[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-316423-105":3,"detail-sidebar-cat-0-en-105":81,"doc-detail-316423-en":130},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","cpcp011-version-10-applied-behavior-analysis-clinical-payment-and-coding-policy","CPCP011 - Version 1.0 - Applied Behavior Analysis - Clinical Payment and Coding Policy","","Clinical Payment and Coding Policy CPCP011 (Version 1.0) governs reimbursement for Covered Applied Behavior Analysis (ABA) services. It establishes that plan documents, and then provider contracts, control in case of conflicts and that Blue Cross and Blue Shield of Texas holds final discretionary authority within applicable plan documents. Providers must submit accurate, appropriately coded claims using HIPAA-approved code sets and comply with code edit protocols, benefit terms, and coding policy logic. Reimbursement requires qualified provider certification, excludes educational/vocational/respite/custodial purposes, and demands supporting documentation for non-conventional settings and unusual POS codes.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/document/","Document",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/document/healthcare/","Healthcare",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/document/cpcp011-version-10-applied-behavior-analysis-clinical-payment-and-coding-policy/316423/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/cpcp011-version-10-applied-behavior-analysis-clinical-payment-and-coding-policy/316423.png","ImageObject",300,407,{"name":42,"@type":43},"Ben Jamin","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-22","2026-09-20",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",9,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Which document controls if there is a conflict affecting reimbursement?","Question",{"text":63,"@type":64},"Plan documents govern conflicts involving a Clinical Payment and Coding Policy and coverage plan documents. If a conflict arises between a CPCP and a provider contract under which the provider participates and/or provides Covered Services, the provider contract governs.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What coding and documentation obligations apply to providers?",{"text":68,"@type":64},"Providers are responsible for submitting accurate documentation and must submit claims using valid code combinations from HIPAA-approved code sets. Claims must be coded according to industry-standard coding guidelines and are subject to code edit protocols and claim review.",{"name":70,"@type":61,"acceptedAnswer":71},"When are Applied Behavior Analysis (ABA) services reimbursable?",{"text":72,"@type":64},"ABA services are reimbursable only when provided by a Qualified Healthcare Professional certified by BACB and/or licensed in the provider’s state as a Licensed Behavior Analyst or Licensed Psychologist. Reimbursement is not available for educational, vocational, respite, or custodial purposes, and non-conventional settings require supporting documentation.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},316423,1790379677,{"code":4,"msg":82,"data":83},"success",[84,88,92,96,101,106,110,115,119,122,126],{"id":22,"doc_module":4,"doc_module_name":25,"category_name":85,"show_sort_weight":86,"slug":87},"Story & Novel",90,"story-novel",{"id":26,"doc_module":4,"doc_module_name":25,"category_name":89,"show_sort_weight":90,"slug":91},"Literature",80,"literature",{"id":33,"doc_module":4,"doc_module_name":25,"category_name":93,"show_sort_weight":94,"slug":95},"Exam",70,"exam",{"id":97,"doc_module":4,"doc_module_name":25,"category_name":98,"show_sort_weight":99,"slug":100},5,"Comic",60,"comic",{"id":102,"doc_module":4,"doc_module_name":25,"category_name":103,"show_sort_weight":104,"slug":105},6,"Technology",50,"technology",{"id":107,"doc_module":4,"doc_module_name":25,"category_name":29,"show_sort_weight":108,"slug":109},7,40,"healthcare",{"id":111,"doc_module":4,"doc_module_name":25,"category_name":112,"show_sort_weight":113,"slug":114},8,"Research & Report",30,"research-report",{"id":55,"doc_module":4,"doc_module_name":25,"category_name":116,"show_sort_weight":117,"slug":118},"Religion & Spirituality",20,"religion-spirituality",{"id":117,"doc_module":4,"doc_module_name":25,"category_name":120,"show_sort_weight":117,"slug":121},"World Cup","world-cup",{"id":123,"doc_module":4,"doc_module_name":25,"category_name":124,"show_sort_weight":123,"slug":125},10,"Lifestyle","lifestyle",{"id":127,"doc_module":4,"doc_module_name":25,"category_name":128,"show_sort_weight":97,"slug":129},19,"General","general",{"code":4,"msg":82,"data":131},{"doc_id":79,"user_id":132,"nickname":42,"user_avatar":133,"doc_module":4,"category_id":107,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":111,"language":139,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":12,"update_tm":143,"read_time":117},2336478466772,"https://ap-avatar.wpscdn.com/davatar_3d24733baf745e90a7e4bdd5f77d97b2","If a conflict arises between a Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern. If a conflict arises between a CPCP and any provider contract pursuant to which a provider participates in and/or provides Covered Services to eligible member(s) and/or plans, the provider contract will govern.“Plan documents”include, but are not limited to, Certificates of Health Care Benefits, benefit booklets, Summary Plan Descriptions, and other coverage documents. Blue Cross and Blue Shield of TX may use reasonable discretion interpreting and applying this policy to services being delivered in a particular case. Blue Cross and Blue Shield of TX has full and final discretionary authority for their interpretation and application to the extent provided under any applicable plan documents.  \nProviders are responsible for submission of accurate documentation of services performed. Providers are expected to submit claims for services rendered using valid code combinations from Health Insurance Portability and Accountability Act approved code sets. Claims should be coded appropriately according to industry standard coding guidelines including, but not limited to: Uniform Billing Editor, American Medical Association, Current Procedural Terminology, CPT® Assistant, Healthcare Common Procedure Coding System, ICD-10 CM and PCS, National Drug Codes, Diagnosis Related Group guidelines, Centers for Medicare and Medicaid Services National Correct Coding Initiative Policy Manual, CCI table edits and other CMS guidelines.  \nClaims are subject to the code edit protocols for services/procedures billed. Claim submissions are subject to claim review including but not limited to, any terms of benefit coverage, provider contract language, medical policies, clinical payment and coding policies as well as coding software logic. Upon request, the provider is urged to submit any additional documentation.  \nApplied Behavior Analysis  \nPolicy Number: CPCP011  \nVersion 1.0  \nClinical Payment and Coding Policy Committee Approval Date: October 7, 2024  \nPlan Effective Date: February 1, 2025  \nBlue Cross and Blue Shield of Texas, a Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association  \nDescription  \nThis policy was created to serve as a general reference on the reimbursement for covered Applied Behavior Analysis services. Health care providers are expected to exercise independent medical judgment in providing care to patients. CMS Medically Unlikely Edits-MUE indicate that direct services are typically requested for up to 40 hours per week. Claims should be coded appropriately per industry standard coding guidelines.  \nReimbursement Information  \nGuidelines (unless otherwise provided in the member’s benefit) :  \nConsistent with plan medical policy PSY301.021 Applied Behavior Analysis (ABA) for Autism Spectrum Disorder (ASD) Diagnosis, and applicable state mandates:  \n• ABA services are not reimbursable to providers if the services are not provided by a Qualified Healthcare Professional-QHP who is certified by the Behavior Analyst Certification Board-BACB as a Behavior Analyst and/or licensed in their state as a Licensed Behavior Analyst or Licensed Psychologist.  \n• Reimbursement to providers is not available for ABA services that are provided for educational, vocational, respite or custodial purposes.  \n• Reimbursement for programs/services rendered in a non-conventional setting, such as anything other than Place of Service/POS codes 10, 11, and 12, even if performed by a licensed provider, should have supporting documentation on file within the member records and made available upon request.  \n• Documentation must include rationale and a description for any unusual POS code in order to be considered for reimbursement.  \n• Treatment plans and/or evaluations (inclusive of time for administrat","cbCaimoeR6TSEJaF","https://ap.wps.com/l/cbCaimoeR6TSEJaF","pdf",648338,"English","# Policy Scope and Authority\n## Conflict Governing Documents\n## Discretionary Interpretation\n# Provider Coding and Claims Review\n## Accurate Documentation Requirements\n## Valid Code Combinations and Coding Standards\n# Applied Behavior Analysis Reimbursement Guidelines\n## Qualified Healthcare Professional Requirement\n## Exclusions and Allowed Purposes\n## Place of Service and Documentation Rules\n## Unit Limits, Reporting Edits, and Code Pairing","[{\"question\":\"Which document controls if there is a conflict affecting reimbursement?\",\"answer\":\"Plan documents govern conflicts involving a Clinical Payment and Coding Policy and coverage plan documents. If a conflict arises between a CPCP and a provider contract under which the provider participates and/or provides Covered Services, the provider contract governs.\"},{\"question\":\"What coding and documentation obligations apply to providers?\",\"answer\":\"Providers are responsible for submitting accurate documentation and must submit claims using valid code combinations from HIPAA-approved code sets. Claims must be coded according to industry-standard coding guidelines and are subject to code edit protocols and claim review.\"},{\"question\":\"When are Applied Behavior Analysis (ABA) services reimbursable?\",\"answer\":\"ABA services are reimbursable only when provided by a Qualified Healthcare Professional certified by BACB and/or licensed in the provider’s state as a Licensed Behavior Analyst or Licensed Psychologist. Reimbursement is not available for educational, vocational, respite, or custodial purposes, and non-conventional settings require supporting documentation.\"}]","CPCP011 - Version 1.0 - Applied Behavior Analysis - Clinical Payment and Coding Policy | PDF",1789916788]