Oregon Administrative Rules › Chapter 410 - OREGON HEALTH AUTHORITY, HEALTH SYSTEMS DIVISION: MEDICAL ASSISTANCE PROGRAMS › Division 172 - MEDICAID PAYMENT FOR BEHAVIORAL HEALTH SERVICES › Section 410-172-0770 - Individual Eligibility for Applied Behavioral Analysis Treatment

Current through Register Vol. 63, No. 7, July 1, 2024
(1) Prior to
			 receiving services, individuals receiving ABA services for the treatment of
			 autism spectrum disorder (ASD) shall have an evaluation by a licensed
			 practitioner, described in OAR 410-172-0760(1) (a-d), experienced in the
			 diagnosis and treatment of autism using the current DSM criteria that includes:
(a) A diagnosis of an ASD listed on the ASD
			 line of the Health Evidence Review Commission's (HERC) Prioritized List;
(b) Documentation of and results
			 from a standardized, validated tool, such as the Autism Diagnostic Observation
			 Schedule (ADOS), that has been used to substantiate the autism disorder;
(c) Documentation of individual
			 core features of autism as identified through a review of ASD diagnostic
			 criteria from the Diagnostic and Statistical Manual of Mental Disorders (DSM
			 5);
(d) Documentation that a
			 parent or caregiver has been interviewed;
(e) Documentation that there was a review of
			 relevant medical records;
(f)
			 Documentation that the practitioner was able to observe the individual
			 directly;
(g) Documentation of
			 developmental status using validated assessments or a combination of such
			 assessments, such as the Vineland. This information may be provided by a
			 licensed ABA provider;
(h)
			 Documentation of a comprehensive medical exam. A physical exam from the most
			 recent well child care visit may be submitted if within one year for children
			 aged 1-6, or within two years for children 6-18. The physical exam must be
			 completed before starting ABA but may not be allowed to delay or interrupt ABA
			 services;
(i) Documentation that
			 an audiology or hearing test has been performed within one year for children
			 aged 2 through 5, or within two years for children aged 6 through 18. The
			 audiology or hearing test must be completed before starting ABA but may not be
			 allowed to delay or interrupt ABA services;
(A) Newborn assessment is not sufficient
			 after the age of 24 months;
(B)
			 Hearing tests from primary care offices and schools are sufficient if there are
			 no concerns regarding hearing;
(j) Any other documentation, if available,
			 that would substantiate the diagnosis of autism or stereotyped movement
			 disorder with self-injurious behavior due to neurodevelopmental disorder
			 including but not limited to the following:
(A) Notes from well-child visits or other
			 medical professionals;
(B) Results
			 from any additional assessments including but not limited to IQ, achievement
			 tests, speech and language tests, and assessments of adaptive functioning.
(k) A referral for ABA
			 treatment with or without specification of hours or intensity that shall
			 include:
(A) A diagnosis of ASD or
			 stereotyped movement disorder with self-injurious behavior due to
			 neurodevelopmental disorder;
(B) A
			 copy of the evaluation described in 410-172-0770(1);
(C) A referral for ABA treatment with or
			 without specification of hours or intensity.