Blue Cross Autism Coverage

The following comes from a Blue Cross newsletter: 

Expanded autism benefits now available Blue Care Network began offering expanded coverage for autism spectrum disorder on Oct. 15 in compliance with Michigan law. There have been some updates since we first announced the expanded coverage in the Sept.‑Oct. 2012 BCN Provider News.

                        Only applied behavior analysis counts toward the $50,000 annual benefit limit.

                        In order for applied behavior analysis services to be covered the following must occur: An autism diagnosis must be made or confirmed by a BCN-approved autism evaluation center.

                        The treatment plan recommendations prepared by the AAEC must include a recommendation for applied behavior analysis.

                        The applied behavior analysis must be provided by a board-certified behavior analyst who participates with the member’s health plan.

                        The board-certified behavior analyst must obtain prior approval from BCN before providing applied behavior analysis services.
                       
                        Services other than applied behavior analysis require an autism diagnosis from a BCN health care provider participating with the member’s health plan.
                        Physical, occupational and speech therapy services, when performed for an autism diagnosis, are managed by BCN’s Care Management department, not Landmark or BCN Behavioral Health. The treating provider must submit an authorization request to BCN through e-referral or call BCN Care Management at 1‑800‑392‑2512. A treatment plan does not need to be submitted for physical, occupational or speech therapy services for autism unless these therapies are being reviewed for medical necessity.
                        Physical, occupational and speech therapy providers who provide autism services can request autism as a service in their listing in the online BCN provider directory. Send an email with the annual number of autism patients you treat and the percentage of your practice focused on autism to bcnproviderpictures@bcbsm.com.
                        Nutritional counseling requires an order or prescription from a physician, but does not require authorization by BCN.
BCN, together with parent company, Blue Cross Blue Shield of Michigan, mailed letters in October explaining the new autism benefit to primary care physicians, psychiatrists, fully licensed psychologists, pediatric neurologists and therapy providers. A copy of the letter is available on web-DENIS in BCN Provider Publications and Resources on the Autism page. Check this page for the latest information on BCN’s autism coverage. Resources available on the web-DENIS Autism page include:

                        Letter to providers

                        Provider FAQ

                        Reimbursable autism procedure codes

                        Member notice

                        Letter to hospitals about approved autism evaluation center designation

                        Letter of intent to apply for AAEC designation
Remember:

                        Expanded autism coverage does not apply to all members. Always check member eligibility and benefits before providing services. If a member has autism coverage, it will be noted on web-DENIS on the Medical Benefits page under Mental Health Outpatient.

                        Autism-related physical, occupational and speech therapy services are subject to medical outpatient therapy deductible, copayment or coinsurance. Other outpatient autism-related services apply the primary care physician copayment and deductible when applicable. Physical, occupational and speech therapy services used as part of the autism benefit do not count toward the number of medical visits or day limit for these therapies.

                        There is an age limit through the age of 18 (until the member’s 19th birthday) for any autism services. There is also an annual benefit limit of $50,000 applicable only for applied behavior analysis services. Services beyond the dollar benefit limit or age limit will be reviewed for medical appropriateness and may be covered if medically necessary.

If you have questions, please contact your BCN provider representative.

You can find this and more on page 24 of: http://www.bcbsm.com/newsletter/providernews/current/bcnprovidernews.pdf