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