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Applied Behavior Analysis Treatment Request Form

IMPORTANT NOTE:  ABA approvals follow the policy posted under the Clinical Resources tab on .This form can only be used when requesting ABA treatment for certain Medicaid accounts and certain Indiana policies. Please ensure you have called the number on the back of the card to confirm eligibility for ABA and use of this portal.

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

1) Prior authorization/notification must be obtained for coverage of ABA services when required by the member's benefit plan.
2) Notification/Authorization is based on the member's eligibility, terms of the benefits plan, Federal/State regulations, Our Policies & Procedures, and the Optum ABA Clinical Policy.
3) It is in your best interest to confirm the member has benefits for ABA services (here) prior to submitting the request.

Important Note: Please use Chrome with this form. Internet Explorer is not recommended due to performance issues.
  = Required Information

Member Information:

6/2/2020 ]

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