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Applied Behavioral Analysis Guidelines for Treatment of Autism Spectrum Disorders

 

Initiated: 10/14
Revised: 1/16, 1/17
Reviewed: 2/15, 1/16, 1/17

 

Maladaptive behaviors may be found in children with Autism Spectrum (ASD) conditions. 

Type I ABA Therapy: 

This is used when the maladaptive behavior is of a severity that the child’s personal safety, or the safety of others in the child’s environment is jeopardized, and/or there is significant interference with functioning.  It refers to narrowly targeted interventions for specific problematic severe potentially hazardous self-injury and aggressive behaviors.

Type I ABA, Medical Necessity Review:

  1. Essential Criteria have been met: 
    1. ConnectCare requires a diagnosis of a condition on the Autism Spectrum (f84.0 through f84.5).
    2. The behaviors of the child must be of a severity that that their safety and/or the safety of others in their environment is placed in jeopardy or the behaviors significantly interfere with the child’s ability to function.
    3. Parent(s) (or guardians) must be involved in training in behavioral techniques so that they can provide additional hours of intervention.
    4. The provider has an individualized, time limited treatment plan developed that addresses the following:
      • Is child-centered, strengths specific, family-focused, community-based, multi-system, culturally-competent, and least intrusive
      • Clearly defines specific target behaviors
      • Records frequency, rate, symptom intensity or duration, or other objective measures of baseline levels
      • Establishes quantifiable criteria for progress
      • Describes behavioral intervention techniques appropriate to the target behavior, reinforces selected interventions, and strategies for generalization of learned skills
      • Documents the plan for transition through the continuum of interventions, services, and settings, as well as discharge criteria
    5. Collaboration and involvement of community resources to include the school district if the child is 3 or older, or early intervention if appropriate.
    6. Services must be provided directly or billed by individuals licensed by the state or certified by the Behavioral Analyst Certifying Board (BACB), unless state mandates, plan documents or contracts require otherwise. The BACB requires that BCaBAs, or Assistant Behavior Analyst, work under the supervision of a BCBA-D, BCBA or BCaBA.
  2. A functional behavioral assessment is planned to be completed within the first 60 days where specific target behaviors are clearly defined.
  3. The frequency, rate, symptom intensity or duration, or other objective measure of baseline levels of each target behavior is recorded and quantifiable criteria for progress are established.
  4. Specific type, duration and frequency of interventions are tied to the function served by the specific target behaviors.
  5. Parent is to be trained and required to provide specific additional interventions.

 

* A through E criteria must be evaluated.  Initial authorization is for up to 25 hours per week for up to 60 consecutive days, unless state mandates dictate otherwise.

Type I ABA, Medical Necessity Criteria for Continued Care:

  1. Essential Criteria have been met.
  2. The frequency of the target behavior has diminished since the last review, or if not:
    1. There has been modification of the treatment or additional assessments have been conducted.
    2. If progress has not been measurable after two such modifications, a functional analysis will be completed which:
      • Records the child’s maladaptive serious target behavioral symptom(s), the precipitants, and that makes a determination of the function a particular maladaptive behavior serves for the child in the environment context. 
    3. Appropriate consultations from other staff or experts have occurred (psychiatric consults, pediatric evaluation for other conditions) and interventions have been changed, including the number of hours per week or setting (higher level of care) for ABA.
  3. Parent(s) have received retraining on these changed approaches.
  4. The treatment plan documents a gradual tapering of higher intensities of intervention and a shifting to supports from other sources (ie:  schools) as progress occurs.

Type II ABA Therapy: 

This type of therapy refers to broader behavioral interventions focusing on developing social and communication skills to allow children with ASD to fit into environments with their peers.  The interventions are typically educational in nature, need to start early in the child’s life.

Type II ABA, Medical Necessity Review:

  1. Essential Criteria have been met:
    1. ConnectCare requires a diagnosis of a condition on the Autism Spectrum (f84.0 through f84.5) and the member must be under the age 18 (unless there are mandates specifying other age limits).
    2. There are identifiable target behaviors having an impact on development, communication, interaction with typically developing peers or others in the child’s environment, or adjustment to the settings in which the child functions, such that the child cannot adequately participate in developmentally appropriate essential community activities such as school.
    3. Parent(s) (or guardians) must be involved in prioritizing target behaviors, and training in behavioral techniques so that they can provide additional hours of intervention.
    4. The ABA is not custodial in nature (The child has reached the maximum level of physical or mental function and such person is not likely to make further improvement).
    5. The provider has an individualized, time limited treatment plan developed that addresses the following:
      • Is child-centered, strengths specific, family-focused, community-based, multi-system, culturally-competent, and least intrusive
      • Clearly defines specific target behaviors
      • Records frequency, rate, symptom intensity or duration, or other objective measures of baseline levels
      • Establishes quantifiable criteria for progress
      • Describes behavioral intervention techniques appropriate to the target behavior, reinforces selected interventions, and strategies for generalization of learned skills
      • Documents the plan for transition through the continuum of interventions, services, and settings, as well as discharge criteria
    6. There is involvement of community resources to include at a minimum, the school district if the child is 3 or older, or early intervention, if not.
    7. Services must be provided directly or billed by individuals licensed by the state or certified by the Behavioral Analyst Certifying Board, unless state mandates, plan documents or contracts require otherwise.
  2. A functional behavioral assessment is planned to be completed within the first 60 days where specific target behaviors are clearly defined.
  3. The assessment data are used to develop a plan to address each skill.  Does the plan reflect stimulus response consequence for each skill?
  4. The frequency, rate, symptom intensity or duration, or other objective measure of baseline levels of each target behavior is recorded and used to evaluate the impact of interventions and need to modify methods, and to identify when to progress to more advanced skills.
  5. Specific type, duration and frequency of interventions are tied to the function served by the specific target behaviors.  Instructional tactics must be selected based on the assessment of skills and be in accordance with generally accepted standards of practice.
  6. Parent is trained and required to provide specific additional interventions with the goal of generalization of skills.

Type II ABA, Medical Necessity Criteria for Continued Care:

  1. Esssential Criteria are met.
  2. The frequency of the target behavior has diminished since the last review, or if not:
    1. There has been modification of the treatment or additional assessments have been conducted.
    2. If progress has not been measurable after two such modifications, a functional analysis will be completed which:
      • Records the child’s maladaptive serious target behavioral symptom(s), the precipitants, and that makes a determination of the function a particular maladaptive behavior serves for the child in the environment context.
    3. Appropriate consultations from other staff or experts have occurred (psychiatric consults, pediatric evaluation for other conditions) and interventions have been changed, including the number of hours per week or setting (higher level of care) for ABA.
  3. Parent(s) have received retraining on these changed approaches.
  4. The treatment plan documents a gradual tapering of higher intensities of intervention and a shifting to supports from other sources (ie:  schools) as progress occurs.

ConnectCare

Utilization Management

ConnectCare's Utilization Management Staff is available to address questions and issues related to case management and utilization by using the telephone or fax numbers listed below.

ConnectCare Medical Management
4000 Wellness Drive
Midland, MI 48670
Toll free: 888-646-2429
Local: 989-839-1613
Fax: 989-839-1679
 
Hours of Operation
8:00 a.m. - 12:00 p.m.
1:00 p.m. - 5:00 p.m.
Monday - Friday (Eastern Time)

After normal business hours, inbound communications and information may be relayed via fax, confidential voice mail or electronic mail. All precertification requests and/or communications received after normal business hours are returned on the next business day and communications received after midnight on Monday through Friday are responded to on the same business day.

Certified by NCQA since 2007

NCQA Certified Utilization Management"Achieving Utilization Management Certification from NCQA demonstrates that ConnectCare has the systems, process and personnel in place to conduct utilization management in accordance with the strictest quality standards." -- Margaret E. O'Kane, President, NCQA

NCQA has reviewed and certified ConnectCare's Utilization Management functions only. For complete details on the scope of this review, visit www.ncqa.org.