Frequently Asked Questions - Ubhonline.com
Frequently Asked Questions - Ubhonline.com
Frequently Asked Questions - Ubhonline.com
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Autism/Applied Behavior Analysis<br />
<strong>Frequently</strong> <strong>Asked</strong> <strong>Questions</strong><br />
Q1: How do I apply to join the Optum or OptumHealth Behavioral Solutions of California<br />
(Optum) Autism Applied Behavior Analysis Network?<br />
A1: Optum has developed credentialing/contracting criteria for Applied Behavior Analysis (ABA)<br />
Providers as outlined below:<br />
Individual BCBA<br />
• Board Certified Behavior Analyst (BCBA) with active certification from the national Behavior<br />
Analyst Certification Board, and<br />
• State licensure in those states that license behavior analysts<br />
• Stage certification in those states that certify behavior analysts<br />
• A minimum of six (6) months of supervised experience or training in applied behavioral<br />
analysis/ intensive behavior therapies<br />
• Minimum professional liability coverage of $1 million per occurrence / $1 million aggregate<br />
ABA Agency Provider<br />
• BCBAs must meet standards above<br />
• Licensed clinicians must have appropriate state licensure and six (6) months of supervised<br />
experience or training in applied behavior analysis/intensive behavior therapies<br />
• BCBA or licensed clinician on staff providing program oversight<br />
• BCBA or licensed clinician performs skills assessments and provides direct supervision of<br />
paraprofessionals in joint sessions with client and family<br />
• Board Certified Assistant Behavior Analysts (BCaBAs) and Paraprofessionals receive<br />
appropriate training and supervision by BCBAs or licensed clinician and hold applicable state<br />
licensure or certification<br />
• Minimum $1 million per occurrence and $3 million aggregate of professional liability and<br />
$1m/$1m of general liability if services are provided in a clinic setting<br />
• Minimum $1 million per occurrence and $3 million aggregate of professional liability and<br />
$1m/$1m of supplemental insurance if the agency only provides services in the patient’s home<br />
If you meet this criteria and wish to apply, please refer to the Join our Autism/ABA Network<br />
section on Provider Express in the Autism/Applied Behavior Analysis Corner.<br />
Q2. What is an NPI number and how do I obtain one?<br />
A2. NPI is a required National Provider Identifier set forth in the Health Insurance Portability<br />
and Accountability Act (HIPAA) regulations. HIPAA requires that covered entities (i.e., health<br />
plans, health care clearinghouses, and those health care providers who transmit any health<br />
information in electronic form in connection with a transaction for which the Secretary of Health<br />
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United Behavioral Health operating under the brand Optum<br />
U.S. Behavioral Health Plan, California doing business as OptumHealth Behavioral Solutions of California
and Human Services has adopted a standard) use NPIs in standard transactions. Please use<br />
the National Plan and Provider Enumeration System (NPPES) link below to obtain an NPI:<br />
https://nppes.cms.hhs.gov/NPPES/StaticForward.do?forward=static.npistart<br />
Q3. How do I verify a member’s benefits, copay, or coinsurance?<br />
A3. To inquire about member benefits, copay or coinsurance, please call the number on the<br />
member’s insurance card listed for providers or for benefits and eligibility information.<br />
Q4. What services are covered for Autism ABA services?<br />
A4. Coverage is dependent upon the member’s certificate of coverage. Services that are typically<br />
covered for ABA treatment include:<br />
• Skills or Behavior Assessment by BCBA or qualified licensed clinician<br />
• Conjoint Treatment Planning and Supervision of Paraprofessionals by BCBA (or qualified<br />
licensed clinician) with clients present<br />
• Direct ABA services by a BCBA or licensed clinician<br />
• Direct ABA services by a paraprofessional or BCaBA (if appropriately supervised)<br />
Q5. How is supervision by a BCBA defined?<br />
A5. Supervision of a BCaBA or a paraprofessional by a BCBA or licensed clinician is defined as<br />
services rendered jointly, in-person, during directly supervised fieldwork of the paraprofessional or<br />
BCaBA by the supervisor.<br />
Q6. How do I obtain an authorization/notification for ABA services?<br />
A6. After verification of benefits is received for ABA services, the intake coordinator refers the<br />
request to an Autism Care Advocate, who will contact you to coordinate the review process for<br />
appropriate treatment.<br />
Q7. I faxed in my authorization/notification request packet, how long does it take to get<br />
a determination?<br />
A7. You should receive a phone call about your authorization/notification within 10 calendar days<br />
of sending in your <strong>com</strong>pleted packet. You will also receive a paper copy in the mail. Your<br />
submitted packet includes; diagnostic assessment, treatment plan, release of information, and<br />
the behavioral benefit assessment form. Where mandated by state law, the packet must include<br />
a physician prescription for services. You will also receive a paper copy in the mail or by fax.<br />
Once the packet is received, if we determine that additional information is needed before an<br />
authorization/notification can be generated, you will receive a phone call from the Autism Care<br />
Advocate requesting the necessary information. You will also receive a letter in this regard, and will<br />
have 45 days in which to provide the requested information in order to <strong>com</strong>plete the<br />
authorization/notification review process.<br />
Q8. When do I submit my request for continued services?<br />
A8. You should submit the information needed for the next review within one week of the<br />
current authorization/notification expiring. Please submit an updated treatment plan,<br />
quantitatively detailing the member’s progress.<br />
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United Behavioral Health operating under the brand Optum<br />
U.S. Behavioral Health Plan, California doing business as OptumHealth Behavioral Solutions of California
Q9. How do I request hours for supervision of BCaBAs and paraprofessionals, and how<br />
many are allowed?<br />
A9. Please request hours for supervision and treatment planning on the Behavioral Benefit<br />
Assessment form. A minimum of one hour of supervision per month is expected for each case. The<br />
maximum hours approved are based on the member’s direct hours, (i.e., one hour supervision for<br />
every ten hours direct service not to exceed eight hours per month). All services must be<br />
authorized by an Autism Care Advocate. If you have a need for more than this, please include<br />
your rationale in the request and it will be reviewed for clinical necessity.<br />
Q10. Do you cover treatment planning?<br />
A10. Treatment planning is an expected part of member care. A minimum of one hour of treatment<br />
planning per month is required. You may request up to one hour for every ten hours of direct<br />
service, not to exceed eight hours per month. If you have a need for more than this, please include<br />
your rationale in the request and it will be reviewed for clinical necessity.<br />
Q11. What should be in the treatment plan?<br />
A11. Required elements are included in the Treatment Plan template. This template is housed on<br />
the Autism Corner page of Provider Express.<br />
Q12. How do I request hours for an ABA assessment?<br />
A12. You will need to fill out an ABA Assessment Request Form. You can obtain this form on<br />
Provider Express, in the Autism/Applied Behavioral Analysis Corner. You can fax the <strong>com</strong>pleted<br />
form to your assigned Autism Care Advocate.<br />
Q13. Should I include a request for my next assessment?<br />
A13. If you are requesting less than six hours for a re-evaluation, please include this on the<br />
Behavioral Benefit Assessment form (list the assessments you will be using). If you are requesting<br />
more than six hours of testing, you will need to <strong>com</strong>plete the ABA testing request form.<br />
Q14. What forms do I use to submit claims?<br />
A14. Participating ABA agencies and individual BCBAs should bill on the standard CMS-1500<br />
claim form with the billing codes indicated on your contracted fee schedule. Please see our<br />
website Provider Express and go to Quick Links > Claim Tips >Outpatient Claims > CMS-1500<br />
claim form to see a sample CMS-1500 claim form and view Required Fields.<br />
If you are out-of-network and have the capacity to generate a CMS-1500 form, please do. If you<br />
are interested in using CMS-1500 forms, you may get more information at www.cms.gov.<br />
Q15. I am a contracted provider. What procedure codes should I use to bill services?<br />
A15. If you are a participating provider, you should bill your contracted billing codes and<br />
customary charges after receiving appropriate authorization. You will be reimbursed based<br />
on your contracted rate.<br />
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United Behavioral Health operating under the brand Optum<br />
U.S. Behavioral Health Plan, California doing business as OptumHealth Behavioral Solutions of California
Q16. I am not yet a contracted provider. What procedure codes should I use to bill<br />
services?<br />
A16. If you are not contracted with us yet, you should call for authorization and bill your<br />
authorized billing codes.<br />
Q17. Where do I submit claims for processing?<br />
A17. You should fax your claims to 1-855-835-6130, Attn: Autism Claims Processing.<br />
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United Behavioral Health operating under the brand Optum<br />
U.S. Behavioral Health Plan, California doing business as OptumHealth Behavioral Solutions of California
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