Prior authorization for ABA Therapy, in North Carolina
Prior authorization is the plan agreeing in writing to cover a specific number of ABA Therapy hours over a specific period, and it is where most delays between a diagnosis and a first session actually happen. This page is written for practice managers, billing staff and care coordinators who want to understand what the request requires by payer type, what predictably slows it down, and what iCare Therapy handles so that neither the family nor the referring practice has to.
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What authorization requires, by payer type
The requirements share a common core: a qualifying autism spectrum diagnosis from an appropriate evaluator, a referral, and a treatment plan or assessment supporting the number of hours requested. Where they differ is in the route and the detail.
Commercial fully insured plans are regulated by North Carolina and required to cover autism treatment; the request goes through the insurer’s behavioral health process, which is sometimes delegated to a specialist administrator such as Carelon Behavioral Health, in which case the request must go to the administrator rather than the plan. Self funded employer plans, including many that use the MedCost network, are regulated federally, and coverage is set by the employer’s plan document; the first step is confirming, in writing, that ABA Therapy is a covered benefit and whether it carries limits on hours or age. Tricare covers ABA Therapy through the Autism Care Demonstration, which has its own enrollment, referral and outcome measure requirements.
What slows a request down
An incomplete diagnostic report is the most common cause. A report that does not clearly state the diagnosis, the evaluator’s credentials and the assessment tools used gets sent back. A missing or unclear referral is the second. A plan change mid request is the third, because the authorization has to be requested again under the new plan even though nothing about the child has changed. A request sent to the wrong desk, most often to a health plan rather than to the behavioral health administrator it has delegated to, is the fourth, and it is entirely avoidable.
iCare Therapy catches the first, second and fourth before submission, because it assembles the request itself from the diagnostic report and its own assessment and sends it to the right place the first time. The third it cannot prevent, but it can shorten: a family who tells iCare Therapy a plan change is coming has the new request started before the change takes effect.
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What a complete request contains
A complete request carries the diagnostic report, stating the diagnosis, the evaluator’s credentials and the assessment tools used. It carries the referral, addressed to the family’s current plan. It carries the assessment or treatment plan written by the Board Certified Behavior Analyst, which describes the child’s present skills, the goals proposed, the number of hours requested and the clinical reasoning for that number. It carries the family’s consent. And it goes to the correct desk, which for a plan that has delegated behavioral health to an administrator means the administrator rather than the plan.
That last point sounds small and it is the cause of a surprising share of stalled requests. A well assembled packet sent to the health plan when the plan has delegated to Carelon Behavioral Health, or the reverse, sits on the wrong desk until somebody notices. iCare Therapy verifies where the request should go as part of verifying benefits, before anything is sent.
Typical timelines
Ranges only, and only where a range is honest. Timelines vary by plan and by how complete the request is on arrival. A range on this page that turns out optimistic costs more trust than no range at all, so if a range cannot be stated honestly for a payer, say so plainly instead.
What iCare Therapy will tell a family or a practice at any point is which step a request is at and what is being done about it. That is the honest form of a timeline, and it is available on request.
What iCare Therapy handles
Assembly, submission, follow up and, where necessary, appeal. iCare Therapy verifies benefits first, so the family knows what is covered before anything is submitted. It assembles the request from the diagnostic report and its own assessment. It submits to the correct desk. It follows up rather than waiting. If the plan asks for something more, iCare Therapy obtains it directly. If a request is denied, iCare Therapy tells the family and, with consent, the practice why in plain language and what the appeal route looks like. Neither the family nor the referring practice is the one on hold with the plan.
Renewals are handled the same way. Authorizations are issued for a defined period and renewed on progress data. iCare Therapy prepares each renewal from the session data it already collects, so a renewal is a routine step rather than an event.
What the practice can do to help
Send the diagnostic report as soon as it exists, even in draft, and say what is coming. Make sure the report states the diagnosis, the evaluator’s credentials and the tools used. Send the referral with the family’s current plan name, not a previous one; a referral written to a plan that has since merged, such as WellCare into Carolina Complete Health, gets sent back for correction. And tell iCare Therapy if you know a plan change is coming for the family. Those four things remove most of the avoidable delay.
A note on hours
Practices sometimes ask what number of hours to recommend in a referral. The answer is none. The hours requested come from the Board Certified Behavior Analyst’s assessment of the child, and the clinical reasoning behind that number is what the plan reviews. A referral that specifies hours does not speed anything up and occasionally creates a conflict between the referral and the assessment that has to be explained.
What does help is any clinical detail that bears on intensity: the child’s current communication, the presence of behaviors that affect safety, previous therapy and how it went. Put that in the referral and the assessment starts from a better place.
Why authorization is worth understanding
For a practice manager, prior authorization is often the least visible part of a referral and the part that most determines whether it succeeds. A family that waits three months for an authorization that could have taken six weeks frequently does not start therapy at all, and the practice sees the same child again with nothing changed. Understanding what a complete request looks like is therefore worth more than it appears.
The four things a practice controls are the completeness of the diagnostic report, the accuracy of the plan name on the referral, the speed with which both are sent, and telling the provider about a plan change before it happens. Everything else sits with the provider and the plan. iCare Therapy handles its side and reports where a request stands whenever asked.
