Autism spectrum disorder (ASM) evaluation and treatment
Coverage may vary by the member's plan
- 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.
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.
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.
- Psychotherapy: Behavioral Health Outpatient Services Request form
- ABA Therapy Authorization Request form
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.
Submitting medical records
When you request an authorization, or a post payment appeal determination, you may need to send us medical records.
To submit medical records for a specific claim (post-claim):
- Find the claim online using the Claims tool
- From the remittance advice (claim detail) screen, click Contact us
- In the drop down menu, select Medical records
- Attach medical records to your message.
You'll receive a confirmation screen after submitting your message, and a confirmation email from our Provider Services team.
To submit medical records that are not related to a specific claim (pre-claim):
- Go to your Priority Health Secure Mailbox.
- Click the Compose tab
- In the What is your message about? field, choose Medical record submission (pre-existing)
- Use the Attachments field to attach your documents
- In the body of the email include: member name, DOB and member ID number.
- If you are submitting a pre-claim appeal; you must complete and attach the most current Priority Health appeal form and submit a detailed letter of appeal. For more information on appeals access our Reviews and appeals requirements.
If you don't have a Priority Health provider account, request one now.
- ADHD services
- Autism services
- Coordination of care
- Depression diagnosis and management
- Discharge process
- Electroconvulsive therapy
- Medicaid behavioral health
- Mental health services
- Neuropsych/psychological exams, testing
- Psychological E&M of non-mental-health disorders
- Substance use disorder services
- Transcranial magnetic stimulation