in the Eligibility Criteria chapter. Services must be directed by a BCBA or a BCBA-D. The services provided must demonstrate consistency with ABA core characteristics, Essential Practice Elements, and Assessment, Formulation of Treatment Goals, and Measurement of Client Progress as delineated in the Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers Second Edition issued by the BACB and/or the Council of Autism Service Providers.
The ABA provider must satisfy the following service requirements:
The ABA provider must complete service requirements 1. and 2. above within 30 calendar days of the onset of services. If extenuating circumstances have precluded the completion of these service requirements within the 30 calendar-day timeframe, the BCBA directing services should submit a written clinical explanation and/or justification for the delay to the Department, with a projected date by which the service requirements will be completed. Extenuating circumstances include, but are not limited to, serious illness or family emergency.
Members who meet the above Eligibility Criteria and whose providers agree to satisfy the service requirements may use any of the following CPT codes for services within ABA treatment:
97151 Behavior identification assessment by professional (BCBA), each 15 minutes
97152 Behavior identification assessment by technician, each 15 minutes
97153 Adaptive behavior treatment by technician using an established plan, each 15 minutes
97154 Adaptive behavior treatment by technician with multiple patients using an established plan, each 15 minutes
97155 Adaptive behavior treatment by professional (BCBA) or intermediate professional (BCaBA) using the TC modifier using an established plan, each 15 minutes
97156 Adaptive behavior treatment by professional (BCBA) or intermediate professional (BCaBA) with family using an established plan, each 15 minutes
97157 Adaptive behavior treatment by professional (BCBA) or intermediate professional (BCaBA) with multiple family group members using an established plan, each 15 minutes
97158 Adaptive behavior treatment by professional (BCBA) or intermediate professional (BCaBA) with group using an established plan, each 15 minutes
The package of services that will be offered within the initial 180 calendar days includes 1,260 total units of service. Units of service may be utilized as the BCBA provider sees fit and within nationally accepted standards of practice. Should the member exhaust the initial package of units of service or intend to extend service delivery beyond the initial 180 calendar days, the BCBA must request additional units of service by the process defined below. Of note, unused units of service will be considered expired once the initial 180 calendar days have elapsed. Expiration of units of service does not necessarily preclude the application for additional units of service after the initial 180 calendar days. All additional units of services must be authorized before service delivery may commence. Please see the Authorization of Additional Units of Service section of this manual.
In the case of a member transitioning services to a different BCBA provider, the member’s new provider must notify the Behavioral Health and Developmental Disabilities Division Program Officer. This information can be found on the Applied Behavior Analysis Services webpage.
Providers must utilize the Applied Behavior Analysis (ABA) Services Provider Transfer Request form to continue utilization of the member's authorized units of service.
The member must continue to meet the eligibility criteria and service requirements. In addition, the following three (3) things are required:
The following criteria exclude members from being eligible for service.
The Montana Medicaid Children’s Mental Health Bureau (CMHB) services listed below may be provided concurrently with ABA services. For a member to have concurrent services, the ABA services must be provided and billed outside authorized treatment hours of other programs and the providers must demonstrate and document their attempts to coordinate with community-based services.
The following CMHB services may not be provided concurrently for a Medicaid member that is receiving ABA services due to the duplicative nature of the services.
The following explains the rules governing authorization of additional units of service.
Providers intending to continue to deliver services after the initial 180 calendar days or 1,260 units of service, whichever elapses first, will be required to submit for authorization. For authorization, the BCBA must complete and submit the ABA Services Additional Units of Service Request form and additional required documentation. The BCBA must submit the form and additional documentation at least 14 calendar days prior to the intended onset of continued service delivery.
Any physician, licensed mental health professional, or other qualified healthcare professional may refer a member for the initiation of ABA services under a provisional qualifying diagnosis. However, to be eligible for authorization of continued receipt of ABA services, the provisional qualifying diagnosis must have been established as a qualifying diagnosis through a Diagnostic Evaluation completed by a qualified healthcare professional with expertise in the diagnostic area. A qualified healthcare professional with expertise in the diagnostic area must be one of the following:
Any additional units of services must be authorized by the Department before service delivery may begin. The Department may not give providers reimbursement retroactively for failure to submit timely, complete, and required documentation.
The process to request and the review for additional units of service is as follows:
A service provider may resubmit a request for additional units for service if they have additional information which would satisfy the deficiencies noted on the previous denial. It is important to note that this will be considered a new submission and all required documents will need to be submitted for review and determination.
A member may appeal the reviewer’s or designee’s determination. To appeal a determination outcome, a member or representative for the member may request an Administrative Review. For information regarding Administrative Reviews and Fair Hearings, please see Administrative Reviews and Fair Hearings section in the General Information for Providers Manual.
For general information about authorization, see the Prior Authorization chapter in the General Information for Providers Manual.
Forms, including those listed below, are available on the Applied Behavior Analysis Services page of the Montana Healthcare Programs Provider Information website.
(applies to Additional Units of Service Requests only)
Services provided by a BCBA covered in this manual must be either electronically billed or on a CMS-1500 claim form. CMS-1500 claim forms are available from various publishing companies and are not available from the Department or Provider Relations.
Members receiving ABA services are exempt from cost sharing.
If a member has additional insurance coverage, including Medicare, or a third party has responsibility for the member's healthcare costs, please see the Members Eligibility and Responsibilities chapter in the General Information for Providers Manual.
Providers billing Medicaid should use the Department’s fee schedule, designated by provider type, as well as the detailed coding descriptions listed in the CPT and Healthcare Common Procedure Coding System (HCPCS) coding books. Current fee schedules are available on the Applied Behavior Analysis Services page on the Provider Information Website.
The BCBA assumes full professional responsibility for all services provided by a BCaBA or RBT. All services are billed under the BCBA’s National Provider Identifier (NPI). Providers bill using standard Current Procedural Terminology (CPT) procedure codes and are reimbursed according to the Department’s Resource-Based Relative Value Scale (RBRVS) system.
Though providers do not need the information in this chapter to submit claims to the Department, the information allows providers to understand how payment is calculated and to predict approximate payment for claims.
Most services by provider types covered in this manual are reimbursed for using the Department’s RBRVS fee schedule. The fee schedule includes CPT codes and Healthcare Common Procedure Coding System (HCPCS) codes. Within the CPT coding structure, only anesthesia services and clinical lab services are not reimbursed for using the RBRVS fee schedule.
RBRVS was developed for the Medicare program. Medicare does a major update annually, with smaller updates performed quarterly. Montana Medicaid’s RBRVS-based fee schedule is based largely on the Medicare model, with a few differences as described below. By adapting the Medicare model to the needs of the Montana Medicaid program, the Department was able to take advantage of the research performed by the federal government and national associations of physicians and other healthcare professionals. RBRVS-based payment methods are widely used across the United States by Medicaid programs, workers’ compensation plans, and commercial insurers.
Each fee is the product of a relative value times a conversion factor.
For almost all services, Medicaid uses the same relative values as Medicare in Montana. Nationally, Medicare adjusts the relative values for differences in practice costs between localities, but Montana is considered a single locality. For less than 1% of codes, relative values are not available from Medicare. For these codes, the Department has set the relative values.
The Department sets the conversion factor for the state fiscal year (July through June) and it is listed on the fee schedule.
This manual has 3 search options.
09/23/2022
07/26/2022
Updated age limit in Initial Eligibility section of Eligibility Chapter and SED section of Clinical Guidelines Chapter.
02/01/2022
Montana Medicaid Applied Behavior Analysis (ABA) Services Manual created in HTML format to meet 508 Accessibility Standards.
For a list of contacts and websites see the Applied Behavior Analysis Services webpage.
For information on the certification types listed below, access the Behavior Analyst Certification Board website at https://bacb.com.
The website is https://medicaidprovider.mt.gov and the following information is available:
This manual includes information for Applied Behavior Analysis Providers.
Notification of manual updates are provided through provider notices and web postings. Refer to “Recent Website Posts” on the bottom of the Home page of the Provider Information Website.
Older versions of the manual may be found through the Archive page on the Provider Information Website.
Printing the manual material found at this website for long-term use is not advisable. Department policy material is updated periodically, and it is the responsibility of the users to ensure that the policy they are researching or applying has the correct effective date for their circumstances.
Providers must be familiar with all current rules and regulations governing the Montana Medicaid program. Provider manuals are to assist providers in billing Medicaid; they do not contain all Medicaid rules and regulations. Rule citations in the text are a reference tool; they are not a summary of the entire rule. If a manual conflicts with a rule, the rule always prevails. Paper copies of rules are available through the Secretary of State's office. Choose ARM, Contact Us, and Purchasing ARM in Print at https://sosmt.gov/arm/ordering/.
The Department is committed to paying Medicaid providers’ claims as quickly as possible. Medicaid claims are electronically processed and usually are not reviewed by medical experts prior to payment to determine if the services provided were billed appropriately. Although the claim processing system can detect and deny some erroneous claims, there are many erroneous claims that it cannot detect. Therefore, payment of a claim does not mean the service was correctly billed or the payment made to the provider was correct. If a claim is paid and the Department later discovers that the service was incorrectly billed or paid, or the claim was erroneous in another way, the Department is required by Federal regulation to recover any overpayment, regardless of whether the incorrect payment was the result of the Department or provider error or other cause. (42 CFR Part 455)
ABA Applied Behavior Analysis
ASD Autism Spectrum Disorder
BIA Behavior Identification Assessment
BCBA Board Certified Behavior Analyst
BCBA-D Board Certified Behavior Analyst-Doctoral
BCaBA Board Certified Assistant Behavior Analyst
DD Developmental Disability
RBT Registered Behavior Technician
SED Serious Emotional Disturbance
Applied Behavior Analysis (ABA)
A type of therapy that applies human behavior principles to improve a member’s adaptive functioning and reduce problem behaviors due to a psychiatric and/or behavioral condition.
Autism Spectrum Disorder (ASD)
Condition as defined in the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM®) of the American Psychiatric Association.
Behavior Identification Assessment (BIA)
A developmentally appropriate assessment that identifies strengths and weaknesses across domains and potential barriers to progress.
Board Certified Behavior Analyst® (BCBA®)
An individual with a graduate-level certification in behavior analysis. Professionals certified at the BCBA level are independent practitioners who provide applied behavior analysis services.
Board Certified Behavior Analyst-Doctoral® (BCBA-D®)
A BCBA who has earned their Ph.D., in addition to their master’s and bachelor’s degrees.
Board Certified Assistant Behavior Analyst® (BCaBA®)
An individual with an undergraduate-level certification in behavior analysis. Professionals certified at the BCaBA level provide behavior analysis services under the supervision of a BCBA.
Department, the
The Montana Department of Public Health and Human Services (DPHHS).
Developmental Disability (DD)
Disabilities defined in 53-20-202(3), MCA.
Diagnostic Evaluation
An evaluation that is performed by a qualified healthcare professional with expertise in the diagnostic area and that establishes the qualifying diagnosis.
DD Eligible
A member found eligible for the receipt of state-sponsored developmental disabilities services as per ARM 37.34.201.
Eligibility Criteria
ABA services criteria the Department authorizes, which are found in this Montana Medicaid Applied Behavior Analysis Services Manual.
Expertise in the Diagnostic Area
For the purposes of Montana Medicaid, ABA services refers to one of the following qualified healthcare professionals:
a. Child and adolescent psychiatrist;
b. General psychiatrist with adequate child and adolescent experience;
c. Psychiatric mental health nurse practitioner with adequate child and adolescent experience;
d. Developmental pediatrician; or
e. Neuropsychologist or psychologist.
Functional Impairment Criteria
The criteria listed and defined in the Clinical Guidelines chapter of this manual.
Intermediate Professional
A graduate student who has completed basic coursework requirements for Behavior Analyst Certification Board® (BACB®) certification and is in the process of completing the experience portion of the eligibility requirements as delineated in the Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers Second Edition issued by the BACB and/or the Council of Autism Service Providers.
Member
A person enrolled in Montana Medicaid who is eligible to receive those services.
Provisional Qualifying Diagnosis
A member’s diagnosis that qualifies the member for initiation of ABA services but that has not yet been confirmed by a qualified healthcare professional with expertise in the diagnostic area. The diagnosis must meet Functional Impairment Criteria and be:
a. SED; or
b. ASD; or
c. DD Eligible.
Qualified Healthcare Professional
A physician, nurse practitioner, or psychologist.
Qualifying Diagnosis
A member’s diagnosis established by a qualified healthcare professional with expertise in the diagnostic area, through a diagnostic evaluation. The diagnosis must meet functional impairment criteria and be:
a. SED; or
b. ASD; or
c. DD Eligible.
Registered Behavior Technician (RBT)
An individual with a paraprofessional certification in behavior analysis. RBTs assist in delivering behavior analysis services and practice under the direction and close supervision of a BCBA. The supervising BCBA is responsible for all work RBTs perform.
Serious Emotional Disturbance (SED)
For the purposes of the program of ABA services authorized by the Department, an emotional disturbance as defined in the Clinical Guidelines chapter of this manual.
Treatment Plan
An individualized written document that has been developed from the BIA and contains all the critical features listed in the Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers Second Edition issued by the Behavior Analyst Certification Board, Inc.® (BACB®) and/or Council of Autism Service Providers.
Unit of Service
15 minutes of treatment service.
Montana Medicaid Applied Behavior Analysis (ABA) services administered by the Department may be provided to a member under the following required conditions:
Any physician, licensed mental health professional, or other qualified healthcare professional may refer a member for the initiation of ABA services under a provisional qualifying diagnosis. However, the Department may only determine a member to be eligible for receipt of continued ABA services after the initial 180 calendar days or the initial authorized units of service are exhausted if:
The medical necessity review and authorization process for continued eligibility and receipt of ABA services will occur every 180 calendar days or when the initial or subsequent authorized units of service are exhausted.
The Department may also review the medical necessity of services or items at any time, either before or after payment, in accordance with the provisions of ARM 37.85.410. If the Department determines that services or items were not medically necessary or otherwise in compliance with applicable requirements, the Department may deny payment or may recover any overpayment in accordance with applicable requirements.
The following clinical guidelines must be employed for each covered Montana Medicaid Applied Behavior Analysis (ABA) service:
Members with a primary Developmental Disability (DD) diagnosis must be determined eligible for services administered by the Developmental Disabilities Program. Members must also meet Functional Impairment Criteria listed in this section.
Neurodevelopmental Disorders
• Attention Deficit/Hyperactivity Disorder (if accompanied by another SED diagnosis)
• Other Specified Neurodevelopmental Disorder
Schizophrenia Spectrum and Other Psychotic Disorders
• Schizophreniform Disorder
• Schizophrenia
• Schizoaffective Disorder, Bipolar Type
• Schizoaffective Disorder, Depressive Type
• Other Specified Schizophrenia Spectrum and other Psychotic Disorder
Bipolar and Related Disorders
• Bipolar I Disorder
• Bipolar II Disorder
• Cyclothymic Disorder
• Other Specified Bipolar and Related Disorder
Depressive Disorders
• Disruptive Mood Dysregulation Disorder
• Major Depressive Disorder, Single Episode
• Major Depressive Disorder, Recurrent Episode
• Persistent Depressive Disorder (Dysthymia)
• Other Specified Depressive Disorder
Anxiety Disorders
• Separation Anxiety Disorder
• Panic Disorder
• Generalized Anxiety Disorder
• Other Specified Anxiety Disorder
Obsessive-Compulsive and Related Disorders
• Obsessive-Compulsive Disorder
• Hoarding Disorder
• Excoriation Disorder
• Other Specified Obsessive-Compulsive and Related Disorder
Dissociative Disorders
• Dissociative Identity Disorder
• Other Specified Dissociative Disorders
Trauma- and Stressor-Related Disorders
• Reactive Attachment Disorder
• Disinhibited Social Engagement Disorder
• Posttraumatic Stress Disorder
• Other Specified Trauma- and Stressor-Related Disorder
Somatic Symptom and Related Disorders
• Somatic Symptom Disorder
• Conversion Disorder
• Other Specified Somatic Symptom and Related Disorder
Feeding and Eating Disorders
• Anorexia Nervosa
• Bulimia Nervosa
• Binge Eating Disorder
• Other Specified Feeding or Eating Disorder
Gender Dysphoria
• Gender Dysphoria
• Other Specified Gender Dysphoria
Disruptive, Impulse-Control, and Conduct Disorders
• Oppositional Defiant Disorder
• Intermittent Explosive Disorder
• Other Specified Disruptive and Impulse-Control Disorder
Members referred for ABA services under a provisional qualifying diagnosis or subsequently established qualifying diagnosis (SED, ASD, or DD eligible) must consistently demonstrate active symptomatology which is clearly documented by the BCBA. Active symptomology means substantial impairment in functioning for at least 180 calendar days or that is reasonably predicted to last at least 180 calendar days, as manifested by two (2) or more of the following:
This chapter provides covered service information that applies specifically to services performed by BCBAs, BCBA-Ds, RBTs, and BCaBAs. Like all healthcare services received by Medicaid members, services rendered by these providers must also meet the general requirements listed in the Provider Requirements chapter of the General Information for Providers Manual.
Services are covered only when they are within the scope of the provider’s license. As a condition of participation in the Montana Medicaid program, all providers must comply with all applicable state and federal statutes, rules, and regulations.
Medicaid ABA services must be deemed medically necessary and meet the eligibility criteria as established by the Department and as defined in the Eligibility Criteria chapter. Services must be directed by a BCBA or a BCBA-D. The services provided must demonstrate consistency with ABA core characteristics, Essential Practice Elements, and Assessment, Formulation of Treatment Goals, and Measurement of Client Progress as delineated in the Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers Second Edition issued by the BACB and/or the Council of Autism Service Providers.
The ABA provider must satisfy the following service requirements:
The ABA provider must complete service requirements 1. and 2. above within 30 calendar days of the onset of services. If extenuating circumstances have precluded the completion of these service requirements within the 30 calendar-day timeframe, the BCBA directing services should submit a written clinical explanation and/or justification for the delay to the Department, with a projected date by which the service requirements will be completed. Extenuating circumstances include, but are not limited to, serious illness or family emergency.
Members who meet the above Eligibility Criteria and whose providers agree to satisfy the service requirements may use any of the following CPT codes for services within ABA treatment:
97151 Behavior identification assessment by professional (BCBA), each 15 minutes
97152 Behavior identification assessment by technician, each 15 minutes
97153 Adaptive behavior treatment by technician using an established plan, each 15 minutes
97154 Adaptive behavior treatment by technician with multiple patients using an established plan, each 15 minutes
97155 Adaptive behavior treatment by professional (BCBA) or intermediate professional (BCaBA) using the TC modifier using an established plan, each 15 minutes
97156 Adaptive behavior treatment by professional (BCBA) or intermediate professional (BCaBA) with family using an established plan, each 15 minutes
97157 Adaptive behavior treatment by professional (BCBA) or intermediate professional (BCaBA) with multiple family group members using an established plan, each 15 minutes
97158 Adaptive behavior treatment by professional (BCBA) or intermediate professional (BCaBA) with group using an established plan, each 15 minutes
The package of services that will be offered within the initial 180 calendar days includes 1,260 total units of service. Units of service may be utilized as the BCBA provider sees fit and within nationally accepted standards of practice. Should the member exhaust the initial package of units of service or intend to extend service delivery beyond the initial 180 calendar days, the BCBA must request additional units of service by the process defined below. Of note, unused units of service will be considered expired once the initial 180 calendar days have elapsed. Expiration of units of service does not necessarily preclude the application for additional units of service after the initial 180 calendar days. All additional units of services must be authorized before service delivery may commence. Please see the Authorization of Additional Units of Service section of this manual.
In the case of a member transitioning services to a different BCBA provider, the member’s new provider must notify the Behavioral Health and Developmental Disabilities Division Program Officer. This information can be found on the Applied Behavior Analysis Services webpage.
Providers must utilize the Applied Behavior Analysis (ABA) Services Provider Transfer Request form to continue utilization of the member's authorized units of service.
The member must continue to meet the eligibility criteria and service requirements. In addition, the following three (3) things are required:
The following criteria exclude members from being eligible for service.
The Montana Medicaid Children’s Mental Health Bureau (CMHB) services listed below may be provided concurrently with ABA services. For a member to have concurrent services, the ABA services must be provided and billed outside authorized treatment hours of other programs and the providers must demonstrate and document their attempts to coordinate with community-based services.
The following CMHB services may not be provided concurrently for a Medicaid member that is receiving ABA services due to the duplicative nature of the services.
The following explains the rules governing authorization of additional units of service.
Providers intending to continue to deliver services after the initial 180 calendar days or 1,260 units of service, whichever elapses first, will be required to submit for authorization. For authorization, the BCBA must complete and submit the ABA Services Additional Units of Service Request form and additional required documentation. The BCBA must submit the form and additional documentation at least 14 calendar days prior to the intended onset of continued service delivery.
Any physician, licensed mental health professional, or other qualified healthcare professional may refer a member for the initiation of ABA services under a provisional qualifying diagnosis. However, to be eligible for authorization of continued receipt of ABA services, the provisional qualifying diagnosis must have been established as a qualifying diagnosis through a Diagnostic Evaluation completed by a qualified healthcare professional with expertise in the diagnostic area. A qualified healthcare professional with expertise in the diagnostic area must be one of the following:
Any additional units of services must be authorized by the Department before service delivery may begin. The Department may not give providers reimbursement retroactively for failure to submit timely, complete, and required documentation.
The process to request and the review for additional units of service is as follows:
A service provider may resubmit a request for additional units for service if they have additional information which would satisfy the deficiencies noted on the previous denial. It is important to note that this will be considered a new submission and all required documents will need to be submitted for review and determination.
A member may appeal the reviewer’s or designee’s determination. To appeal a determination outcome, a member or representative for the member may request an Administrative Review. For information regarding Administrative Reviews and Fair Hearings, please see Administrative Reviews and Fair Hearings section in the General Information for Providers Manual.
For general information about authorization, see the Prior Authorization chapter in the General Information for Providers Manual.
Forms, including those listed below, are available on the Applied Behavior Analysis Services page of the Montana Healthcare Programs Provider Information website.
(applies to Additional Units of Service Requests only)
Services provided by a BCBA covered in this manual must be either electronically billed or on a CMS-1500 claim form. CMS-1500 claim forms are available from various publishing companies and are not available from the Department or Provider Relations.
Members receiving ABA services are exempt from cost sharing.
If a member has additional insurance coverage, including Medicare, or a third party has responsibility for the member's healthcare costs, please see the Members Eligibility and Responsibilities chapter in the General Information for Providers Manual.
Providers billing Medicaid should use the Department’s fee schedule, designated by provider type, as well as the detailed coding descriptions listed in the CPT and Healthcare Common Procedure Coding System (HCPCS) coding books. Current fee schedules are available on the Applied Behavior Analysis Services page on the Provider Information Website.
The BCBA assumes full professional responsibility for all services provided by a BCaBA or RBT. All services are billed under the BCBA’s National Provider Identifier (NPI). Providers bill using standard Current Procedural Terminology (CPT) procedure codes and are reimbursed according to the Department’s Resource-Based Relative Value Scale (RBRVS) system.
Though providers do not need the information in this chapter to submit claims to the Department, the information allows providers to understand how payment is calculated and to predict approximate payment for claims.
Most services by provider types covered in this manual are reimbursed for using the Department’s RBRVS fee schedule. The fee schedule includes CPT codes and Healthcare Common Procedure Coding System (HCPCS) codes. Within the CPT coding structure, only anesthesia services and clinical lab services are not reimbursed for using the RBRVS fee schedule.
RBRVS was developed for the Medicare program. Medicare does a major update annually, with smaller updates performed quarterly. Montana Medicaid’s RBRVS-based fee schedule is based largely on the Medicare model, with a few differences as described below. By adapting the Medicare model to the needs of the Montana Medicaid program, the Department was able to take advantage of the research performed by the federal government and national associations of physicians and other healthcare professionals. RBRVS-based payment methods are widely used across the United States by Medicaid programs, workers’ compensation plans, and commercial insurers.
Each fee is the product of a relative value times a conversion factor.
For almost all services, Medicaid uses the same relative values as Medicare in Montana. Nationally, Medicare adjusts the relative values for differences in practice costs between localities, but Montana is considered a single locality. For less than 1% of codes, relative values are not available from Medicare. For these codes, the Department has set the relative values.
The Department sets the conversion factor for the state fiscal year (July through June) and it is listed on the fee schedule.
This manual has 3 search options.