Covered and Noncovered Services : Covered Services and Requirements

Comprehensive Behavioral Treatment

Comprehensive behavioral treatment may be provided by licensed supervisors, treatment therapists, or treatment technicians.

The behavioral treatment benefit covers high-intensity, early-intervention comprehensive behavioral treatment typically lasting for a year or more. The aim of comprehensive treatment is for the member to acquire a broad base of skills (e.g., communication, social-emotional development, adaptive functioning) with an emphasis on "closing the developmental gap" between the member and same-age peers in the primary deficit areas associated with autism. The broad scope of goals and focus on early developmental impacts are the defining features of this treatment. Comprehensive treatment must be administered face-to-face with the member. Only face-to-face services are reimbursable.

PA requirements for comprehensive behavioral treatment are available.

ForwardHealth reimburses comprehensive behavioral treatment services under federal EPSDT authority. EPSDT authority limits services to ForwardHealth members under 21 years of age. PA requests and claim submissions for comprehensive behavioral treatment for members 21 years of age or older will be denied by ForwardHealth.

Hours of Treatment

ForwardHealth authorizes comprehensive treatment for no fewer than 20 hours per week at the outset of treatment. Fewer than 20 hours of comprehensive treatment may be approved as part of a planned reduction in hours following a course of high-intensity treatment.

Location of Treatment

Treatment may occur in the member's home, the provider's office, or in the community.