Amazon and Subsidiaries
Applied Behavior Analysis (ABA) for
Autism Spectrum Disorders (ASD) Program Treatment Plan Checklist
Important: The Checklist must be completed in its entirety before claims can be processed.
1) Subscriber
ID#:
2) Diagnosis Verification –all that apply
Autistic Disorder (ICD-9-CM code 299.0, 299.00 or 299.01/Autism Spectrum Disorder in DSM-5, code 299.00)
(ICD-10 code F84.0)
DSM-5 now has only one disorder: Autism Spectrum Disorder (DSM-5 code 299.00 through 9/30/14; ICD-10
code F84.0 effective 10/1/14)
Other Childhood Disintegrative Disorder (ICD-9-CM code 299.1, 299.10, or 299.11/Autism Spectrum Disorder in
DSM-5, code 299.00) (ICD-10 code F84.3)
Asperger’s Disorder (ICD-9-CM code 299.8, 299.80, or 299.81/Autism Spectrum Disorder in DSM-5, code
299.00) (ICD-10 code F84.5)
Rett’s Disorder (not listed in ICD-9-CM; listed in DSM-IV with codes 299.8, 299.80, 299.81) (ICD-10 code F84.2)
Other Pervasive Developmental Disorder (ICD-10 code F84.8)
Pervasive Development Disorder Not Otherwise Specified (ICD-9-CM codes 299.9, 299.90, or 299.91/Autism
Spectrum Disorder in DSM-5, code 299.00) (ICD-10 code F84.9)
3) Provider of Service (List name of Program Manager and provider address)
Indicate and Attest named Provider is BCBA Certified
Note: Submit Provider Verification Form
4) Treatment Plan
A. Start Date
(mm/dd/yyyy):
B.
Identify Problems/Goals: Statement of individualized goals for the member’s intervention program:
C.
Treatment Modality: Indicate intervention or interventions for each goal:
026871 (02-2014)
Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association
Amazon and Subsidiaries
D.
Frequency: Anticipated number of days per week and number of hours per day for services:
1. Provide plan for coordination with other clinicians who are providing care to the member and
coordination with school personnel when appropriate:
2. Plan for supervision of therapy assistants (unlicensed paraprofessionals), when therapy
assistants are the providers of direct services:
5) Re-assessment: Check all that apply.
Member progressing
Changes anticipated
Signature: X
Send this completed checklist to:
Date:
Premera Blue Cross
PO Box 91059
Seattle, WA 98111-9159
Fax Number: 888-617-0495
026871 (02-2014)
Premera Blue Cross is an Independent Licensee of the Blue Cross Blue Shield Association