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Welcome  » March 29, 2024 7:44 AM
Program Name: BadgerCare Plus and Medicaid Handbook Area: Behavioral Treatment Benefit
03/29/2024  

Prior Authorization : Services Requiring Prior Authorization

Topic #20477

Prior Authorization Requirements for Members Under Age 6

In order to expedite early intervention for young children, ForwardHealth allows simplified requirements for comprehensive behavioral treatment PA requests for members who have not yet reached 6 years of age, the age of mandatory school attendance. Providers are expected to conduct a behavior identification assessment, which is reimbursable without PA, in order to identify target behaviors and develop an appropriate POC for the member. The PA requirements include:

  • Initial and amendment PA requests must be submitted before the member's sixth birthday.
  • ForwardHealth will authorize up to 30 hours per week of direct treatment (CPT code 97153) through the member's third birthday and up to 40 hours per week thereafter.
  • PA requests may be approved for up to 12 months if the request meets the criteria for medical necessity.
  • Approval criteria for initial PA requests will be modified for children under age 6. The following information will be required:
    • A PA/RF.
    • Diagnostic evaluation or, if not available, the provider's attestation that the member has been diagnosed with an autism spectrum disorder by a qualified professional.
    • A POC consistent with current requirements that covers all DOS in the authorization period. The POC must include family/caregiver goals and behavior reduction goals, when needed.
    • Documentation of a medical evaluation within the past 12 months.
    • A prescription consistent with current requirements that covers all DOS in the authorization period.
    • The provider's initial assessment of the member, which must be retained on file and consistent with current requirements.
    • Additional information, including the initial assessment, that will be requested only when required to establish the medical necessity of the PA request.
  • Approval criteria for PA amendment requests and subsequent PA requests must include the following:
    • A Prior Authorization Amendment Request or PA/RF.
    • A POC consistent with current requirements that covers all DOS in the authorization period. The POC must include family/caregiver goals and behavior reduction goals, when needed.
    • Documentation of a medical evaluation within the past 12 months. If the medical evaluation submitted with the previous PA request occurred within the past 12 months, an update is not required prior to submission. However, an updated evaluation must be maintained in the member's file.
    • An updated prescription consistent with current requirements that covers all DOS in the authorization period. If the prescription submitted with the previous PA request covers all dates in the current PA request, an update is not required prior to submission. However, an updated prescription must be maintained in the member's file.
    • A progress summary consistent with current requirements, required annually after 12 months of continuous behavioral treatment.
    • Additional information that will be requested only when required to establish the medical necessity of the PA request.

If a member under age 6 is enrolled in school, ForwardHealth may require additional information about the member's schedule and coordination with school staff in order to establish the medical necessity of the requested service. Providers may elect to submit additional information with their initial PA submission.

ForwardHealth's policy is based on the member's chronological age, not developmental age equivalent or school enrollment status.

 
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