Changes made to autism benefits for 2014

Blue Cross Blue Shield of Michigan and Blue Care Network will be making some changes to benefits covering autism spectrum disorder beginning in 2014.

The current $50,000 per member, per calendar year limit for applied behavior analysis will be replaced with a new limit of up to 25 hours of direct line therapy for ABA per member, per seven calendar days (procedure code H2019). The frequency limits take effect for members when the plan year begins. The current $50,000 per year limit will still apply to some members in 2014 until their new plan year begins.

Remember to check member eligibility and benefits before providing services to ensure the member has autism coverage and to determine which of the limits applies for ABA treatment.

ABA authorizations

For those BCBSM members whose ABA benefit requires authorization from Magellan, please be aware that Magellan authorizes ABA services based on medical necessity. They do not review frequency or dollar limits. An authorization from Magellan is not a guarantee of payment. A service authorized by Magellan could be denied for payment due to the member exceeding a frequency or dollar limit, or due to a coverage or benefit change. Always check eligibility and benefits at each visit.

PT, OT and ST visit limits in 2014 for autism

Physical, occupational and speech therapy visits for most BCBSM group members with an autism diagnosis will be subject to visit limits specified by the member’s plan, beginning with their new plan year that starts on Jan. 1, 2014, or later. Due to the differences in visit limits among group plans, providers should be sure to check member benefits and eligibility.

More information about billing for ABA services

Providers should bill for ABA in units based on 15-minute increments. If a member received four-and-a-half hours of ABA treatment, for example, it should be billed as 18 units. More information is available in the Applied Behavior Analysis Billing Guidelines and Procedure Codes document on web-DENIS.

• Click on BCBSM Provider Publications and Resources.
• Click on Newsletters & Resources.
• Click on Clinical Criteria & Resources.
• Click on Autism.