Chapter 519.23 ABANewSite - Policy

Sep 20, 2026

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Chapter 519.23 defines policy, member eligibility, medical necessity, provider enrollment, provider qualification requirements, and verification methods for Applied Behavior Analysis (ABA) services. It explains how prior authorization reviews ensure the appropriateness and quality of ABA treatment plans at initiation and through ongoing clinical progress reviews. The chapter also outlines core practitioner roles, the individualized nature of interventions based on assessment results, and documentation expectations using measurement, data analysis, and indicators of behavior change to support approved services.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages13

Reading Time33 min

AccessFree to download

Background

Policy

519.23.1 Member Eligibility

519.23.2 Medical Necessity

519.23.3 Provider Enrollment

519.23.4 Provider Qualifications And Participation Requirements

519.23.5 Methods of Verifying Bureau for Medical Services Requirements

519.23.6 Prior Authorization

519.23.7 Billing Procedures

519.23.8 Assessment Services

519.23.9 Behavior Identification Assessment

519.23.10 Skills Training and Development

Glossary

Change Log

SECTION PAGE NUMBER Background ............................................................................................................................................... 2 Policy ......................................................................................................................................................... 2 519.23.1 Member Eligibility ....................................................................................................................... 2 519.23.2 Medical Necessity ...................................................................................................................... 2 519.23.3 Provider Enrollment .................................................................................................................... 3 519.23.4 Provider Qualifications And Participation Requirements ........................................................... 3 519.23.5 Methods of Verifying Bureau for Medical Services Requirements .............................................4 519.23.5.1 Administrative Services ........................................................................................................... 4 519.23.6 Prior Authorization ...................................................................................................................... 5 519.23.7 Billing Procedures ...................................................................................................................... 5 519.23.8 Assessment Services ................................................................................................................. 5 519.23.9 Behavior Identification Assessment ........................................................................................... 6 519.23.9.1 Adaptive Behavior Treatment .................................................................................................. 7 519.23.10 Skills Training and Development .............................................................................................. 8 519.23.10.1 ABA – Group Skills Training and Development .................................................................... 9 519.23.10.2 End of Participation ............................................................................................................... 9 Glossary .................................................................................................................................................. 10 Change Log ............................................................................................................................................. 12 Applied Behavior Analysis (ABA) is the application of the principles, methods, and procedures of the experimental analysis of behavior and applied behavior analysis (including principles of operants and respondent learning) to assess and improve socially important human behaviors. Many scores of ABA intervention procedures have proved effective for building functional skills and reducing challenge behaviors in many member populations. Professional practitioners of ABA engage in activities such as conducting assessments, analyzing data, writing and revising behavior analytic treatment plans (i.e. plans based on collected data), training others to implement components of a behavior change treatment plans, and overseeing the implementation of those plans. All ABA interventions are individualized to each client’s strengths, needs, and preferences. The goal of these plans is to bring about improvement for the client by addressing issues such as skill deficits (for example, in communication, self-care and other adaptive behaviors), as well as problem behaviors (such as aggression toward others or self-injurious behaviors, among others) . ABA services involve highly specific, individualized interventions based on results of interviews with caregivers, functional assessments, direct observation and measurement of behavior

FAQs

Who is eligible for ABA services under 519.23.1?

Medicaid members ages 18 months through 20 years with a primary diagnosis of Autism Spectrum Disorder (ASD) prior to their eighth birthday may be eligible when referred for necessary diagnostic and treatment services identified during an EPSDT encounter.

How does medical necessity work for ABA services (519.23.2)?

Medical necessity is determined through a prior authorization review process that evaluates the appropriateness and quality of the ABA services plan at initiation and during ongoing clinical progress reviews, supported by measurement and data analysis of treatment progress.

What documentation is required when requesting a first prior authorization for ABA services?

When the first PA is requested, the provider must submit documentation showing the primary diagnosis was rendered prior to the child’s eighth year of age.

Sep 20, 2026

Upload by Connor