Medical Necessity Review Criteria for Applied Behavior Analysis (ABA) Services
Date: 09/23/25
Reminder: Medical Necessity Review Criteria forApplied Behavior Analysis (ABA) Services
Effective June 1, 2025, Arizona Complete Health and its affiliates began using Centene Clinical Policy Applied Behavior Analysis CP.BH.104 to conduct medical necessity reviews for Applied Behavior Analysis (ABA) services for all lines of business, along with Clinical Policy Applied Behavioral Analysis Documentation Requirements CP.BH.105.
This is a reminder, in compliance with CP.BH.104, documentation must show that services are delivered or supervised by an ABA-credentialed professional and consistent with ABA techniques. This includes:
- 1-2 hours of supervision per 10 hours of direct treatment or
- 2 hours of supervision if direct treatment is under 10 hours/week
Supervision is essential to ensure quality of care and appropriate treatment adjustments. Our data, however, shows a high number of claims lacking required supervision hours relative to direct treatment hours. Claims will be reviewed and audited to ensure compliance with policy requirements and insufficient supervision of direct treatment may result in recoupment.
Action Required:
Please review both CP.BH.104 and CP.BH.105 and update your procedures to align with clinical criteria.
Access Policies:
Visit the Arizona Comaplete Health Website > For Providers > Provider Resources > Clinical & Payment Policies.
Prior Authorization Requests:
Prior authorization requests for ABA may be submitted electronically (preferred) via our secure provider portal or Availity, or via fax 844-918-1192.
Questions?
Please contact your Provider Engagement Account Manager. If you need their contact information, email us at: 📧 AzCHProviderEngagement@azcompletehealth.com