11-01 – Insurance coverage for autism and autism spectrum disorders, Jan. 3, 2011

INSURANCE BULLETIN 11-01 Insurance coverage for autism and autism spectrum disorders Issued Jan. 3, 2011

To: Health insurance companies, health service corporations, health maintenance organizations, third party administrators, medical providers and the public From: John M. Huff, Director Re: Section 376.1224, insurance coverage for autism and autism spectrum disorders

In the 2010 legislative session, the Missouri legislature enacted House Bills 1311 and 1341, which mandate insurance coverage for various treatments for autism and autism spectrum disorders, in addition to establishing a licensure process for certain providers of autism services.

The insurance coverage provisions of the legislation go into effect for policies which are written, issued, or renewed on or after Jan. 1, 2011.

As the insurance industry implements the provisions of this law, the Department has been asked to provide guidance to the industry and the public as to certain provisions of the law.

Claim coding The Department is not aware of established procedural codes specific to Applied Behavior Analysis (ABA). Medical providers and the insurance industry rely upon these procedural codes to effectuate the billing and payment of insurance claims. The Department has been advised that a majority of the top 10 insurance companies in the state of Missouri intend to rely upon HCPCS (Healthcare Common Procedure Coding System) Codes H0031, H0032, H2012, and H2019 for billing and payment of insurance claims related to ABA therapy.

Code Long description H0031 Mental health assessment, by non-physician H0032 Mental health service plan development by non-physician H2012 Behavioral health day treatment, per hour H2019 Therapeutic behavioral services, per 15 minutes

By the issuance of this bulletin, the Department wishes to acknowledge and publicize the prevalent reliance upon these HCPCS codes and encourage the industry to, wherever possible, recognize and accept these procedural codes. The usage of these codes will provide uniformity within the industry and will also reduce confusion within the medical provider community.

If any insurance companies are not able to utilize these HCPCS codes, the Department encourages these companies to make information readily available to providers, both in- and out-of-network, to disclose what codes providers should utilize for ABA services to facilitate the prompt processing and payment of claims.

Failure to provide care and improper claim denials The Department remains concerned about and will closely monitor the delivery of autism related services and consumer complaints to ensure no unnecessary barriers to medically necessary treatment or coverage restrictions are imposed by any insurance company. This would include denials based upon a mere administrative technicality, such as if a provider or insured provides all of the essential information necessary to review or evaluate a claim or treatment, but fails to complete a specific form. Any consumer or provider complaints received by Consumer Affairs that indicate inappropriate denials or coverage restrictions will be immediately forwarded to the Market Conduct Section for investigation and the company may be subject to an enforcement action.

Transitional and implementation concerns The Department has also received inquiries from parents and providers as to what will happen on Jan. 1, 2011, to those children that are currently receiving treatments for autism or autism spectrum disorders, including ABA therapy. There is a concern that children in this situation may face an interruption in treatment. An interruption may occur while transitioning to the new coverage available under Section 374.1224 RSMo., while the provider seeks licensure under the new law or while the provider is completing the provider credentialing process. The Department encourages companies to exercise flexibility in accommodating children in these situations. Companies can make accommodations for providers who have undertaken the measures necessary to become licensed and/or credentialed. Companies may also choose to waive existing prior authorization or pre-certification requirements, relying instead upon retrospective reviews for determinations of medical necessity.

The Department encourages and welcomes such accommodations to help ensure that those children currently undergoing treatment will not see an interruption in their treatment on or immediately after Jan. 1, 2011. For those carriers instituting a temporary modification or deviation to their practices or procedures to accommodate these individuals, the Department will extend a “safe harbor” of one year from the date of this bulletin from any enforcement or disciplinary action related to those temporary modifications or deviations.