10.09.28.05

.05 Limitations.

A. ABA services are only available to participants under the EPSDT program.

B. ABA services shall be delivered in a home or community setting, including a clinic, when medically necessary.

C. The provider may not bill the Program for:

(1) Services that are:

(a) Provided in:

(i) A hospital;

(ii) An institution for mental disease;

(iii) An ICF-IID;

(iv) A crisis residential program;

(v) A residential treatment center;

(vi) A 24-hour, 365-day residential program funded with federal, State, or local government funds; or

(vii) Nonconventional settings, including but not limited to resorts, spas, and camps;

(b) Rendered when measurable functional improvement or continued clinical benefit is not met, and treatment is not deemed necessary;

(c) Not preauthorized by the Department or its designee;

(d) Beyond the providerís scope of practice;

(e) Rendered but not documented in accordance to Regulation .04 of this chapter;

(f) Rendered by mail or telephone;

(2) Services whose purpose is vocationally based or recreationally based;

(3) Respite services;

(4) Custodial care;

(5) Completion of forms and reports;

(6) Broken or missed appointments;

(7) Travel to and from site of service; and

(8) Services which duplicate a service that a participant is receiving under another medical care program.

D. The participantís parent or caregiver shall:

(1) Be trained to reinforce ABA services for the participant in a clinically effective manner; and

(2) Be present or available in the setting where services are being provided at all times, even if not directly participating in the services.

E. Services shall be discontinued if no longer medically necessary because:

(1) Long-term treatment goals and objectives are achieved; or

(2) Participant is not demonstrating progress towards treatment goals and objectives and measurable functional improvement is no longer expected.

F. The provider shall obtain approval by the Department or its designee for remote supervision.