Guidance for RB-BHT Providers

To help streamline review of RB-BHT service requests for Alliance members with autism spectrum disorder (ASD), providers are encouraged to complete and submit the Cover Sheet with their service request. The Cover Sheet highlights some of the essential elements required by CCP 8F as well as topics discussed in the MCG criteria for ABA, which Alliance also utilizes as part of its UM process. The Cover Sheet uses fillable fields for provider convenience.

Diagnostic tools: CCP 8F (§ 3.2.1) requires that RB-BHT recipients be “diagnosed with ASD utilizing a scientifically validated diagnostic tool.”

• • Some tools are well validated for the purpose of ASD diagnosis. Many others are intended or only validated for other purposes (e.g., screening tools, symptoms checklists, ratings scales, functional assessments) and cannot be used for diagnosis on their own.

• • Appropriate diagnostic tools for this purpose include:
    • • Autism Diagnostic Interview–Revised (ADI-R)
    • • Autism Diagnostic Observation Schedule–Second edition (ADOS-2)
    • • Childhood Autism Rating Scale–Second edition (standard version) (CARS-2)
    • • TELE-ASD-PEDS for age ≤36 months and barriers to in-person assessment

• • Other tools not well validated for diagnosis of ASD on their own include:
    • • Gilliam Autism Rating Scale–Third edition (GARS)
    • • Modified Checklist for Autism in Toddlers (M-CHAT)
    • • Brief Observation of Symptoms of Autism (BOSA) and BOSA-PSYF
    • • Social Responsiveness Scale (SRS)
    • • Autism Spectrum Rating Scale (ASRS)
    • • Social Communication Questionnaire (SCQ)
    • • Pervasive Developmental Disorders Screening Test-Second Edition (PDDST-II)
    • • Gilliam Asperger’s Disorder Scale (GADS)
    • • Childhood Asperger Syndrome Test (CAST)
    • • Autism Behavior Checklist (ABC)
    • • Asperger Syndrome Diagnostic Scale (ASDS)
    • • Monteiro Interview Guidelines for Diagnosing the Autism Spectrum-2 (MIGDAS-2)
    • • Sensory Profile-2

Service Orders: CCP 8F (§ 3.2.2) requires that a licensed medical doctor (MD), doctor of osteopathic medicine (DO), or licensed psychologist (LP) according to their scope of practice shall complete and sign a service order, which must be: signed and dated by the authorizing professional; indicate the date on which the service was ordered; be in place prior to or on the day the service is initially provided; and be based on a Behavioral, Adaptive, or Functional Assessment of the beneficiary’s needs. Service orders are valid for one year.

• • As noted, a valid service order must include evidence it was based on a Behavioral, Adaptive, or Functional Assessment of the beneficiary’s needs; failure to provide this evidence may result in denial.

• Similarly, a “recommendation and/or referral,” “statement of medical necessity,” or list of recommended services do not on their own constitute a valid service order; per CCP 8F, the requesting provider must show the service order was based on a Behavioral, Adaptive, or Functional Assessment of the beneficiary’s needs.