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Applied Behavior Analysis Assessment Form

IMPORTANT NOTE:  ABA approvals follow the policy posted under the Clinical Resources tab on . This form may only be used for 8 hours or less for the Initial ABA Assessment. If more than 8 hours are required, please call the number on the back of the Member's card.

Professionals completing the ABA Assessment Request form should consider the following information:

1) Prior authorization/notification must be obtained for coverage of ABA assessment services when required by the member's benefit plan.
2) Notification/Authorization is contingent upon the member's eligibility, terms of the benefits plan, Federal/State regulations, Our Policies & Procedures, and the Optum ABA Clinical Policy.
3) Please confirm member coverage and availability for this service (here) prior to completing this form. If online access for coverage is not available for you please call the number on the back of the member's card.
4) If you are an out of network provider interested in requesting an accommodation to treat a member using their in network benefits, please call the number on the back of the member’s card.

  = Required Information

Member Information:

9/21/2018 ]
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