QUALIFIED AUTISM PROVIDER CERTIFICATION
Intensive Level Services
PSYCHIATRIST, PSYCHOLOGIST, BEHAVIORAL ANALYST OR
LICENSED CLINICAL SOCIAL WORKER
Wisconsin Statute 632.895(12m) provides coverage for the treatment of autism spectrum disorders (“ASD”) when a
psychiatrist, psychologist, behavioral analyst or licensed clinical social worker is considered “qualified” to provide
intensive-level services. Wisconsin Administrative Code INS 3.36 sets forth the requirements in order for such a provider
to be qualified and they are as follows:
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Must be licensed or certified in WI
Must have completed at least 2080 hours that includes all of the following:
o 1500 hours supervised training involving direct 1:1 work with individuals with ASD using evidenced-based,
efficacious therapy models
o Have supervised experience with all of the following:
 Working with families as the primary treating provider and ensuring treatment compliance
 Treating individuals with ASD who function at a variety of cognitive levels and exhibit a variety of skill deficits
and strengths.
 Treating individuals with ASD with a variety of behavioral challenges
 Treating individuals with ASD who have shown improvement to the average range in cognitive functioning,
language ability, adaptive and social interaction skills
 Designing and implementing progressive treatment programs for individuals with ASD
o Academic coursework from a regionally accredited higher education institution with demonstrated coursework in
the application of evidenced-based therapy models consistent with best practice and research on effectiveness
for individuals with ASD.
In addition, if a provider is going to supervise and bill for services performed by paraprofessionals and, if working at an
outpatient mental health clinic, professionals, the provider must have completed at least 4,160 post-degree hours of
experience as a supervisor of less experienced providers, professionals and paraprofessionals.
If a provider meets these qualifications, they are eligible to provide non-intensive level services as well.
By signing and returning this form to Anthem BlueCross and BlueShield, I hereby certify that I meet the qualified
provider requirements set forth above. I understand that Anthem may, in its discretion, review its claim history or
request supporting information in order to verify the accuracy of this certification.
Signature:
Print Name:
Date:
NPI Number(s):
Tax Id Number:
Email Address:
Phone Number:
If you supervise and bill for professionals and/or paraprofessionals, provider must also submit the Qualified Autism
Paraprofessional Certification unless the provider works for an outpatient mental health clinic.
1. Please complete this form for each provider qualified to provide autism services
2. Print and have each qualified provider sign the form
3. Fax the signed form to 262-523-4783 or scan and attach it to your completed online Provider Maintenance Form.
The Qualified Autism Paraprofessional Certification Form can be found on our public provider website at
http://www.anthem.com/home-providers.html. Choose Answers@Anthem, and then choose Provider Forms.
Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ("BCBSWi") which underwrites or administers the PPO and indemnity policies; Compcare Health Services
Insurance Corporation ("Compcare") which underwrites or administers the HMO policies; and Compcare and BCBSWi collectively which underwrite or administer the POS policies. Independent licensees
of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of
the Blue Cross and Blue Shield Association.
Revision Date December 2013