March 2020 update




Applied Behavior Analysis Provider Report Guidelines


Assessment


The following is a guide to what is expected in the individual assessment for members with Autistic Spectrum
Disorder. (Refer to page 3 for the Concurrent (Progress) Report guidelines.)

I. Member?s identifying information
a. Name
b. Date of birth
c. Age
d. Member?s insurance ID number
e. Service address
f. Parent/caregiver name
g. Diagnosis, include date, name and title of the professional
h. Date(s) of original assessment
i. Name, title and credential of the assessor
j. Name of the supervising BCBA ? If there was a change in supervisor, indicate date

of change and name of prior supervisor
k. Current report date


II. Basic biopsychosocial information

a. Family composition
b. Family primary concerns
c. Medical and mental health history, including treatment and medication, if applicable
d. Current or prior services (i.e., ABA, speech, occupational, social skills group, etc.)
e. Overall school functioning


III. Member?s capabilities/strengths and family?s support system


IV. Member?s current problem areas/skills deficits relating to their ASD diagnosis. If there is no

skill deficit in an area, indicate normal/average or further assessment is required.
a. Cognitive/pre-academic skills
b. Language/communication skills
c. Reduction of interfering or mild inappropriate behaviors
d. Severe behavior (aggression, property destruction)
e. Safety skills
f. Social skills
g. Play and leisure skills
h. Independent living/self-help skills
i. Community integration
j. Coping and tolerance skills
k. Other











V. List dates and data source/assessment tools used

a. Indirect observations used
i. Family/caregiver(s) interview (in-person, phone)
ii. Records reviewed (i.e., IEP, psychological evaluations, reports from other ABA

providers, etc.)
iii. Functional Assessment Screening Tool
iv. Other ? please specify

b. Direct observations used
i. ABC charting
ii. Functional behavioral assessment (direct and indirect)
iii. Verbal Behavior Milestones Assessment & Placement Program, include grid
iv. Assessment of basic language and learning skills ? revised, include grid
v. Other ? Specify other methods to systematically evaluate abilities and

development of structured program.


Note: If further assessment is needed or will be used during the first authorization
period, specify tool/type and why.


VI. Functional Behavior Assessment (FBA) of target behaviors/presenting problems (identified

above)
a. Description of the problem (topography, onset/offset, cycle, intensity, severity)
b. History of the problem (long-term and recent)
c. Antecedent analysis (setting, people, time of day, events)
d. Consequence analysis
e. Impression and analysis of the function of the problem

Note: If an FBA was not conducted, provide an explanation and time frame as to when an
FBA will be administered.


VII. Description of parent/caregiver behavioral management training progress/knowledge transfer

plan progress
a. Condition and frequency of parent/caregiver trainings
b. Progress related to observable and measurable goals for the parent/caregiver
c. Describe barriers to parent/caregiver involvement, if applicable


VIII. Signature, title and credential of the author of the report as well as the supervising BCBA, if

different than the author.









Concurrent (Progress) Report

Below are specific guidelines to what is expected in the Concurrent (Progress) Report. All progress
reports are due, at minimum, two weeks prior to, and no more than 30 days, to the authorization
end date.

I. Member?s identifying information


II. History of program summary
a. Treatment start date
b. Current authorization end date
c. If applicable, gaps in treatment such as vacation, change in staff, etc.


III. Re-assessment description and tools used

IV. Progress per domain/behavior

a. Progress data
i. Baseline data

Status of current behavior (in progress, met, cancelled, modified), include skill(s)
introduction date. Note: If no or minimal progress was made, describe barriers.

ii. Graphic representation of the data collected during the current
authorization period, per goal, including baseline data and parent goals.

iii. Interpretation of graph / data
Note: Item ii above is mandatory. If a mastery criterion was defined as per
session or per week, then the data on the graph must be displayed as per
session or per week. Do not aggregate or average data such as per month or
per quarter unless goal was written in that way.

Example 1: Client will initiate and reciprocate various forms of the greetings ?hi?
and ?bye? with adults and peers, in 80% or more opportunities, across three
consecutive days, by June 2019.












Figure 1. Client?s performance per session with the target reciprocates ?Hi?.
















Pe
rc

en
t C

or
re

ct









Example 2: By January 2019, client will decrease her toileting accidents (urinating
and bowel movements) to 1 time per week, across three consecutive weeks, as
measured by therapist and parent data.


Status: Goal Not Achieved. More time is needed to achieve this goal. Client has
0 accidents during sessions with her therapist, although she occasionally has
accidents when outside of therapy sessions. New goal target date September 2019.
Client is currently on a 30-minute toileting schedule.




















V. Parent/caregiver behavioral training progress

VI. Report in the same fashion as described in section Progress per domain/behavior (IV.a)


VII. Description of program supervision delivery (if applicable)


VIII. Transition/Discharge Plan

a. Member?s and family?s ability to generalize the skills in multiple settings and mastery of
the majority of the program goals

b. Step-down in program hours
c. Member?s readiness to move from current level of service (in-home) to lower level of

service (i.e., outpatient individual, social skills group therapy, medication
management, mainstream education, adult assistant living, other community
resources)

d. Communication and coordination between the supervising clinician and other
professionals such as psychotherapist, speech therapist, occupational therapist,
social worker, etc.


IX. Program recommendations, justification for continued treatment


X. Signature, title and credential of the author of the report as well as the supervising BCBA, if

different than the author




This Document is Proprietary and Confidential
Do Not Print or Distribute Without Permission

Provider Information Forum
Applied Behavior Analysis (ABA)

April 2020
Behavioral Health Team



Proprietary & Confidential

Topics of Discussion

? ABA Overview and MCO Basics
? ABA Services and Codes
? ABA Unit Guidance and Allowable Specialties
? Authorizations
? NaviNet
? Network ? Credentialing and Demographic Information Updates
? 21st Century Cures Act
? Claims
? Additional Supports



Proprietary & Confidential

? The management of Applied Behavior Analysis (ABA) services has transitioned from the
Division of Medical Assistance and Health Services, Children?s System of Care (CSOC) to the
Managed Care Organizations as of 4/1/20.


? Effective 4/1/20, Horizon New Jersey Health (HNJH) covers all medically necessary ABA

services for eligible Horizon Medicaid members.


? Services are available to any child diagnosed with an Autism Spectrum Disorder (ASD) as
defined by ICD-10 diagnoses F84.0 ? F84.9






ABA ? Managed Care Organization Basics



Proprietary & Confidential


? Providers should contact Horizon to ensure eligibility and benefits by contacting Horizon

member services at 1-800-682-9091


? For eligible Horizon members already receiving ABA services through CSOC, Horizon will
honor authorizations up until the current authorization end date to ensure services continue
uninterrupted


? Prior authorization will be required to continue services after the authorization end date


? Providers should bill Horizon for ABA services for all dates of service 4/1/20 and beyond





ABA ? Managed Care Organization Basics (cont.)



Proprietary & Confidential

ABA Services and Codes
CPT Code CPT Code Definition

97151
Behavior identification assessment, administered by a physician or other qualified healthcare professional, each 15 minutes of the physician's or
other QHP's time face-to-face with patient, and/or guardian(s) administering assessments and discussing findings and recommendations, and non
face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan

97152 Behavior identification supporting assessment, administered by one technician under the direction of a physician or other qualified healthcare professional, face to face with the patient, each 15 minutes.

0362T
Behavior identification supporting assessment, each 15 minutes of technician's time face-to-face with a patient requiring the following
components: *administered by the physician or other qualified healthcare professional who is on-site, * with the assistance of two or more
technicians,*for a patient who exhibits destructive behavior, *completed in an environment that is customized to a patient's behavior

97153 Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other QHP, face-to-face with one patient, each 15 minutes

97154 Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other QHP , face-to-face with 2 or more patients, each 15 minutes

97155 Adaptive behavior treatment, with protocol modification, administered by physician or other QHP, which includes simultaneous direction of technician, face-to-face with one patient, each 15 minutes

97156 Family adaptive behavior treatment guidance administered by physician or other QHP (with or without the patient present), face-to-face with guardians(s)/caregiver(s), each 15 minutes

97157 Multiple-family group adaptive behavior treatment guidance administered by physician or other qualified healthcare professional (without the patient present) face-to-face with multiple sets of guardians(s)/ caregiver(s)

97158 Group adaptive behavior treatment with protocol modifications, administered by a physician or other QHP , face to face with multiple patents', each 15 minutes

0373T
Adaptive behavior treatment with protocol modification, each 15 minutes of technician's time face-to-face with a patient requiring the following
components: *administered by the physician or other qualified healthcare professional who is on site, * with the assistance of two or more
technicians,*for a patient who exhibits destructive behavior, *completed in an environment that is customized to a patient's behavior

H0032 Mental Health service plan development by a non-physician, per 15 minutes



Proprietary & Confidential 6











Authorization Unit Guidance and Allowable
Specialties



Proprietary & Confidential 7


? Provider submits the ABA Authorization Request Form via Utilization Management Request Tool accessible in

NaviNet
NOTE: Providers can obtain a copy of the ABA Authorization Request Form from the horizonblue.com website:


? Click on Provider Tab
? Select Products and Programs, then Horizon Behavioral Health
? Click on Frequently used forms
? Applied Behavior Analysis (ABA) Authorization Request
? https://www.horizonnjhealth.com/securecms-documents/900/ABA_Authorization_Request_Form_40001.pdf



? Request for assessment includes a copy of the Autism Spectrum Diagnosis (ASD) script with recommendation for

ABA therapy as completed by a Qualified Health Professional (QHP)


? Acceptable QHPs for the treatment planning for adaptive behavior services shall include:
? Physicians
? Psychologists trained and certified in behavior analysis, and
? Board Certified Behavior Analysts


? Horizon checks eligibility and benefits, confirms diagnosis and completes the assessment authorization for 32 units

of 97151 for 30 days













Process for Obtaining Authorization



Proprietary & Confidential 8


? After completing the assessment, provider submits the ABA Request Form via the Utilization

Management Request Tool, accessible via NaviNet

? Horizon, again, checks eligibility and benefits pursuant to internal processes


? A Horizon Behavioral Health Utilization Management (UM) Clinician reviews request form

against MCG Medical Necessity Criteria
o If clinical information meets medically necessary criteria, Horizon BH Clinician creates

authorization
o If clinical information does not meet medical necessity criteria, the Horizon BH

Clinician calls provider to discuss
o If necessary, Horizon BH Clinician sends the case to the Horizon Medical Director

Review for a Medical Necessity Review


? For cases that do meet criteria ? once approved ? Horizon BH clinician creates authorization
for 6 months












Process for Obtaining Authorization (cont.)



Proprietary & Confidential 9


? Horizon NJ Health offers multiple online services via NaviNet that can greatly benefit providers
? This is a free, secure website that offers a single sign-on where providers can access

transactions and services for multiple health plans
? NaviNet helps providers reduce administrative costs and time
? When providers have a claim inquiry, they can go to NaviNet
? By joining NaviNet, providers will get access to:

? Administrative Reports

? Utilization Management Tools

? Claims Appeals Checks and Status inquiries

? Search Eligibility and Benefit information











NaviNet



Proprietary & Confidential 10




Providers can access the Utilization Pre-authorization Management Tool through
NaviNet. Simply select Horizon NJ Health from the Plan Central page; mouse over
Referrals and Authorization on the left-hand navigation; then select Utilization
Management requests. Please refer to the Utilization Management Request Tool
Tutorial by visiting www.horizonblue.com:

? Under the Provider?s tab, select Products & Programs
? Click on Horizon Behavioral Health
? Under Training, click on Utilization Management Request Tool Tutorial


? NaviNet Support: 1-888-482-8057











NaviNet (cont.)




Proprietary & Confidential 11

Credentialing



? BCBAs and BCBA-Ds are required to successfully complete the credentialing process prior to being

accepted as a network provider. Recredentialing is required every 3 years.

? Bachelor?s level behavior analysts and support staff/technicians are not required to complete

credentialing with Horizon. Services they provide are required to be under the supervision of the
QHP. Horizon is not requiring Behavior Technicians to be Registered Behavioral Technicians, but it is
preferred.


? Please visit https://www.horizonnjhealth.com/for-providers/provider-recruitment

for more information and Horizon NJ Health Applications.
- Agreements are accessible via NaviNet?s Horizon BCBSNJ

plan central page. If you don?t have access to this page, email
EnterprisePDM@horizonblue.com to request an Agreement.


? A complete application can take between 45 and 90 days from date of receipt to process.





Proprietary & Confidential 12

Credentialing

Helpful Hints

? CAQH Tips

? Current attestation
? Horizon authorized to access the application
? Assure that new practitioners joining your group have the group?s location information included in the

practice locations
? Ensure consistency in formatting of office locations

? Leave the effective dates blank in the agreements

? Include all pages of the agreements

? All documents must be sent via mail

? Include all documents on the checklist

? Ensure all documents are up to date







Proprietary & Confidential 13

Updating Your Demographic Information

? Use CAQH ProviewTM

? Or email Demographic Update requests to EnterprisePDM@horizonblue.com
? Submit requests & supporting documentation at least 30 days before the effective date of

the change.
? Always include the submitter?s name, email & telephone # with all email requests.
? EnterprisePDM@horizonblue.com is not managed by a representative who reads &

responds immediately to your emails. Emails received are converted to Service Requests
which are then addressed offline by our Provider team.

? Submit ONLY demographic Updates to this email address.
DO NOT email initial credentialing submissions, claims, questions, etc.

? To help ensure that you are getting these responses (and that they are not flagged as
spam), please add EnterprisePDM@HorizonBlue.com to your list of safe or approved
senders/contacts. This will keep emails from us out of your junk/spam folder.








Proprietary & Confidential 14

21st Century Cures Act

? Effective January 1, 2018, the 21st Century Cures Act 114 P.L. 255 requires that all Medicaid managed care
network providers must enroll with the State Medicaid program or risk being removed from the provider network.
This is both a federal and state requirement.


? Each individual BCBA is required to register for a Medicaid number. Providers do not need to wait for their
Medicaid number to be assigned to submit the credentialing applications to Horizon for network participation.
Please notify us of your Medicaid number once received so we can update our systems accordingly.


? Registering as an NJ FamilyCare provider does not require you to service NJ FamilyCare Fee-for-Service

beneficiaries.

? To register, Go to the NJ Medicaid Management Information System?s (NJMMIS) website at njmmis.com and select

Provider Enrollment Application on the left blue bar OR use the following direct link
njmmis.com/onlineEnrollment.aspx. Under the Your Information section, click the down arrow in the Provider
Type field and select 21st Century Cures Act.



? Please note: If you select your specialty from the drop down menu, the fee-for-service 20 page application will
generate. However, by selecting the 21st Century Cures Act option, the 4-page application needed to satisfy the
law?s requirement will appear.


? You can submit your application and credentials by:
? Fax: 1-609-584-1192
? Mail: P.O. Box 4804, Trenton, NJ 08650









15


Horizon?s participating providers are assigned to a Network Specialist based on their county.
Your Network Specialist is available via phone or email and is your primary point of contact
for the following areas:


? General Education
? Requests for a Site/Education Visit
? NaviNet Training
? Network Status Inquiries


Please continue to contact Customer Service for all claims related concerns.







Network Management



Behavioral Health Provider Relations:
Horizon NJ Health

16

Dottie Laisi
LaTanya
McLean Barkley Michelle McCusker Olivia Inniss

Atlantic Hunterdon Burlington Bergen

Cape May Mercer Camden Essex

Cumberland Morris Middlesex Hudson

Gloucester Somerset Salem Passaic

Monmouth Sussex

Ocean Union

Warren

856-638-3215 856-638-3228 856-638-3223 973-466-4609

Dorothy_Laisi@horizonblue.
com

LaTanya_Barkley@horizonblue.
com

Michelle_McCusker@horizonblue.
com Olivia_Inniss@horizonblue.com



17

? Horizon NJ Health encourages all health care professionals to submit claims electronically


? Claims should be submitted with the BCBAs name and NPI as the rendering provider


? HNJH members to not have copays and/or coinsurance

? We utilize the TriZetto Provider Solutions (TTPS) Direct Data Entry (DDE) SimpleClaim system

? For more information on registering, please go to https://www.trizettoprovider.com/horizon/simpleclaim. If you have any further

questions about registering with TTPS for DDE claims submission, please contact TriZetto at 1-800-556-2231 or email
ttpssupport@cognizant.com. Payer Number: 22326


? While Horizon NJ Health strongly encourages submitting claims via EDI, if a paper claim is necessary, please submit red and white

paper claims only for all services to Horizon NJ Health at the following address:


Horizon NJ Health
Claims Processing Department
PO BOX 24078
Newark, NJ 07101-0406


? Electronic Funds Transfer forms for providers who wish to use EFT to receive payments can be found by visiting

https://www.horizonnjhealth.com/for-providers/resources/forms/electronic-funds-transfer-eft-forms


? EDI Technical Support Team is available during regular business hours, 8 a.m. through 5 p.m., Monday through Friday at 1-800-556-

2231





Claims















Proprietary & Confidential 18


? Horizon?s Case Management can also help facilitate linkages to care and coordinate care with

other providers and caretakers in the member?s environment


? Provider referrals can also be found via Horizon?s Doctor & Hospital Finder ? our on-line
Provider Directory (https://www.horizonnjhealth.com/findadoctor)


? Provider Referrals can also be given by calling Horizon Customer Service at 1-800-682-9091

? For any additional questions, please contact Vincent_Visioli@horizonblue.com















Applied Behavioral Analysis ? Additional Supports






Thank you for your time today






Network - BHNetworkRelations@horizonblue.com
Clinical ? Vincent_Visioli@horizonblue.com



Q & A

19

Presenter
Presentation Notes
remove





20

Sample MLTSS Member ID Card

Confirm eligibility at NaviNet.net or call MLTSS Provider Services at
1-855-777-0123.





21

Sample FIDE-SNP Member ID Card

Confirm eligibility at NaviNet.net or call Provider Services at
1-855-955-5590.





22

Sample NJ FamilyCare Member ID Card

Confirm eligibility at NaviNet.net or call Provider Services at
1-800-682-9091.





23

Products are provided by Horizon Insurance Company and/or Horizon NJ Health. Communications are issued by
Horizon Blue Cross Blue Shield of New Jersey in its capacity as administrator of programs and provider relations for
all its companies. All are independent licensees of the Blue Cross and Blue Shield Association. ECN00524 (0720)



Provider Information Forum
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Behavioral Health Provider Relations:?Horizon NJ Health
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Q & A
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