Insurance, Medicaid & Business Practices



+ - What coverage do individuals with autism have through their private health insurance?

According to Autism New Jersey,  the state passed a mandate, P.L. 2009 c. 115 Health Benefits Coverage for Autism and Other Developmental Disabilities, which requires fully-insured plans written in the state of New Jersey to cover the following for autism and other developmental disabilities:

  • Expenses for screening and diagnosis of autism spectrum disorders (ASD) or other developmental disability (DD)
  • Medically necessary physical therapy, occupational therapy and speech therapy for individuals with ASD or other DD
  • Medically necessary behavioral intervention based on the principles of applied behavior analysis (ABA) for individuals with ASD
  • Certain family cost share expenses incurred through New Jersey Early Intervention

Their publication, Autism and Health Insurance Benefits Fact Sheet  provides an overview of coverage for autism-related therapies, and their publication, Health Coverage Options for Autism and Other Developmental Disabilities, provides a more in-depth explanation. Regularly check the insurance section of Autism New Jersey’s website for updates given the likely repeal and replacement of the Affordable Care Act and the changes in coverage the replacement may bring.

+ - What is the process in starting ABA services through health insurance?

Each health insurance company, or carrier, has its own process regarding implementing ABA therapy for their members. It is recommended to contact the carrier directly (by calling the Provider phone number listed on the back of the member’s insurance card) to get details on its specific policies.

Typically, the provider should first call to verify benefits by calling the carrier. Contact information for several major health insurance carriers can be found on Autism New Jersey’s website.

+ - What are some guidelines to follow when providing ABA services through health insurance?

Both the Association of Professional Behavior Analysts (APBA) and the Behavior Analyst Certification Board (BACB) have information available online about the provision of ABA services through health insurance (note that the APBA’s information is available to members only). One helpful resource is: Applied Behavior Analysis Treatment of Autism Spectrum Disorder: Practice Guidelines for Healthcare Funders and Managers (2nd ed.).

+ - Who can provide ABA services through an insurance company?

 Each carrier may have specified the credentials of various provider types that may implement behavior-analytic services. Most carriers require a program to be overseen by a Board Certified Behavior Analyst (BCBA-D/BCBA) or a Qualified Health Care Professional (QHCP); while the QHCP does not necessarily specify certification that a BCBA possesses, most carriers will specify the BCBA-D/BCBA certification to fulfill that role. It is recommended that providers discuss specific requirements with each individual carrier under which they may be providing services. Similarly, carriers may have different requirements for individuals who are performing direct therapy under the supervision of the BCBA. Common titles for these individuals may be “therapist,” “tutor,” “paraprofessional,” or Registered Behavior Technician (RBT). It is recommended that providers discuss specific requirements with each individual carrier under which they may be providing services.

+ - Do therapists need to be certified as RBT to perform therapy?

Not necessarily. Many carriers currently do not require the RBT credential for “line therapy.” However, they may do so in the future. It is recommended that providers discuss specific requirements with each individual carrier under which they may be providing services.

+ - I have concerns about the ethical practices in a group home where an adult with ASD lives. What can I do about it?

If you suspect abuse or neglect, review Unusual Incident Reporting forms and instructions.

+ - What happens if a family’s plan doesn’t cover ABA services?

If a family’s plan does not cover ABA services, their insurance plan will not pay for or reimburse the cost of the services. Note that the state autism mandate only applies to “state-funded” health insurance plans; “self-funded” plans are not subject to the mandate and may list ABA as an “excluded” service. Providers should verify benefits prior to delivering services. Autism Speaks has created the Self-Funders Employer Toolkit to help families lobby their employers to opt to cover ABA services.

+ - What is an NPI?

NPI stands for Provider National Identifier. There are 2 types of NPI numbers: individual and group. NPI numbers are required when providers bill health insurance carriers. Application information can be found here.

+ - What is CAQH?

CAQH stands for Council for Affordable Quality Healthcare. The CAQH maintains a database verifying the credentials of providers that carriers can access. Completion of the CAQH process is necessary for providers joining the networks. (Out-of-network providers do not need to complete the CAQH process.)

+ - What does it mean to become “credentialed” with an insurance company?

Credentialing is the process by which the CAQH verifies the experience and credentials of service providers. Providers need to be credentialed to become “in-network.”

+ - What are the pros and cons to being an “in-network” provider?

Being an “in-network” provider means that you or your practice has contracted with an insurance carrier and have joined their network of providers.

Some pros to joining the network may include:

·         Steady stream of clientele referred to you by the carrier

·         Your practice may be listed on the carrier’s website so families can locate/contact you

·         Access to electronic submission of claims and forms

·         Access to numerous informative documents that may help guide your practice

·         Lower cost to families

Some cons to joining the network may include:

·         Subject to the carrier’s guidelines for practice

·         Subject to the carrier’s set rates for each service

+ - What are the pros and cons to being an “out-of-network” provider?

Being an “out-of-network” provider means that your practice will work with an insurance company, but have not signed a contract to join their network.

Some pros to being an “out-of-network” provider include:

·         Free to develop own practice and record keeping guidelines in accordance with best practices

·         Free to negotiate rates with a carrier

·         Not required to charge families copayments for services

Some cons to being an “out-of-network” provider include:

·         Carriers disseminate limited information to you

·         Carriers may not permit e-submission of claims

·         Some families may not have “out-of-network” benefits in their policy

·         Extra cost for families (e.g., co-insurance, deductibles)

+ - What is CPT?

CPT stands for Current Procedural Terminology. These are alpha-numeric codes assigned for specific services. Each carrier has assigned their own CPT codes (so they are not uniform across all carriers). It is recommended to contact each carrier to inquire about which CPT codes to use when providing services.

Common CPT codes when providing ABA services include:















+ - What are the services specified with the CPT codes?

A coalition of autism and Applied Behavior Analysis organizations compiled a crosswalk of CPT® code information to achieve consistency in utilization and implementation of – and ultimately in establishing valuation and reimbursement rates for – the new Category III codes for reporting adaptive behavior assessment and treatment services to health insurance plans.

This chart is organized by the essential elements of ABA services, as indicated by the Behavior Analyst Certification Board (BACB). Those services include assessment and reassessment, treatment plan development and revision, direct treatment of individual clients, supervision or direction of technicians by a professional behavior analyst or other Qualified Healthcare Professional (QHCP), family or caregiver training, and group treatment.

Autism New Jersey’s Executive Director, Dr. Suzanne Buchanan serves on the workgroup that reports to the Steering Committee for this and related efforts and welcomes your questions and input.

+ - What is the diagnosis code for Autism Spectrum Disorder?

According to the DSM-V and ICD-10, the diagnosis code for ASD is F84.0. This code is required when getting services authorized as well as when submitting claims.

+ - How to I submit a claim form to have services reimbursed?

Each health insurance company, or carrier, has its own process regarding submitting claims for ABA therapy. It is recommended to contact the carrier directly (by calling the Provider phone number listed on the back of the member’s insurance card) to get details regarding its specific policies.

Typically, a “CMS-1500” form is used to submit claims. Options to either mail, fax, or submit electronic versions differ from carrier to carrier. There are also different policies regarding claims depending on whether a provider is in-network or out-of-network. For example, Value Options offers these tips for completing the CMS 1500.

+ - Who can I call at the insurance company if I have any questions?

Autism New Jersey has worked with the major insurance carriers to identify the best contacts for each carrier and disseminate this to parents and providers. Contact information for several major health insurance carriers can be found on Autism New Jersey’s website.

+ - What is a Single Case Agreement (SCA)?

If a provider has not joined the network, it is possible for the carrier and provider to develop a Single Case Agreement so they can still perform the services. In this case, the provider remains out-of-network, but an agreement as to the policies, procedures, and rates has been negotiated.

+ - What is an In-network Exception?

If a member’s insurance plan does not offer out-of-network services, by law, if their network is unable to provide services within a reasonable time frame (2 weeks from initial intake) or within a reasonable geographic radius (up to a distance of 100 miles), the carrier must grant an “In-Network Exception.” In this case, the carrier is required to approve an out-of-network provider to perform the services and the carrier has to pay charges to the provider but the cost to the insured (e.g., coinsurance, copay) is going to be the same as they would have paid if the provider were in-network.

+ - How does cost sharing work?

Each health insurance plan has a pre-specified deductible, which is a dollar amount that the member must pay prior to co-insurance being paid by the carrier the insurance company paying. In other words, the member must pay towards the deductible when services first begin. Then, once the deductible has been met, the costs of services are shared between the member and the carrier. At this point, the carrier is typically responsible for the majority of costs, but the member is responsible for a pre-specified percentage. This percentage would remain in effect until the member has paid their Maximum Out-of-Pocket (MOOP) expense. Then, the insurance company becomes responsible for 100% of the allowed amounts of charges.

There are a number of options for health insurance plans within and across carriers. Deductibles, co-insurance, and maximum out-of-pocket expenses may differ from plan to plan. It is recommended that providers and member determine these costs prior to the onset of treatment.

+ - What is DOBI?

DOBI stands for the New Jersey Department of Banking and Insurance, and its website contains information for consumers and providers. DOBI is responsible for ensuring appropriate implementation of the state autism mandate by providers and carriers. It is noted that DOBI oversees “state-funded” health insurance plans, which are subject to the autism mandate; “self-funded” plans are not subject to this state mandate.

+ - Who can I contact if I have an issue or complaint about an insurance carrier?

DOBI has created a unique webpage dedicated to appeals and complaints.

+ - What are some professional organizations that can assist me in dealing with implementation of ABA through health insurance?

+ - Often insurance carriers request for a rationale or discharge criteria for individuals with autism. What are some examples to explain the rationale for on-going treatment and appropriate discharge statements for an individual with a life-long neurological disorder, such as autism?

Rationale for on-going access to medical intervention for autism-related impairment:

Currently, autism is considered to be a life-long and incurable neurological disorder of unknown origin.  However, symptoms often respond to scientifically-based ABA interventions, and these interventions may reduce the frequency, rate, intensity and/or duration of many barrier behaviors. Discharge criteria should depend upon the insured’s deficits compared to developmental norms across multiple domains of functioning.

Sample Criteria of Transition/Discharge Statements:

– A plan to discharge will be formulated when target performance has been achieved, e.g., 80-90% of typical peer model for 5-10 consecutive data points for each goal.  Until that time, targets will continue to be adjusted to reflect new goals/objectives to address medically necessary symptoms related to diagnosis.

– A plan to discharge will be formulated when age-level communication, social, and play/leisure skills and clinically significant reductions in behavioral outbursts are attained, generalized across settings, and maintained over time.  Behavior should be able to be well-managed independently by parents/caregiver at time of therapy exit/discharge.

– Transition of care will be coordinated with the school when the child is school-aged. Medically necessary intervention sessions will be adjusted per clinical need and the child’s availability.  Incremental changes in treatment frequency will be adjusted per data-based criteria e.g., 80-90% of typical age performance of target goals for 5-10 consecutive data points per goal.

+ - I heard there are new CPT codes for “adaptive behavior services” services beginning January 1, 2019. Where can I learn more?

+ - How should I structure my business as a legal entity?

Before you register your business you’ll need to consider how you wish to structure your business as a legal entity; whichever structure is right for you will determine further registration requirements. If you decide to create a corporation, a non-profit, an LLC or a partnership, you will have to register your business and file certain documents with your state government. If you are operating as a sole proprietorship, you don’t need to register your business with your state. However, if you choose to operate your business under any other name than your own, you will need to formally file your trade name or “Doing Business As” (DBA) name with your state.

+ - How do I register my business name?

If you choose to name your business under a trade name – for example ‘Number One Autism Services’ – you cannot operate that business under that name until it is officially registered with your state government. Until then, the legal name of your business essentially defaults to your given name. New Jersey residents: all the information needed to register your business.

+ - How do I register with the IRS and get a Federal Tax ID/EIN?

This won’t apply to all new businesses, but if you have employees, any business partnerships, are a corporation or other organization, you’ll need an Employer Identification Number (EIN). To obtain more information, read the EIN section of the IRS website. If you don’t need an EIN, you can simply use your Social Security Number to administer your business finances.

+ - How do I register with my state tax or revenue office?

As well as a federal tax ID, you’ll need to pay state and local taxes – although each region has its own laws. As a rule, you’ll need to register your business with your state’s revenue office. As a business operator, you’ll also need to comply with state income tax and employment laws. Obtain more information on state tax registration requirements.

+ - How do I obtain professional liability insurance?

Both Association of Professional Behavior Analysts (APBA) and Association for Behavior Analysis International (ABAI) members can receive discounts on professional liability insurance.

APBA – CPH & Associates offers liability insurance for BCBAs, BCaBAs, and students in accredited programs who are completing practica towards degree requirements; blanket policies that colleges and universities can purchase to cover students in their programs; and group policies that service agencies can purchase to cover paraprofessionals who implement intervention plans under the supervision of BCBAs.

• APBA members can receive a discount on insurance policies from this company. To get the discount, you must select “APBA Member” from the menu of professional associations in the online application and be a member in good standing of APBA. The administration fee shown in the price quote will then be $10 rather than $20. An additional 5% discount is available on policies purchased online.

• For rate estimates and an application, contact CPH & Associates.

ABAI is pleased to provide access to competitively-priced, professional liability insurance in the U.S. and Canada (except Quebec). Also known as Errors and Omissions or Professional Indemnity, this insurance provides coverage against a valid claim, or the co-defense, made against you for professional negligence, error, or omission in your business practice.

• If you reside outside the U.S., ABAI’s partner, Wells Fargo Insurance Services, will provide you with a reference to obtain professional liability insurance in your country.

• For rate estimates and an application, contact ABAI.

+ - How do I apply for an NPI number?

NPI number is the National Provider Identifier.  There are two types individual and organization.  Any provider billing health insurance companies must have an NPI number.  To obtain an NPI number go to

Always apply for an individual NPI number, sole proprietors will use your social security number. If you are establishing a LLC, partnership, or corporation, also apply for an NPI for the group using the company EIN number.