§ 1155.33. Payment conditions for ABA services.
(a) Payment will be made to a licensed IBHS agency for ABA services if the following conditions are met:
(1) There is a written order for ABA services based on a face-to-face interaction with the child, youth or young adult that meets the following:
(i) Written within 12 months prior to the initiation of ABA services.
(ii) Written by a licensed physician, licensed psychologist, certified registered nurse practitioner or other licensed professional whose scope of practice includes the diagnosis and treatment of behavioral health disorders and the prescribing of behavioral health services, including IBHS.
(iii) Includes a behavioral health disorder diagnosis listed in the most recent edition of the DSM or ICD.
(iv) Orders ABA services for the child, youth or young adult and includes the following:
(A) The clinical information to support the medical necessity of each ABA service ordered.
(B) The maximum number of hours of each ABA service per month.
(C) The settings where ABA services may be provided.
(D) The measurable improvements in targeted behaviors or skill deficits that indicate when services may be reduced, changed or terminated.
(2) A face-to-face assessment has been completed by an individual qualified to provide behavior analytic services or behavior consultation-ABA services within 30 days of the initiation of ABA services and prior to completing the ITP in accordance with § 5240.85 (relating to assessment) or a face-to-face assessment has been reviewed and updated within 12 months of the previous face-to-face assessment.
(3) The assessment and all updates have been signed by the staff person who completed the assessment.
(4) An ITP based upon the assessment and the written order for ABA services has been completed within 45 days after the initiation of ABA services in accordance with § 5240.86 (relating to individual treatment plan) or an ITP has been reviewed and updated within 6 months of the previous ITP.
(5) The ITP and all updates have been reviewed and signed by the youth, young adult, or parent or legal guardian of the child or youth, the staff person who completed the ITP and an individual who meets the qualifications of a clinical director in § 5240.81 (relating to staff qualifications for ABA services).
(6) For continued ABA services, a child, youth or young adult shall have an order written within 12 months of the initiation of the continued services that complies with subsection (a)(1)(ii)—(iv).
(b) Payment will be made to a licensed IBHS agency for ABA services for up to 75 days after initiation of services, if an ITP has not yet been completed but there is a written order for services that complies with subsection (a)(1) and there is a treatment plan for the ABA services provided.
Cross References This section cited in 55 Pa. Code § 1155.35 (relating to payment conditions for EBT delivered through individual services, ABA services or group services); 55 Pa. Code § 1155.37 (relating to limitations); 55 Pa. Code § 5240.41 (relating to individual records); 55 Pa. Code § 5240.84 (relating to ABA services initiation requirements); and 55 Pa. Code § 5240.86 (relating to individual treatment plan).
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