autism stakeholders meeting presentation (1)

Became operational November 1, 1979

Chartered in West Virginia and domiciled in Ohio as a 501-C-4 Non-Profit Corporation

Licensed to do business in Ohio & West Virginia

Expanded into North Central WV in 1994

Expanded Statewide 2010 / 2011

UPSHUR

LEWIS

RANDOLPH

BARBOUR

PLEASANTS

WYOMING

RALEIGH

WOOD RITCHIE

WIRT

WAYNE

BRAXTON

HARRISON

SUMMERSMONROE

MERCER

ROANE

KANAWHA

CLAYPUTNAM

CABELL

PRESTON

WEBSTER

POCAHONTASNICHOLAS

DODDRIDGE

TYLER

MONONGALIAWETZEL

MARSHALL

MINGOLOGAN

MCDOWELL

MASON

JACKSON

LINCOLN

BOONE

GILMER

FAYETTE

GREENBRIER

CALHOUN

BERKELEYMORGAN

JEFFERSON

HANCOCK

OHIO

BROOKE

PENDLETON

TUCKER

HARDY

GRANT

MINERALHAMPSHIRETAYLOR

MARION

OHIO

PENNSYLVANIA

MARYLAND

VIRGINIA

KENTUCKY

24 additional West Virginia CountiesOver 2100 New Providers27 New Hospitals

Tertiary Facilities Include:

All contracting and service items (new providers, claims inquiries, questions, etc.) serviced by Health Plan directlyNo Programs or Services Carved Out

Health Plan requires credentialing of all providers including extendersContact Provider Relations (800) 624-6961Ext. 7633 for contracting information

WV Legislative mandate for coverage effective January 2012Large employer groups required to cover: in preceding year averaged over 25 eligible employeesCoverage effective upon reenrollment of large groups throughout the yearDiagnosis of ASD prior to age 8Coverage applies to children age 18 months to 18 years.

Coverage of Autism Spectrum Disorder

Establishing the Diagnosis of Autism Spectrum Disorder

Primary Care Physician (PCP) completes ASD screenings as per AAP and AAN guidelines as part of the preventive health visitsMultidisciplinary approach to establishing diagnosisReferrals to specialists, ancillary support, and testing are directed by the PCPDiagnosis of ASD based on DSM-IV-TR

Establishing the Diagnosis of Autism Spectrum Disorder

Once diagnosis is confirmed, coverage for autism treatment is initiated as per the member’s insurance benefit plan.

To assure payment of treatment and therapy under the benefit, services related to ASD require preauthorization

Applied Behavior Analysis provided and/or supervised by a Board Certified Behavior Analyst (BCBA)Information found at www.healthplan.org > provider services > additional BHU resources > Initial Authorization for ABA and Concurrent Authorization for ABAMedically necessary treatments, such as OT, ST, PT

Covered services:

Coverage of ABA

Initial authorization:

Results of screening and scalingFunctional Behavioral AssessmentGoalsRisk AssessmentTargeted interventions aimed at specific behaviorsParental training

Continuation of ABA

Behaviors and interventions identified on initial authorization formImprovements and achievementsSupporting documentation

Billing for ABA

Evaluation and Management Codes from Current Procedural Terminology have been assigned to various levels of treatment

Billing details will be in your contract