Questions to Ask Your Insurance Company About ADHD Coverage

Insurance coverage for ABA services provided by a Board Certified Behavior Analyst® (BCBA®) for ADHD is limited and varies significantly by insurance plan. While ABA coverage is nearly guaranteed for Autism Spectrum Disorder diagnoses, coverage for ADHD is less common and depends on your specific plan and state regulations. Here are some questions to ask your insurance company to help figure out if any of our services would be covered.

Questions to Ask:

Benefits & Credentialing

Do I have out-of-network benefits for applied behavior analysis (ABA) or behavioral health services?

At this time, we are not credentialed to be in network with any insurance providers. This means your coverage would fall under out-of-network benefits, if you have them.

Mentaya Partnership

When working with out-of-network benefits, we partner with Mentaya, a service that helps simplify the reimbursement process. They submit claims to your insurance company on your behalf. See the handout at the end of this packet.

Note: Mentaya helps with claim submission for out-of-network benefits. This does not guarantee coverage or reimbursement.

Diagnosis & Referrals

What diagnosis is required for ABA coverage?

  • Does my plan cover ABA services for [your/your child's diagnosis]?
  • Do I need a formal diagnosis from a specific type of provider?
  • Do I need a physician referral or prescription?
  • Do I need prior authorization?

Exceptions & Approvals

Could you approve a single case agreement, gap exception, or network adequacy exception?

Allows an insurance company to cover services with an out-of-network provider at in-network rates for a specific patient/case.

Billing Codes

Do you cover the following billing codes for ABA services with an ADHD diagnosis?

CPT Codes (Commercial):

97151 - ABA assessment/reassessment

97153 - Adaptive behavior treatment

97155 - Protocol modification

97156 - Family adaptive behavior guidance

HCPCS Codes (Medicaid):

H2014 - Skills training and development

H2019 - Therapeutic behavioral services

Exception Types:

Single Case Agreement: Typically used when in-network providers exist but don't meet your specific needs (specialty, location, continuity of care, or provider expertise)

Gap Exception/Network Adequacy Exception: Typically used when there are NO in-network providers available who can provide the needed service

⏱ Timeline expectations: The process of requesting and receiving approval for a single case agreement or gap exception can take 2-4 weeks or longer. We recommend starting this process before services begin whenever possible.
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