Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association

Microsoft Autism/ABA Therapy Program Treatment Plan Checklist

Important: The Treatment Plan Checklist must be completed in its entirety before claims can be processed. Please allow seven business days for the Treatment Plan to be processed. Once the Treatment Plan is approved, associated claims will then be processed accordingly and no further action is required.

1) Patient/Member

Provider name and address

     

Provider email address

Tax ID number

BCBA certification number

Original certification date (M/dd/yyyy) Certification expiration date (M/dd/yyyy)

Therapy Assistant name(s)*

2) Provider of Service – must be a Board-Certified Behavior Analyst (BCBA)

3) In-person assessment completed by BCBA certified provider The written portion of the assessment is not required to be submitted with this form but should include:

Documented parent/family interview. Documented provider interaction with or observation of child. Written assessment, in format of provider’s choosing, of the child’s delays, strengths, and weaknesses that

specifically address the symptoms of ASD that the child presents. Written assessment, in format of provider’s choosing, of child’s preferences for activities, rewards, and/or sensory

stimulation and readiness for intervention (including behavior problems that would interfere with one-on-one intervention).

Written statement of the intervention. For example: 1:1 therapy assistants; materials for therapy; space and materials in the home for the therapy assistant to work with the child.

Written agreement by the family indicating agreement with the provider’s plan.

*As of July 1, 2017, Therapy Assistant services must be billed through the Licensed Behavior Analyst who is supervising the therapy. For established relationships, treatment plan and/or claim prior to this date, where the family pays the therapy assistant directly, this can continue through December 31, 2018 to allow for transition. Therapy Assistants must have applicable license or certification, as required by the state in which they practice and must be supervised by the Licensed Behavior Analyst.

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Premera Blue Cross ID card number Name

     

Date of birth (M/dd/yyyy)

Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association

4) Diagnosis Verification

Diagnosis of an Autism Spectrum Disorder (ASD) from a qualified provider (specialist, physician, neurologist, psychiatrist, or psychologist). Diagnosis includes any of the below:

Autistic Disorder (International Classification of Diseases, 9th Revision, Clinical Modification) Childhood Disintegrative Disorder Asperger’s Disorder Rett’s Disorder and Pervasive Development Disorder Not Otherwise Specified/Atypical Autism Pervasive Developmental Disorder

5) Treatment PlanA. Start date (M/dd/yyyy)

     

End date (M/dd/yyyy)

B. Identify problems/goalsStatement of individualized goals for the member’s intervention program:

     

C. Treatment modalityIndicate intervention(s) for each goal:

     

D. FrequencyAnticipated number of days per week and number of hours per day for services:

     

E. Provide plan for supervision of Therapy Assistant(s)     

*As of July 1, 2017, Therapy Assistant services must be billed through the Licensed Behavior Analyst who is supervising the therapy. For established relationships, treatment plan and/or claim prior to this date, where the family pays the therapy assistant directly, this can continue through December 31, 2018 to allow for transition. Therapy Assistants must have applicable license or certification, as required by the state in which they practice and must be supervised by the Licensed Behavior Analyst.

034052 (06-19-2017)

Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association

F. Provide plan for coordination with other clinicians who are providing care to the member and coordination with school personnel, when appropriate.

     

6) Re-assessmentCheck all that apply and provide any necessary details

Member progressing

Changes anticipated     

7) Signature (required for treatment checklist to be valid)

Send this completed Treatment Plan Checklist to:

Fax: 425-918-5231 Mail: Premera Blue Cross PO Box 91059 Seattle, WA 98111-9159

*As of July 1, 2017, Therapy Assistant services must be billed through the Licensed Behavior Analyst who is supervising the therapy. For established relationships, treatment plan and/or claim prior to this date, where the family pays the therapy assistant directly, this can continue through December 31, 2018 to allow for transition. Therapy Assistants must have applicable license or certification, as required by the state in which they practice and must be supervised by the Licensed Behavior Analyst.

034052 (06-19-2017)

Licensed Behavior Analyst Signature

     

Date (M/dd/yyyy)

     

Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association

034052 (06-19-2017)

Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association

034052 (06-19-2017)