Covered and Noncovered Services : Covered Services and Requirements

Focused Behavioral Treatment

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

ForwardHealth covers time-limited, lower-intensity treatment that focuses on specific behaviors or deficits. The aim of focused behavioral treatment is to reduce challenging behaviors of the member, develop replacement behaviors, and develop discrete skills that enhance personal independence. A narrow scope of goals and a 12-month timeline for goal mastery are the defining features of focused treatment, in contrast to the broad scope of goals with comprehensive treatment. Focused treatment must be administered face-to-face with the member. Only face-to-face services are reimbursable.

ForwardHealth covers the following two levels of focused behavioral treatment:

• Focused treatment for members whose significant maladaptive behavior (e.g., aggression, self-injury, property destruction) or complex conditions (e.g., comorbid mental health diagnoses) require skilled direct treatment by licensed supervisors and/or treatment therapists.
• Focused treatment to address specific behaviors or skill deficits for members with ongoing behavioral needs for whom early intervention is no longer appropriate. Focused treatment to address skill building or management of low-level behaviors can be safely and effectively addressed by treatment technicians. ForwardHealth covers symptoms or behaviors associated with a diagnosed condition that impairs or limits the member's functional community living but does not cover skill acquisition unrelated to functional community living.

These two levels of focused behavioral treatment are distinguished for the purpose of PA and claims via modifiers.

ForwardHealth adjudicates PA requests based on individual needs and circumstances of members. Treatment plans may be reviewed for appropriateness of the member's full schedule of cognitive and social demands.

Location of Treatment

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

Requirements for Technicians Delivering Focused Behavioral Treatment

Behavioral treatment technicians may deliver focused behavioral treatment under the following conditions:

• PA requests must be submitted by a behavioral treatment licensed supervisor.
• The licensed supervisor must attest that treatment technicians can safely and effectively implement the POC. ForwardHealth will review all information in the client's file to evaluate whether technicians are appropriate providers. Services will be authorized based on ForwardHealth's determination of the appropriate provider level.
• A licensed supervisor or treatment therapist must provide regular face-to-face observation with simultaneous direction of behavioral treatment technicians during delivery of direct treatment. ForwardHealth requires a minimum of one hour of direct case supervision per 10 hours of direct treatment provided by treatment technicians.
• The reimbursement rate for behavioral treatment technicians is the same for both focused and comprehensive behavioral treatment.

Enrollment for Technicians

Behavioral treatment technicians should enroll under the behavioral treatment technician provider specialty. Only one enrollment per technician is required, even if the technician will render both comprehensive and focused behavioral treatment.