Get Tn Bcbs 19ped504697 2019-2026

This guide provides a clear and comprehensive approach to filling out the TN BCBS 19PED504697 form online. The form is used for requesting Applied Behavior Analysis (ABA) therapy services for individuals with Autism Spectrum Disorder.

Follow the steps to successfully complete the form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering the member's name and date of birth. Ensure the information is accurate as it is crucial for identification purposes.
3. Fill in the member identification number, followed by the parent's or guardian’s name and their current telephone number.
4. Provide the details of the ABA services provider including the name, address, and contact information, ensuring to include the provider ID or NPI number.
5. Indicate whether the member has an established diagnosis of Autism Spectrum Disorder by selecting Yes or No. If Yes, provide the diagnosis code.
6. Using the DSM-5, identify the severity level of the diagnosis and explain the level of support required.
7. Document any prior therapies the member has received along with the most recent date spans.
8. Describe the expected improvements in the member's behavior with ABA therapy, ensuring that explanations are clear and thorough.
9. Identify the parent or caregiver involved in the therapy program, including their name and relationship to the member.
10. Specify the member’s educational involvement by indicating whether they attend early intervention programs, and their attendance status.
11. Record any relevant medical conditions that may affect the ABA therapy.
12. Indicate the proposed locations for ABA therapy services and fill in the start and end dates for treatment.
13. For Assessment Requests, fill in the CPT code and the service description along with units per month.
14. For Initiation/Continuation Requests, respond whether the assessment request has been submitted and approved, and if applicable, provide explanations for any No responses.
15. Review the certification period for ABA therapy and ensure all fields are completed accurately.
16. Provider should attest to the accuracy of the information by signing and dating the form.
17. Once all sections have been completed, save changes, download, print, or share the form as necessary.

Complete your forms online today to ensure timely processing.