The ABCs of ABA Billing

Best Practices for Successful ABA Billing


based upon a webinar with Yvonne McNamee

July 2014 was a historic month. Medicaid programs across the country are now required to offer ABA therapy as a benefit for children with autism. One year later, as Medicaid programs continue to expand to implement this required benefit, it is important that providers become efficient in ABA billing practices.  The more efficient providers are at  billing, the more quickly they can get reimbursed for their services.

ABA claims are unique compared to other claims submitted to insurance companies.  Insurance companies do not always understand the nuances of how ABA services are delivered.  By following a strict protocol for billing, providers can increase the likelihood that their claims will be accepted and reimbursed on the first attempt.

Earlier this month, Rethink hosted a webinar in collaboration with Yvonne McNamee.  Yvonne is an independent consultant providing consultation around coding, billing, claims and appeals, which are essential components in obtaining health insurance coverage for the treatment of physical conditions and biologically based mental illnesses such as Autism Spectrum Disorder.

During the webinar, she offered the following “ABCs of ABA Billing” to support providers in submitting claims in an efficient fashion that ensures timely acceptance and reimbursement.

Below are the key 4 main takeaways from the webinar:

A is For Authorization in ABA BillingA is for Authorization

If you do not authorize you will receive 1 of 2 denials:  either a full denial of service or a request for every service not for each date of service bill. The second can be a time consuming logistical nightmare that can be easily avoidable by ensuring that your first step in submitting a claim is seeking authorization.

ABA is different than other services covered by insurance companies. It is particularly important that when calling the insurance company, you speak with the right person. Be sure to specify that you need ABA authorization for autism, as there are often different authorization department for different kinds of claims.


B is for Benefits in ABA BillingB is for Benefits

Confirming benefits requires a separate phone call from authorization.  This is where things can get a little sticky.  One thing that can save you a headache is checking to make sure that the provider name and tax id match. It is important that your tax id is registered to whoever is doing the billing.  If you are an individual provider, this would be our personal tax id, if you are agency this would belong to the agency.

The most important thing on this phone call, however, is that you ask the right questions. For more specific information, check out our top 10 questions for confirming ABA benefits.


C is for Coding in ABA BillingC is for Coding (and Claims Submittal)

Codes are ever-changing with every carrier, and they are currently in the process of changing.  Make sure you go over each and every code and check that the code is recognized by the carrier in the way that you intend to use it.  Pay particular attention to diagnosis coding, which is also in the process of changing.  Note on October 15, 2015, the autism diagnosis code will be changing.  It’s important to stay up-to-date with coding, as it will likely change again in the future.

When submitting the actual claim, the process is different depending on whether you are in or out-of-network.  If you are in network, determine whether you need to submit electronically or in paper. If you are not in network, you can collect fees directly from the parents.  You will most likely want to invoice the parent using proper coding with a clear description of services. This will help parents get reimbursed when they submit the claim to their insurance company.


D is for Documentation in ABA BillingD is for Documentation

Documentation is imperative to receiving reimbursement for services. Insurance companies demand it and often hold claims based upon receipts of it. Only recently did insurance companies begin requesting it from ABA providers. Reimbursement can be denied if services are not properly documented, so ensure that your documentation is clear, concise, and describes what services you deliver. ABA documentation must also be compliant with the insurance carrier guidelines, so be sure to look into this before developing your treatment plan.

For more information on exactly what your documentation should include, check out our basic documentation requirements checklist.

If you’d like to learn more about industry best-practices for ABA Billing, check out the full recording plus the slides below.


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