Medicaid: Getting Coverage for Behavior Therapy 

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Don't wait until the problem has gotten too big to manage

 
 

Medicaid approves behavior therapy for clients with the presence of one or more of the following for an individual age 20 and younger:

+ 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.

+ 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.

+ 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.

Contact Lighthouse at 720.772.7334 to set up a free initial consultation. 

To obtain preauthorization for services please be prepared to provide the following to Lighthouse:

  1. Copy of the client’s Medicaid Card (please include both sides, if applicable)
  2. Referral for services from client’s Primary physician (this may look like a prescription).

          +This referral MUST say BEHAVIOR THERAPY/ABA/BEHAVIOR CONCERNS.

          + Referral does not need to be specific to Lighthouse or Adam Potter.

  1. Most recent well child visit report from client’s Primary physician
  2. Signed documentation from the initial provider recommending or referring the client for behavior services and identifying the medical necessity for services.

OR

A signed comprehensive diagnostic evaluation performed within the previous twelve (12) months by a qualified health care professional such as the client’s physician, nurse practitioner, or psychologist who prescribes and/or recommends behavioral therapy services.

  1. A copy of the report from a developmental screening tool used like ASQ, MCHAT, etc,

            + If the child doesn’t qualify for one of these i.e. (too old for a screening tool) then the Doctor must send us a letter that specifically requests “behavior intervention as a medically necessary procedure” and includes the patient's full name, date of birth, and diagnosis.

 
 

We are NOT approved to bill to adults with Medicaid. Approval is pending.