Physician Referral Criteria 

For Early Intervention EPSDT services. Individuals over 20 years may be eligible for Adult services.

 1. The client has been diagnosed with a condition for which behavioral therapy services are recognized as therapeutically appropriate (i.e. evidence-based or evidence-informed), including autism spectrum disorder.

 2. The client cannot adequately participate in home, school, or community activities because behavior or skill deficit interferes with these activities. The client must have a standardized assessment of maladaptive behaviors to show their abilities to function in these activities.

 3.  The client presents a safety risk to self or others. Examples include self-injury, aggression towards others, and destruction of property, stereotyped or repetitive behaviors, or elopement. 

ADMISSION CRITERIA All of the following criteria are necessary for admission.

1)The Member has a definitive diagnosis of an Autism Spectrum Disorder (F84.0).

Documentation to send with a Referral- Referral must be TO POSITIVE BEHAVIORAL SERVICES OF THE FOUR CORNERS

2)The diagnosis in (1) above is made by a licensed physician, psychiatrist, or psychologist experienced in the diagnosis and treatment of autism with developmental or child /adolescent expertise.

3)The child or adolescent has received a comprehensive diagnostic assessment (which my include: ABLLS–R, Vineland–III, ADI–R, ADOS–G, CARS2, VB–MAPP, Baley Scales, or Autism Behavior Checklist, etc), which include the following:

a)Complete medical history include pre–and perinatal, medical, developmental, family, and social elements;

b)Physical examination, which may include items such as growth parameters, head circumference, and a neurologic examination;

c)Detailed behavioral and functional evaluation outlining the behaviors consistent with the diagnosis of ASD and its associated comorbidities. A diagnostic evaluation must include the scores from the use of formal diagnostic tests and scales as well as observation and history of behaviors. Screening scales such as the MCHAT–R are not sufficient to make a diagnosis and will not be accepted as the only formal scale; and d)Medical screening and testing has been completed to identify the etiology of the disorder, rule out treatable causes, and identify associated comorbidities as indicated. 4)The Member exhibits atypical or disruptive behavior that significantly interferes with daily functioning and activities or that poses a risk to the Member or others related to aggression, self–injury, property destruction, etc. 5) Initial evaluation from a Licensed Applied Behavior Analyst supports the request for the ABA services.

6)The diagnostic report clearly states the diagnosis and the evidence used to make that diagnosis.

CONTINUING STAY CRITERIA All of the following criteria are necessary for continuing treatment at this level of care.

1)The individual’s condition continues to meet admission criteria for ABA, either due to continuation of presenting problems, or appearance of new problems or symptoms.

2)There is reasonable expectation that the individual will benefit from the continuation of ABA services. Treatment planning is individualized and appropriate to the individual’s changing condition with realistic and specific goals and objectives stated. The treatment plan is updated based on treatment progress including the addition of new target behaviors. 3)Initial assessment from a Licensed Applied Behavior Analyst supports the request for ABA services.

4)A Member’s progress is monitored regularly evidenced by behavioral graphs, progress notes, and daily session notes. The treatment plan is to be modified, if there is no measurable progress toward decreasing the frequency, intensity and/or duration of the targeted behaviors and/or increase in skills for skill acquisition to achieve targeted goals and objectives.

5)There is documented skills transfer to the individual and treatment transition planning from the beginning of treatment.

6)There is a documented active attempt at coordination of care with relevant providers/caretakers, etc., when appropriate. If coordination is not successful, the reasons are documented.

7)Parent(s) and/or guardian(s) involvement in the training of behavioral techniques must be documented in the Member’s medical record and is critical to the generalization of treatment goals to the Member’s environment.

8)Services are not duplicative of services that are part of an Individual Educational Plan (IEP) or Individual Service Plan (ISP) when applicable.

DISCHARGE CRITERIA Any of the following criteria are sufficient for discharge from this level of care.

1)A Member’s individual treatment plan and goals have been met.

2)The individual has achieved adequate stabilization of the challenging behavior and less–intensive modes of treatment are appropriate and indicated.

3)The individual no longer meets admission criteria, or meets criteria for a less or more intensive services.

4)Treatment is making the symptoms persistently worse.

5)The individual is not making progress toward treatment goals, as demonstrated by the absence of any documented meaningful (i.e., durable and generalized) measurable improvement or stabilization of challenging behavior and there is no reasonable expectation of progress.