Provider Quality

Fidelis Care is notifying providers of key updates to the Applied Behavior Analysis (ABA) Clinical Policy (FC.CP.BH.104) The updated policy includes revisions to medical necessity criteria, treatment planning standards, and utilization management requirements for ABA services. Fidelis Care has also adopted a related policy CP.BH.105 ABA Documentation, outlining documentation standards to support medical necessity review and ongoing authorization requests.

In addition, CMS has released the State Medicaid and Children’s Health Insurance Program Applied Behavior Analysis Toolkit, which is being shared as a reference resource.

Effective 10/1/2026, the following changes, which are outlined in greater depth within the policy attached will apply:  

• Requests over 6 hours per day or 30 hours per week may trigger additional clinical review and should include supporting clinical justification.
• Members are expected to maintain at least 80% attendance, with barriers and provider follow-up documented when applicable.
• Caregiver guidance remains a required component of care and must include measurable goals, participation, barriers, and efforts to address engagement.
• Documentation standards have been updated for treatment planning, progress updates, assessment data, crisis planning, discharge/transition planning, and coordination of care.
• Supervision expectations have been clarified, including minimum oversight requirements and rationale for supervision beyond policy standards.
• Diagnostic evaluations must meet updated requirements, including clinician-administered and caregiver-report assessment tools.
• Approved diagnostic tools have been updated to align with current clinical practice standards.
• Telehealth may be considered case by case when clinically appropriate and supported by documentation.
• Documentation Policy CP.BH.105 outlines required ABA documentation standards to support medical necessity review.

For additional information and to become familiarized with the updated policy, please refer to the following resources:

• Applied Behavior Analysis FC.CP.BH.104 Clinical Policy & ABA Documentation Policies can be found under the clinical policies section here:   Provider Policies | Fidelis Care

• NYS Office of Professions ABA Resources

https://www.op.nysed.gov/professions-index/applied-behavior-analysis

• New York State Medicaid Provider Policy Manual

https://www.emedny.org/ProviderManuals/ABA/PDFS/ABA_Policy.pdf

• CMS - State Medicaid & Children’s Health Insurance Program - Applied Behavior Analysis Toolkit

https://www.medicaid.gov/medicaid/downloads/autism-services-aba-toolkit.pdf