[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-283866-105":53,"doc-detail-283866-en":127},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":120,"head_meta":122,"extra_data":124,"updated_unix":126},105,"en","carelon-behavior-health-aba-authorization-request","CARELON BEHAVIORAL HEALTH - ABA AUTHORIZATION REQUEST","","Authorization request form for Applied Behavior Analysis (ABA) services, covering both initial and concurrent submissions. Collects patient demographics, insurance and employer/benefit plan details, provider credentials (BCBA/LBA/LABA or other, license and NPI), service location, and requested program setting with weekly hours. Includes instructions for submitting a complete treatment plan and requests units by CPT code, specifying 15-minute unit increments and maximums for assessment and reassessment categories.",{"@graph":63,"@context":119},[64,80,102],{"@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/carelon-behavior-health-aba-authorization-request/283866/",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/carelon-behavior-health-aba-authorization-request/283866.png","ImageObject",442,249,{"name":88,"@type":89},"Cart","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-28","2026-09-17",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What types of ABA authorization requests does this form support?","Question",{"text":109,"@type":110},"It supports both initial and concurrent requests. Indicate the request type and the services requested, including the number of units and scheduled hours.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What unit measurement does the form use for CPT-based services?",{"text":114,"@type":110},"All units are 15-minute increments, and 4 units equal 1 hour. The form also provides specific maximum unit limits for initial assessments and reassessments where applicable.",{"name":116,"@type":107,"acceptedAnswer":117},"What information is required about the provider and their credentials?",{"text":118,"@type":110},"The form collects the provider/supervisor type (e.g., BCBA, State Licensed/Certified), certification/license number, NPI, provider group/agency identifiers (if known), and contact details for follow-up.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},283866,1791292711,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"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":9},18829141979164,"https://eur-avatar.wpscdn.com/davatar_6f874abed73319feea01a86fa6f0fab8","CARELON BEHAVIORAL HEALTH  \nABA AUTHORIZATION REQUEST  \nUse this form for both initial and concurrent requests. Please indicate the type of request, as well as the type of services requested. Include the number of requested units as well as hours per day, and hours or days per week, as indicated. Please submit a complete treatment plan with this request.  \nRequested Start Date for this Authorization:    \nRequest for:  \n􀂉 Initial Assessment 􀂉 Initial Treatment 􀂉 Concurrent Request  \nPatient’s Name:    \nDate of Birth:   Age:   􀂉 M 􀂉 F 􀂉 Other:    \nPhone Number:   Patient’s Insurance ID\\#:    \nPatient's Employer/Benefit Plan:    \nProvider/Supervisor (BCBA, LBA, LABA, other)  \nName:   ABA Provider Type: 􀂉 BCBA 􀂉 State Licensed/Certified  \nCertification/License \\#:   State:    \nNPI \\#:   Provider ID (if known)  \nPhone Number:    \nEmail address:    \nProvider Group/Agency:    \nTIN \\#:   Provider Group ID \\# (if known):    \nService Address:    \nCity/State/Zip:    \nPhone Number:    \nEmail address:    \nSERVICES REQUESTED  \n(All units are 15 minutes; 4 units equal 1 hour)  \nProgram setting and hours per week:  \n􀂉 Home   􀂉 Facility/Clinic   􀂉 School   􀂉 Other:    \nContinued on next page  \nAssessment / Follow-up Assessment  \nBy physician or other qualified health care professional (QHP) . Behavior identification assessment, administration of tests, detailed behavioral history, observation, caretaker interview, interpretation, discussion of findings, recommendations, preparation of report, development of treatment plan. Assessment of strengths and weaknesses of skill areas across skill domains (e.g. , VB-MAPP, ABLLS-R, Functional Behavior Assessment, Functional Analysis) and follow-up assessments.  \n􀂉 97151: Behavior identification assessment (initial or reassessment) administered by a physician/QHP. Units are in 15-minute increments; up to 32 units max for initial, up to 12 units max for reassessment.  \nUnits Requested:    \n􀂉 97152: Behavior identification supporting assessment administered by technician under direction of physician/ QHP, face to face with patient. Units are in 15-minute increments. Clinical justification required.  \nUnits Requested:    \n􀂉 0362T: Behavior identification supporting assessment for severe behaviors administered by a physician/QHP who is on-site, with the assistance of two or more technicians, for a patient who exhibits destructive behavior, completed in an environment that is customized to a patient's behavior. Units are in 15-minute increments. Clinical justification required.  \nUnits Requested:    \nTreatment Planning  \n􀂉 H0032: Treatment planning. Units are in 15-minute increments, up to 4 units per treatment week.  \nUnits Requested:    \nDirect 1:1 ABA Therapy  \n􀂉 97153: Adaptive behavior treatment by protocol administered by technician under the direction of physician/ QHP, receiving 1 hour of supervision for every 5 to 10 hours of direct treatment. Units are in 15-minute increments.  \nHours per week:   Units Requested:    \n􀂉 97155: Adaptive behavior treatment with protocol modification, administered by physician/QHP. May be used for Direction of Technician (Supervision) face-to-face with one patient. Units are in 15-minute increments. Hours per day:   Days per week:   Units Requested:    \n􀂉 0373T: Adaptive behavior treatment with protocol modification implemented by physician/QHP who is on-site with the assistance of two or more technicians for severe maladaptive behaviors. Units are in 15-minute increments. Clinical justification required.  \nHours per week:   Units Requested:    \nGroup Adaptive Behavior Treatment  \n􀂉 97154: Group adaptive behavior treatment by protocol by technician under the direction of physician/QHP, face  \n-to-face with two or more patients. Units are in 15-minute increments.  \nHours per day:   Days per week:   Units Requested:    \n􀂉 97158: Group adaptive behavior treatment with protocol modification (Social Skills Group) by physician/QHP, face-to-face with two or more patients. Unit","cbCaib7o3gJCtCgx","https://ap.wps.com/l/cbCaib7o3gJCtCgx","pdf",238709,"English","# Requested authorization details\n## Patient information\n## Provider and service location information\n# Services requested (by CPT code)\n## Assessment / follow-up assessment\n## Treatment planning\n## Direct 1:1 ABA therapy\n## Group adaptive behavior treatment\n## Family training guidance","[{\"question\":\"What types of ABA authorization requests does this form support?\",\"answer\":\"It supports both initial and concurrent requests. Indicate the request type and the services requested, including the number of units and scheduled hours.\"},{\"question\":\"What unit measurement does the form use for CPT-based services?\",\"answer\":\"All units are 15-minute increments, and 4 units equal 1 hour. The form also provides specific maximum unit limits for initial assessments and reassessments where applicable.\"},{\"question\":\"What information is required about the provider and their credentials?\",\"answer\":\"The form collects the provider/supervisor type (e.g., BCBA, State Licensed/Certified), certification/license number, NPI, provider group/agency identifiers (if known), and contact details for follow-up.\"}]","CARELON BEHAVIORAL HEALTH - ABA AUTHORIZATION REQUEST | PDF",1789621089]