37.34.1912    CONTINUED ELIGIBILITY FOR ADDITIONAL UNITS OF SERVICE

(1) For a member to continue receiving ABA services after the initial 180 calendar days or the initial authorized units of service are exhausted, they must meet all criteria for continued eligibility and for additional units of service, and the department must authorize such additional units of service. The criteria for continued eligibility and additional units of service, as well as the process and rules governing authorization of additional units of service are set forth below and in the ABA Services manual. 

(2) For a member to meet all criteria for continued eligibility:

(a) The member must continue to meet the age criteria for initial eligibility in ARM 37.34.1908;

(b) The member's original provisional diagnosis must then be confirmed as a qualifying diagnosis through a diagnostic evaluation, performed by one of the qualified healthcare professionals with expertise in the diagnostic area;

(c) The member must continue to meet functional impairment criteria that is supported in documentation the BCBA submits to the department;

(d) The department must deem the member eligible through its authorization process; and

(e) Both the BCBA and the referring physician, nurse practitioner, licensed mental health professional, or psychologist must deem the services medically necessary.

(3) For a member to meet the criteria for additional units of service:

(a) The member must continue to meet the eligibility criteria outlined above, the service requirements in ARM 37.34.1918, and:

(i) the BCBA providing services must have a reasonable expectation that the member will continue to benefit from the services and that the skill deficits and behaviors identified in the treatment plan will improve to a clinically meaningful extent;

(ii) the member must demonstrate progress in each of the identified treatment goals or provide a clinical explanation and modification to address a lack of progress; and

(iii) the treatment plan demonstrates that the member is not experiencing a worsening of skill deficits or behaviors due to the treatment services.

(b) The member must be excluded from eligibility for service if any of the following criteria occur:

(i) The member demonstrates consistent worsening of skill deficits and/or behaviors with the service being delivered;

(ii) The member's parent/guardian is not engaged in treatment and/or does not agree to continued service delivery;

(iii) The member has medical conditions or impairments that would prevent beneficial utilization of services;

(iv) The member has demonstrated no significant progress in treatment goals for two consecutive additional units of service request reviews, and the BCBA provider cannot sufficiently explain the lack of progress to justify continuing to authorize the service; or

(v) The member can be safely and effectively treated at a less intensive level of service or care.

(4) The BCBA must receive authorization from the department for additional units of services before such units of service can be provided.

(5) For the department to authorize additional units of service:

(a) The BCBA must complete and submit the ABA Services Additional Units of Service Request form and additional required documentation at least 14 calendar days prior to the intended onset of continued service delivery. Additional required documentation is specified in the ABA Services manual; and

(b) The member must continue to have a qualifying diagnosis that meets the criteria of (2)(b).

(6) The processes for a service provider to request additional units of service and for the department's review and authorization are outlined in the ABA Services manual's Authorization of Additional Units of Service section.

(7) If a previous request is denied, a service provider may submit a request for additional units of service if they have additional information to satisfy any deficiencies noted with respect to such denied request. This is considered a new submission and all required documents will need to be submitted again for a new department review and determination.

History: 53-2-201, 53-6-113, 53-21-703, MCA; IMP, 53-1-601, 53-1-602, 53-2-201, 53-6-101, 53-6-111, 53-21-701, 53-21-702, MCA; NEW, 2022 MAR p. 1850, Eff. 9/24/22.