Autism spectrum disorder (ASM) evaluation and treatment

Coverage may vary by the member's plan

Applies to:

  • Group HMO, EPO, POS and PPO members
  • Individual MyPriority® HMO, POS and PPO members
  • Self-funded plans are not mandated to provide coverage but may have a rider to cover treatment.

Priority Health Choice (Medicaid/Healthy Michigan Plan) members:

  • Under the age of 5, members should be directed to their pediatrician, primary care physician, or the Community Mental Health authority for their county of residence.
  • Members ages 5-18 should be directed to the appropriate staff at their school district. 

Definition

From the National Institute for Mental Health: Autism spectrum disorder (ASD) is the name for a group of developmental disorders. ASD includes a wide range, a "spectrum," of symptoms, skills, and levels of disability. People with ASD often have these characteristics: Ongoing social problems that include difficulty communicating and interacting with others. 

Services for ASD patients may include evaluation, applied behavioral analysis (ABA), psychotherapy, speech therapy, occupational therapy and physical therapy.

Medical policy

Autism Spectrum Disorders - 91615

Autism services coverage

Evaluations are covered for all members of any age.

Treatment is covered for members up to the age of 19 who have an autism spectrum disorder diagnosis that meet InterQual® Behavioral Health criteria, as per the medical policy. Ongoing clinical reviews are required to determine that member continues to meet criteria and to review treatment plan.

Autism services authorizations

Prior authorization is required for applied behavioral analysis (ABA) therapy and psychotherapy when treating a child diagnosed with an autism spectrum disorder.

Prior authorization is not required for initial evaluations, or for speech therapy, occupational therapy or physical therapy when billed with an autism spectrum disorder diagnosis.

To request authorization

Complete and fax the forms to 616.975.0249.

Autism services billing

Evaluations are payable when billed by participating psychologists.

Treatment claims must be billed by providers who have completed the supplemental application process and are approved to treat members diagnosed with an autism spectrum disorder. State legislation requires that a BCBA provide oversight of treatment. In addition, Priority Health requires treating agency have fully licensed clinicians also providing oversight. Claims billed by providers other than those so approved and certified will deny.