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The addendum collects billing provider identifiers and requires confirmation of ASD treatment provider qualifications and credentialing for BCBA-D, BCBA, BCaBA, and BT/RBT. It also includes an attestation requirement and an application questionnaire requesting provider history regarding prior Medicaid/NJ FamilyCare approvals and adverse licensing, criminal, and healthcare-program actions.",{"@graph":63,"@context":118},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/autism-spectrum-disorder-asd-treatment-provider-addendum/306539/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/autism-spectrum-disorder-asd-treatment-provider-addendum/306539.png","ImageObject",442,249,{"name":88,"@type":89},"Violet","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-22","2026-09-19",true,{"@type":98,"interactionType":99,"userInteractionCount":15},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114],{"name":105,"@type":106,"acceptedAnswer":107},"Which ASD provider specialties are listed and what credentials are required for each?","Question",{"text":108,"@type":109},"The document lists BCBA-D, BCBA, BCaBA, and BT/RBT. It requires education qualifications plus credentialing via an applicable BACB certificate and an attestation completion.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"What attestation and experience requirements apply to approved ASD treatment providers?",{"text":113,"@type":109},"Providers must complete an attached ASD Treatment Provider Experience Attestation. Experience requirements differ by specialty, including supervised experience for BA/BT/RBT pathways as described in the qualification table.",{"name":115,"@type":106,"acceptedAnswer":116},"What background and compliance questions must be answered in the application?",{"text":117,"@type":109},"The addendum asks whether the applicant was previously approved under Medicaid/NJ FamilyCare and whether the applicant has faced licensing suspension or other adverse actions, indictments or convictions, and suspension, debarment, disqualification, recovery actions, or criminal convictions involving healthcare programs.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},306539,1790225945,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":15,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":135,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":76},4398048950312,"https://ap-avatar.wpscdn.com/avatar/400002538284de19e3c?_k=1778320343897328908","AUTISM SPECTRUM DISORDER (ASD) TREATMENT PROVIDER ADDENDUM  \nFor Fiscal Agent Internal Use Only  \nProvider Name:   Provider ID \\#:    \nDoc Type:  CHNGREQ Provider Type:   Provider Specialty:    \nState of New Jersey  \nDEPARTMENT OF HUMAN SERVICES  \nDivision of Medical Assistance and Health Services  \nAUTISM SPECTRUM DISORDER (ASD) TREATMENT PROVIDER ADDENDUM  \n(FOR COMPLETION BY ONLY THOSE PROVIDERS CURRENTLY ENROLLED IN THE NJ FAMILYCARE MEDICAID  \nFEE-FOR-SERVICE PROGRAM)  \n\n| Billing Provider Name | Billing Provider ID\u003Cbr>ASD Agency | Billing Provider NPI Number |\n| --- | --- | --- |\n| Legal Name | Professional Title | SSN/TIN DOB |\n\nMedicare Provider No. (If applicable) UPIN No. (if applicable)  \nCONFIRMATION OF ASD TREATMENT PROVIDER QUALIFICATIONS  \nASD Treatment Provider Qualification/Credentialing Requirements are Listed Below  \n\n| Provider Specialty | Education Qualifications | Credentialing Requirements\u003Cbr>(Copy of BACB Certificate Required) | Attestation Requirement\u003Cbr>(Completion of the Attached Attestation Form is Required) |\n| --- | --- | --- | --- |\n| Board Certified Behavior AnalystDoctoral (BCBA-D) | Doctorate degree in psychology, special education, guidance and counseling, social work or a related field | Behavior Analyst Certification Board (BACB) Certificate, doctoral level | At least one year of experience in developing and implementing behavior support plans for individuals who have intellectual/developmental disabilities. |\n| Board Certified Behavior Analyst (BCBA)* | Master level degree in psychology, special education, guidance and counseling, social work or a related field. | Behavior Analyst Certification Board (BACB) Certificate, graduate level | At least one (1) year of experience in developing and implementing behavior support plans for individuals who have intellectual/developmental disabilities. |\n| Board Certified\u003Cbr>Assistant Behavior Analyst (BCaBA) | Bachelor’s level degree in psychology, special education, guidance and counseling, or social work. | Behavior Analyst Certification Board (BACB) Certificate, undergraduate level | At least one (1) year of post-graduate experience in developing and implementing behavior support plans for individuals who have\u003Cbr>intellectual/developmental disabilities. |\n\nREV: 11/2020  \nAUTISM SPECTRUM DISORDER (ASD) TREATMENT PROVIDER ADDENDUM  \n\n| Behavior Technician (BT) or\u003Cbr>Registered Behavior Technician (RBT) | Bachelor’s degree in psychology, special education, guidance and counseling, social work or a related field; or a highschool diploma or GED; or be an RBT. | Behavior Analyst Certification Board (BACB) Certificate (if applicable) | For a bachelor’s degree, at least one (1) year of supervised experience in implementing behavior support plans for individuals who have\u003Cbr>intellectual/developmental disabilities. For a high school diploma or GED, at least three (3) years of supervised experience in implementing behavior support plans for individuals who have an\u003Cbr>intellectual/developmental disabilities.\u003Cbr>Or be a Registered Behavior Technician (RBT) certified by the Behavior Analyst Certification Board (BACB) . |\n| --- | --- | --- | --- |\n\n*Also psychologists with training in applied behavior analysis  \n\n| List the names, SSA Number, Date of Birth, National Provider Identifier (NPI), BACB Certification Number and Degree(s) for all ASD treatment staff in the organization directly involved with the delivery of Medicaid services and/or the processing of claims. If more space is needed, attach additional sheets. |\n| --- |\n| Name SSA Number Date of Birth NPI Certification Number Provider Specialty* |\n|  |\n|  |\n|  |\n|  |\n|  |\n|  |\n|  |\n|  |\n|  |\n\n*Provider Specialty (e.g. BCBA-D, BCBA, BCaBA, RBT, BT)  \nIn order to be approved with one of the provider specialties indicated above, a completed application package must be submitted including the following:  \n• A copy of an individual’s Behavior Analyst Certification Board (BCBA) Certificate for his/her provider s","cbCaicDdcI9WwIUD","https://ap.wps.com/l/cbCaicDdcI9WwIUD","pdf",204687,7,"English","# Confirmation of ASD Treatment Provider Qualifications\n## Provider information and billing identifiers\n## Credentialing and attestation requirements (BCBA-D, BCBA, BCaBA, BT/RBT)\n## Provider staff list for ASD treatment services\n## Application approval and compliance questionnaire","[{\"question\":\"Which ASD provider specialties are listed and what credentials are required for each?\",\"answer\":\"The document lists BCBA-D, BCBA, BCaBA, and BT/RBT. It requires education qualifications plus credentialing via an applicable BACB certificate and an attestation completion.\"},{\"question\":\"What attestation and experience requirements apply to approved ASD treatment providers?\",\"answer\":\"Providers must complete an attached ASD Treatment Provider Experience Attestation. Experience requirements differ by specialty, including supervised experience for BA/BT/RBT pathways as described in the qualification table.\"},{\"question\":\"What background and compliance questions must be answered in the application?\",\"answer\":\"The addendum asks whether the applicant was previously approved under Medicaid/NJ FamilyCare and whether the applicant has faced licensing suspension or other adverse actions, indictments or convictions, and suspension, debarment, disqualification, recovery actions, or criminal convictions involving healthcare programs.\"}]","Autism Spectrum Disorder (ASD) Treatment Provider Addendum | PDF",1789837749]