Applied Behavior Analysis (Aba) Service Request Form - Bluecross Blueshield Of Texas

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Applied Behavior Analysis

(ABA) Service Request Form

This is a request for medical necessity determination. It does not confirm benefits and eligibility. Provider must call BCBSTX at 800-528-7264

to check eligibility and benefits. After completing the form, please fax form and any attachments to 877-361-7646.

Note: All clinical should be reflected on this form. If necessary, any assessment tools/instruments

(i.e. VB-Mapp, ABLLS, etc.) that are utilized for treatment planning may be faxed with this clinical form.

Date______________________

Check One:

Preauthorization / Initial Request

Concurrent Review

Discharge

Diagnostic Evaluator, Name _____________________________________

NPI#_______________________ Date of ASD DX _____ /_____ /_________

Address_______________________________________________________

City___________________________State________ Zip_______________

Phone#______________________________________________________

Yes

Parents/Caregiver?

Interview: 1. Face to face?

With Patient?

3. List Autism Scale(s) Used? _______________________________________

Patient Name ________________________ _________________________

Date of Birth _____ /_____ /___________

(Last Name)

(First Name)

Subscriber Name________________________________________________

Subscriber ID #______________________ Group#___________________

ABA Clinic/Provider Name ______________________________________

Phone#____________________Rendering NPI#_______________________

Address_______________________________________________________

City___________________________State________ Zip_______________

Prof License /Credentials (i.e. LPC, PhD, etc.) ________________________and/or

BCBA

BCaBA

Other__________________________

Referring MD Name ______________________________________________

Phone#_________________________NPI#__________________________

Therapy hOurs requesT

CPT Code: ____________

Assessment/Intake Date:

# of Hours: ___________

(Hours Per Week)

Current DX — please include all DsM 5 and/or Medical diagnoses that apply.

Code #: _______________________ DX Name: ________________________________ Specifier: _____________________________________

s the member at imminent risk of significant harm to self or others: c No c Yes If yes, which? _________________________________________________

Is the member on medications? c No c Yes If yes, what are current medications/dosages? __________________________________________________

_______________________________________________________________________________________________________________

What has been the response to medications? c Poor c Moderate c Excellent

History of Services with Dates (Recent hospitalizations, PHP, IOP, OP, etc.): ___________________________________________________________________

_______________________________________________________________________________________________________________

Member began treatment with you on what date? ____________________________

If appropriate, please respond. Has the member been screened for substance abuse issues? c No c Yes c NA

If yes, please give details of substance abuse (type of drug, duration of use, last use, episodes of treatment). ________________________________________________

______________________________________________________________________________________________

727508.0915