BCBSM and BCN autism physician letter - e-Referral - Blue Cross ...

600 E. Lafayette Blvd.
Detroit, MI 48226-2998
October 12, 2012
,
Subject: BCBSM and BCN expand benefits for autism spectrum disorder
Dear Blues Participating Provider:
Blue Cross Blue Shield of Michigan and Blue Care Network will expand benefits for autism
spectrum disorder in compliance with Michigan law, effective October 15, 2012. While the Blues
currently offer employer groups the option of covering autism treatment, the new law will allow
us to expand this coverage. Some members’ health plans are not subject to the new law, so
providers must check members’ coverage at the time of service.
We want you to be aware of what is changing so you can partner with us to help guide your
Blues patients who might benefit from evaluation or treatment for autism spectrum disorder.
Here’s what you need to know.
Overview of autism coverage
Autism spectrum disorders include autistic disorder, Asperger’s disorder and pervasive
developmental disorder not otherwise specified.
Covered benefits for children through the age of 18 (until the member’s 19 th birthday) include:
• Applied behavior analysis, a specialized treatment for ASD
• Physical therapy, speech therapy and occupational therapy as part of ASD treatment
• Nutritional counseling as part of ASD treatment as individually needed
• Other mental health services to diagnose and treat autism as individually needed
• Other medical services used to diagnose and treat autism as individually needed
The Blues adopted the maximum state mandated benefit limit of $50,000 per year. Refer to
Reimbursable Autism Procedure Codes on the web-DENIS Autism pages for information on
which services apply to the benefit limit. (Instructions for finding these pages are included
below.) Services beyond the benefit limit or age limit will be reviewed for medical
appropriateness and may be covered if medically necessary. BCN mailed a letter to subscribers
covered by the new ASD benefits. BCBSM mailed similar communications to employer groups
with the new ASD benefits.
bcbsm.com ■ MiBCN.com
Blue Cross Blue Shield of Michigan and Blue Care Network are nonprofit corporations and independent licensees of the Blue Cross and Blue Shield Association.

Applied behavior analysis requires AAEC evaluation and recommendation
For applied behavior analysis treatment to be payable, the following must occur:
• A Blues approved autism evaluation center, or AAEC, participating with the member’s
health plan, must make or confirm a diagnosis of autism spectrum disorder for the
member.
• The treatment plan prepared by the AAEC must include a recommendation for applied
behavior analysis.
• The member must obtain care from a board-certified behavior analyst. For BCN
coverage, the BCBA must participate with the member’s health plan.
• The board-certified behavior analyst must obtain prior approval from BCBSM or BCN
before providing applied behavior analysis services.
We expect to have Blues-approved autism evaluation centers and board-certified behavior
analysts available on our online provider searches by October 15, 2012, at bcbsm.com and
MiBCN.com.
Services other than applied behavior analysis
For covered autism services other than applied behavior analysis, the following procedures
apply:
• Diagnosis – BCN members must use a health care provider participating with the
member’s health plan to diagnose autism spectrum disorder. BCBSM members can
receive the ASD diagnosis from any provider unless they wish to have applied behavior
analysis treatment. For both BCBSM and BCN, applied behavior analysis treatment
requires a diagnosis from a Blues-approved autism evaluation center.
• BCN authorization requirements – BCN requires preauthorization for all behavioral
health services, including all services for autism spectrum disorder with the exception of
nutritional counseling. All services must be provided by a participating provider.
o Physical, occupational and speech therapy services, when performed for an autism
diagnosis, will be managed by BCN’s Care Management department, not Landmark.
A physician must write an order or prescription for therapy. The ordering physician
does not need to submit an authorization request to BCN. The treating provider must
submit an authorization request to BCN through e-referral or call BCN Care
Management at 1-800-392-2512. A treatment plan does not need to be submitted for
physical, occupational or speech therapy services for autism unless these therapies
are being reviewed for medical necessity.
o Mental health counseling requires preauthorization following standard BCN
behavioral health procedures. The ordering physician does not need to submit an
authorization request. The treating provider submits the authorization request
through e-referral or by calling BCN Behavioral Health at 1-800-482-5982.
o Nutritional counseling requires an order or prescription from a physician, but does
not require authorization by BCN.
• BCBSM prior approval requirements – The only autism service that requires prior
approval from BCBSM at this time is applied behavior analysis.
If you provide therapy services for autism and are contracted with BCN, you can request that
BCN list autism as a service you provide in the online BCN provider directory. Send an email
with the annual number of autism patients you treat and the percentage of your practice focused
on autism to bcnproviderpictures@bcbsm.com. Autism services for therapy providers may be
added to the BCBSM online provider directory in the future. Watch for more information in The
Record and on the Autism pages on web-DENIS.

Qualified facilities urged to apply for AAEC designation
The Blues are seeking qualified facilities to receive the approved autism evaluation center
designation. A copy of the letter mailed to all BCBSM participating hospitals in August with
detailed AAEC criteria along with the letter of intent form are available on our web-DENIS
Autism pages.
Board-certified behavior analysts urged to enroll in Blues provider networks
The Blues are building a network of board-certified behavior analysts that specialize in the
treatment of autism spectrum disorder. Qualified individuals are asked to apply online at
bcbsm.com/provider/enrollment.
• Under the Enrollment and Changes banner, click Physicians and Professionals and then
click Next.
• Select Enroll a new provider and then click Next.
• Select Board Certified Behavior Analyst and then click Next.
Where to find more information
The latest information about the Blues autism coverage, including a Frequently Asked
Questions document, is available on the web-DENIS Autism pages. These can be found in two
locations:
• BCBSM Provider Publications and Resources
o Click on Newsletters & Resources.
o Under Other Resources, click on Clinical Criteria & Resources.
o Under Resources, click on Autism.
• BCN Provider Publications and Resources
o Under Resources, click on Autism.
If you have questions, please contact your BCBSM provider consultant or your BCN provider
representative.
Sincerely,
Duane DiFranco, M.D.
Medical Director, Behavioral Health
Blue Care Network
Calmeze H. Dudley, M.D.
Associate Medical Director, Behavioral Health
Blue Cross Blue Shield of Michigan