New Autism Spectrum Disorder (ASD) Treatment Services Policy Effective December 1, 2026

Effective December 1, 2026, Horizon is implementing a new medical policy:

• Autism Spectrum Disorder (ASD) Treatment Services: Applied Behavior Analysis (ABA) and Developmental, Individual-Difference, Relationship-Based Model (DIR/Floortime) Medical Policy

This new policy will replace the following current policy:

• Applied Behavior Analysis in the Treatment of Autism Spectrum Disorders (ABA) medical policy

Key policy changes include:

• Core authorization criteria and documentation expectations are consolidated into a provider submission checklist.
• Treatment intensity and treatment setting requests may require additional clinical rationale, including for home, center, community, school, or telehealth services.
• Policy guidance is updated to address DIR/Floortime when medically necessary.
• Adult ASD guidance is further clarified in the policy.

Implementation of the new policy will not expand the scope of procedures or services that require prior authorization, pre-service medical necessity determination (MND) reviews, or post-service MND reviews. However, the new policy may change how requests for authorization are reviewed.

The following section summarizes key authorization submission expectations. Please refer to the policy for complete documentation, claims submission, and review criteria.

Requirements for clinical authorization requests include:

• Requests must include a current Autism Spectrum Disorder (ASD) diagnosis by a Qualified Health Professional and supporting diagnostic evaluation information.
• Treatment plans must support medical necessity, expected functional improvement, measurable goals, service frequency/intensity, caregiver involvement, care coordination, and discharge/fading planning.
• Clinical documentation should address baseline functioning, comorbidities, prior treatment response, social/educational supports, and rationale for intensity, setting, school-based services, or concurrent treatment when applicable.
• Continuation, reduction, discontinuation, regression-related increases, re-evaluation, exclusions, and treatment appropriateness must align with policy requirements.

For clinical policy questions: Use the "Questions?/Email Us" link within the policy.

For general questions: Email [email protected].