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1303 Hospital Ground • Knud Hansen Complex, Suite 1 • St. Thomas, Virgin Islands 00802-6722 • (340) 774-0930 3012 Golden Rock • Christiansted, St. Croix, Virgin Islands 00820 • (340) 718-2980 Medicaid Program Public Notice Applied Behavioral Analysis (ABA) Provider Policy Manual Public Comment January 16, 2026 The U.S. Virgin Islands (USVI) Medicaid Program is issuing this 30-day public notice requesting public review and comment on the proposed Medicaid Program ABA Provider Manual. This manual establishes guidelines and requirements for the provision, coverage, and billing of ABA services under the Medicaid program. Interested parties can share their feedback on the proposed manual with the USVI Department of Human Services (DHS) by submitting comments via email to: map.public.comment@berrydunn.com. Please include “ABA Manual Comment” in the subject line of the email. The final day to submit comments will be February 16, 2026. Applied Behavior Analysis Manual | January 2026 i Applied Behavioral Analysis (ABA) Chapter Table of Contents Section Page Applied Behavioral Analysis (ABA) Chapter Table of Contents .................................................... i 1.0 General Information ............................................................................................................. 1 2.0 Member Eligibility ................................................................................................................. 2 3.0 Provider Qualifications and Participation Requirements ....................................................... 3 4.0 ABA Services ....................................................................................................................... 4 5.0 Prior Authorization ...............................................................................................................10 5.1 Initial Prior Authorization ..................................................................................................10 5.2 Requests for Continued Services .....................................................................................11 5.3 ABA Services Discharge ..................................................................................................11 6.0 Documentation Requirements .............................................................................................12 6.1 Case Record Documentation ...........................................................................................12 6.2 Treatment Plan Documentation .......................................................................................12 6.3 Periodic Reassessments and Treatment Plan Revisions .................................................13 6.4 Billing Documentation ......................................................................................................14 6.5 USVI Medicaid Record Reviews ......................................................................................14 7.0 Billing Procedures ...............................................................................................................15 8.0 Glossary ..............................................................................................................................16 Revision History ........................................................................................................................17 Applied Behavior Analysis Manual | January 2026 1 1.0 General Information Applied behavior analysis, or ABA therapy, is a type of behavioral therapy for people with autism and other developmental disorders. The principle is based on the idea that reinforcing specific behaviors increases the likelihood that those behaviors will be repeated. Conversely, when certain behaviors are not reinforced, their frequency tends to decrease and they may eventually diminish altogether. ABA may help people with autism: • Improve social interactions. • Learn new skills. • Increase positive behaviors. • Lessen challenging behavior. ABA services are covered under the Medicaid program in accordance with the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) requirement. Sections 1905(a)(4)(B) and 1905(r) of the Social Security Act (SSA) entitles eligible children under the age of 21 to Medicaid coverage of healthcare, diagnostic services, treatment, and other measures described in section 1905(a) that are medically necessary to correct or ameliorate defects and physical and mental illnesses and conditions, whether or not such services are covered under the state plan. ABA services involve highly specific, individualized interventions based on results of interviews with caregivers, functional assessments, direct observation and measurement of behaviors in everyday environments, data collection, and interactions with the child. Some interventions involve substantial amounts of one-to-one, face-to-face interactions with the child, caregivers, and others who implement intervention procedures. ABA interventions must be individualized to each child and must directly benefit the child. Applied Behavior Analysis Manual | January 2026 2 2.0 Member Eligibility To be eligible for ABA services, a member must:  Be at least 3 years of age and under 21 years of age,  Be eligible for USVI Medicaid on the dates of service,  Be referred or have necessary diagnostic and treatment services identified during an EPSDT screening, and  Have a primary diagnosis of autism spectrum disorder (ASD), which is identified prior to age 8, from their primary care provider or other medical care provider qualified to diagnose ASD. Diagnosis must be based on one of the following: o International Classification of Diseases (ICD-11) of 6A02, or o Diagnostic and Statistical Manual (DSM-5). Applied Behavior Analysis Manual | January 2026 3 3.0 Provider Qualifications and Participation Requirements Medicaid payment is made only to providers who are actively enrolled in the USVI Medicaid program. Providers are responsible for working within their scope of practice and maintaining the qualification for their licensure or certification. Services may not be billed to USVI Medicaid during any periods in which there is a lapse in licensure or certification. The following provider types are eligible to enroll with USVI Medicaid to provide ABA services. Providers must enroll with USVI Medicaid and may bill independently or under an affiliated group practice. Billing for services provided by a non-enrolled provider under another provider’s individual name and NPI is not permitted. ABA Adaptive Behavior Assessment may only be completed by one of the following: o Board Certified Behavior Analyst (BCBA) o Licensed Physician o Licensed Psychologist ABA Adaptive Behavior Treatment may only be provided by one of the following: o certified registered behavior technician (RBT) o board certified autism technician (BCAT) o board certified assistant behavior analyst (BCaSA) o board certified behavior analyst (BCBA) o licensed bachelor social worker (LBSW) o licensed certified social worker (LCSW) o licensed certified independent social worker (LCISW) o licensed professional counselor (LPC) o licensed marriage and family therapist (LMFT) o licensed substance abuse counselor (LSAC) o speech and language pathologist o licensed occupational therapist o licensed physical therapist Applied Behavior Analysis Manual | January 2026 4 4.0 ABA Services The USVI Medicaid coverage of ABA services includes Adaptive Behavior Assessment and Adaptive Behavior Treatment. Adaptive Behavior Assessment includes conducting initial and period assessments, developing and revising a treatment plan, training others to provide the direct service (Adaptive Behavior Treatment) identified in the treatment plan, and monitoring the delivery of Adaptive Behavior Treatment to oversee the implementation of the treatment plan. Adaptive Behavior Treatment assists the child in acquiring the skills identified in the treatment plan. Adaptive Behavior Assessment Services Procedure Code: 97151 Definition: Behavior identification assessment, administered by a physician or other qualified healthcare professional, each 15 minutes of the physician’s or other qualified healthcare professional’s time face-to-face with patient and/or guardian(s)/caregiver(s) administering assessments and discussing findings and recommendations, and non-face-to-face analyzing past data, scoring/interpreting the assessment, and preparing the report/treatment plan. Service Unit: 15 minutes Level of Service: Face-to-Face 1:1 Service; along with non-faced-to-face time to analyze past data. Prior Authorization: The behavior identification assessment is required to be submitted with the initial PA request and does not require prior authorization. Service Limits: Maximum of one per year per member Provider Qualifications: Provider types listed under ABA Adaptive Behavior Assessment in Section 3 Provider Qualifications and Participation Requirements Procedure Code: 97152 Definition: Behavior identification supporting assessment, administered by one RBT or BCAT under the direction of a physician or other qualified healthcare professional, face-to-face with the patient, 15 minutes each. Service Unit: 15 minutes Level of Service: Face-to-Face 1:1 Service Prior Authorization: Required Applied Behavior Analysis Manual | January 2026 5 Service Limits: Codes 97152, 0362T, 97153, 97154, 97155, 97156, 97157, 97158, and 0373T may be used in combination up to a maximum of 20 hours per service week and no more than six hours within a 24-hour period. Codes 97155, 97156, 97157, and 97158 used in any combination may be billed for no more than three hours of the six-hour maximum within a 24- hour period. The service week is defined as Sunday at 12:00 a.m. through Saturday at 11:59 p.m. Provider Qualifications: Provider types listed under ABA Adaptive Behavior Treatment in Section 3 Provider Qualifications and Participation Requirements Procedure Code: 0362T Definition: Behavior identification supporting assessment, each 15 minutes of technicians’ time face-to-face with a patient, requiring the following components: • administered by the physician or other qualified healthcare professional who is on site, • with the assistance of two or more technicians, • for a patient who exhibits destructive behavior, • completed in an environment that is customized to the patient’s behavior. Service Unit: 15 minutes Level of Service: Face-to-Face 1:1 Service Prior Authorization: Required. Service Limits: Codes 97152, 0362T, 97153, 97154, 97155, 97156, 97157, 97158, and 0373T may be used in combination up to a maximum of 20 hours per service week and no more than six hours within a 24-hour period. Codes 97155, 97156, 97157, and 97158 used in any combination may be billed for no more than 3 hours of the 6-hour maximum within a 24-hour period. The service week is defined as Sunday at 12:00 a.m. through Saturday at 11:59 p.m. Provider Qualifications: Provider types listed under ABA Adaptive Behavior Treatment in Section 3 Provider Qualifications and Participation Requirements Adaptive Behavior Treatment Services Procedure Code: 97153 Definition: Adaptive behavior treatment by protocol, administered by a technician under the direction of a physician or other qualified healthcare professional, face-to-face with one patient, each 15 minutes. Applied Behavior Analysis Manual | January 2026 6 Service Unit: 15 minutes Level of Service: Face-to-Face 1:1 Service Prior Authorization: Required Service Limits: Codes 97152, 0362T, 97153, 97154, 97155, 97156, 97157, 97158, and 0373T may be used in combination up to a maximum of 20 hours per service week and no more than 6 hours within a 24-hour period. Codes 97155, 97156, 97157, and 97158 used in any combination may be billed for no more than 3 hours of the 6-hour maximum within a 24-hour period. The service week is defined as Sunday at 12:00 a.m. through Saturday at 11:59 p.m. Provider Qualifications: Provider types listed under ABA Adaptive Behavior Treatment in Section 3 Provider Qualifications and Participation Requirements Procedure Code: 97154 Definition: Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with two or more patients, each 15 minutes. Service Unit: 15 minutes Level of Service: Face-to-Face 1:1 Service Prior Authorization: Required Service Limits: Codes 97152, 0362T, 97153, 97154, 97155, 97156, 97157, 97158, and 0373T may be used in combination up to a maximum of 20 hours per service week and no more than 6 hours within a 24-hour period. Codes 97155, 97156, 97157, and 97158 used in any combination may be billed for no more than 3 hours of the 6-hour maximum within a 24-hour period. The service week is defined as Sunday at 12:00 a.m. through Saturday at 11:59 p.m. Provider Qualifications: Provider types listed under ABA Adaptive Behavior Treatment in Section 3 Provider Qualifications and Participation Requirements Procedure Code: 97155 Definition: Adaptive behavior treatment with protocol modification administered by physician or other qualified healthcare professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes. Service Unit: 15 minutes Level of Service: Face-to-Face 1:1 Service Prior Authorization: Required Applied Behavior Analysis Manual | January 2026 7 Service Limits: Codes 97152, 0362T, 97153, 97154, 97155, 97156, 97157, 97158, and 0373T may be used in combination up to a maximum of 20 hours per service week and no more than 6 hours within a 24-hour period. Codes 97155, 97156, 97157, and 97158 used in any combination may be billed for no more than 3 hours of the 6-hour maximum within a 24-hour period. The service week is defined as Sunday at 12:00 a.m. through Saturday at 11:59 p.m. Provider Qualifications: Provider types listed under ABA Adaptive Behavior Assessment in Section 3 Provider Qualifications and Participation Requirements Procedure Code: 97156 Definition: Family adaptive behavior treatment guidance, administered by physician or other qualified health care professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes. Service Unit: 15 minutes Level of Service: Face-to-Face Service with parents/guardians or other caregivers Prior Authorization: Required Service Limits: Codes 97152, 0362T, 97153, 97154, 97155, 97156, 97157, 97158, and 0373T may be used in combination up to a maximum of 20 hours per service week and no more than 6 hours within a 24-hour period. Codes 97155, 97156, 97157, and 97158 used in any combination may be billed for no more than 3 hours of the 6-hour maximum within a 24-hour period. The service week is defined as12 a.m. on Sunday through 11:59 p.m. on Saturday. Provider Qualifications: Provider types listed under ABA Adaptive Behavior Assessment in Section 3 Provider Qualifications and Participation Requirements Procedure Code: 97157 Definition: Multiple-family group adaptive behavior treatment guidance, administered by a physician or other qualified healthcare professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes. Service Unit: 15 minutes Level of Service: Face-to-face service with multiple sets of parents/guardians or other caregivers Prior Authorization: Required Service Limits: Codes 97152, 0362T, 97153, 97154, 97155, 97156, 97157, 97158, and 0373T may be used in combination up to a maximum of 20 hours per service week and no more than 6 hours within a 24-hour period. Codes 97155, 97156, 97157, and 97158 used in any combination Applied Behavior Analysis Manual | January 2026 8 may be billed for no more than 3 hours of the 6-hour maximum within a 24-hour period. The service week is defined as Sunday 12:00 a.m. thru Saturday 11:59 p.m. Provider Qualifications: Provider types listed under ABA Adaptive Behavior Assessment in Section 3 Provider Qualifications and Participation Requirements Procedure Code: 97158 Definition: Group adaptive behavior treatment with protocol modification, administered by physician or other qualified healthcare professional face-to-face with multiple patients, each 15 minutes. Service Unit: 15 minutes Level of Service: Face-to-Face Service with multiple children at one time Prior Authorization: Required Service Limits: Codes 97152, 0362T, 97153, 97154, 97155, 97156, 97157, 97158, and 0373T may be used in combination up to a maximum of 20 hours per service week and no more than 6 hours within a 24-hour period. Codes 97155, 97156, 97157, and 97158 used in any combination may be billed for no more than 3 hours of the 6-hour maximum within a 24-hour period. The service week is defined as Sunday at 12:00 a.m. through Saturday at 11:59 p.m. Provider Qualifications: Provider types listed under ABA Adaptive Behavior Assessment in Section 3 Provider Qualifications and Participation Requirements Procedure Code: 0373T Definition: Adaptive behavior treatment with protocol modification, each 15 minutes of technicians’ time face-to-face with a patient, requiring the following components: • administered by the physician or other qualified healthcare professional who is on site, • with the assistance of two or more technicians, • for a patient who exhibits destructive behavior, • completed in an environment that is customized to the patient’s behavior. Service Unit: 15 minutes Level of Service: Face-to-Face 1:1 Service Prior Authorization: Required Service Limits: Codes 97152, 0362T, 97153, 97154, 97155, 97156, 97157, 97158, and 0373T may be used in combination up to a maximum of 20 hours per service week and no more than 6 hours within a 24-hour period. Codes 97155, 97156, 97157, and 97158 used in any combination Applied Behavior Analysis Manual | January 2026 9 may be billed for no more than 3 hours of the 6-hour maximum within a 24-hour period. The service week is defined as Sunday at 12:00 a.m. through Saturday at 11:59 p.m. Provider Qualifications: Provider types listed under ABA Adaptive Behavior Treatment in Section 3 Provider Qualifications and Participation Requirements Noncovered Services • Services provided by family members or other non-credentialed individuals. • Telephone conversation, electronic mail message (email), or facsimile transmission (fax) between a provider and a member or the member’s parent/guardian. Applied Behavior Analysis Manual | January 2026 10 5.0 Prior Authorization USVI Medicaid requires Prior Authorization (PA) for all ABA services to ensure services are medically necessary, and all coverage criteria are met. PA requests must be submitted to USVI Medicaid by an enrolled Medicaid provider prior to ABA services being rendered. Retrospective review requests will not be accepted, and backdating of PA requests is not allowed. 5.1 Initial Prior Authorization An initial request for PA must include: • Submission of the qualifying diagnostic assessment establishing an ASD diagnosis prior to the child’s eighth birthday and completed within the previous 24 months. Diagnosis must be based on one of the following: o International Classification of Diseases (ICD-11) of 6A02, or o Diagnostic and Statistical Manual (DSM-5) • Diagnostic documentation that demonstrates the following: o Indication of Diagnostic Severity Level, including level of communication and restricted repetitive behaviors. o Specifiers of the ASD diagnosis, including underlying medical causes, if identified, such as:  Example: With or without accompanying intellectual impairment.  Example: Associated with a known medical, neurodevelopmental, genetic condition, or environmental factor (using additional coding to identify the associated medical or another neurodevelopmental, mental, or behavior disorder). • A physician’s order for ABA services. • An EPSDT screening identifying ABA services as necessary for treatment. • A summary of the behavior identification assessment (see Procedure Code 97151 in Section 4 ABA Services) of the child. • A treatment plan (See Section 6 Documentation Requirements) that describes: o Treatment goals o The number of services requested (e.g. per week), for both Adaptive Behavior Assessment Services and Adaptive Behavior Treatment Services Applied Behavior Analysis Manual | January 2026 11 o How the amount of ABA services requested has considered the other non-ABA services needed by the child, describing how the combination of ABA and non- ABA services does not exceed realistic weekly contact hours for the child. o Description of available natural supports, including supports through involved individuals such as parents, guardians, other caretakers, and educational staff; or other non-duplicating services available through an Individualized Education Plan (IEP). o An indication that ABA services will not supplant or duplicate those provided by educational authorities or other funding sources. • Signature of the provider requesting the PA, along with contact information. 5.2 Requests for Continued Services Service authorization is for a twelve-month period; annual review of medical necessity is required. Annual request for continued service must be accompanied by an EPSDT screening and an updated treatment plan. • Documentation of treatment progress must be shown through measurements that reflect the behavior changes resulting from the ABA services. 5.3 ABA Services Discharge Any of the following criteria are sufficient for discharge from ABA therapy services: • A member’s treatment plan and goals have been met, • The member has achieved adequate stabilization of the challenging behavior and less- intensive modes of treatment are appropriate and indicated, • Treatment is making the symptoms persistently worse, or • The member is not making progress toward treatment goals, as demonstrated by the absence of any documented meaningful (i.e., durable and generalized) measurable improvement or stabilization of challenging behavior, and there is no reasonable expectation of progress. Applied Behavior Analysis Manual | January 2026 12 6.0 Documentation Requirements The provider must assure adequate documentation is maintained for all activities related to ABA therapy services provided to members. 6.1 Case Record Documentation Member records must contain sufficient detail to support services provided to members and claims submitted to USVI Medicaid for ABA services. Failure to follow the documentation requirements may result in the reduction or denial of a claim for reimbursement. The members’ case records must: • Be legible. • Be organized using uniform guidelines so that similar information will be found in the same place from case record to case record and can be quickly and easily accessed. • Include complete member identifying information. • Contain the following completed forms: o Release of Information o Informed Consent for Treatment o Authorization to Bill Medicaid • Not contain copied or boilerplate language for information that is member specific. • Include information on third-party insurance or other coverage available to the member. 6.2 Treatment Plan Documentation The member’s treatment plan must contain service goals and objectives, which are derived from a comprehensive member assessment, and must stipulate the planned service activities and how they will assist in goal attainment. Discharge reports must be added to the treatment plan upon case closure. At a minimum, the treatment plan must include: • Name of the member • Age of the member • Family composition • Placement history (if the child has been in a facility, to include admission and discharge dates) • Narrative history or background of child Applied Behavior Analysis Manual | January 2026 13 • Current health status and medical needs • Medication list • Immunization record • Presenting concerns • Diagnosis • Behavioral patterns • Legal responsible party • Relevant information from others, such as parents/guardians or other caregivers, medical providers, or educators • Description of targeted behaviors • Specific treatment goals to address targeted behaviors • Recommended hours of ABA services per week • Summary of progress/goals • Signature of BCBA, physician, or psychologist and date of signature 6.3 Periodic Reassessments and Treatment Plan Revisions To support approval of requests for continued ABA services, periodic reassessments and updates to the treatment plan are required. The periodic reassessments must include: • Data of reassessment • Updates to targeted behaviors • Updates to treatment goals • Narrative description of improvements • Updates regarding parent/guardian or other caregiver interventions to support treatment goals • Updates to recommended hours of ABA services per week • Documentation that the child continues to meet medical necessity criteria • Any referrals made for the child that support achieving the treatment goals (e.g. medical, social, education or other providers/programs) Applied Behavior Analysis Manual | January 2026 14 • Signature of BCBA, physician, or psychologist and date of signature 6.4 Billing Documentation Records must support the time spent rendering a service and must thoroughly document the extent of the services rendered and billed. To bill USVI Medicaid for ABA services, billing documentation must include: • Member’s name and date of birth • Date of service • Start and stop time of time spent with member (to support time-based billing) • Name and title of the provider rendering the service • Description of treatment or service provided • Recommendations for additional treatment or services • Treatment plan outcome • Signature and date of the person rendering the service • Sufficient detail to demonstrate only one provider’s time is billed for any specific activity provided to the member • Description of the place of service for services rendered • Signature and date of the person rendering the service 6.5 USVI Medicaid Record Reviews USVI Medicaid may review records and documentation to ensure ABA service payments are made in accordance with this policy. Should USVI Medicaid request records, the provider must: • Present all requested records to the reviewers completing the review. • Provide copies of Medicaid members’ records within one business day of the request. • Facilitate access to the requested records, including any equipment that may be needed for access. • Identify a point of contact for the review process. Applied Behavior Analysis Manual | January 2026 15 7.0 Billing Procedures Providers must submit claims for ABA services using the appropriate procedure codes. See Section 4 ABA Services for a list of allowable codes. Providers of ABA services must enroll with USVI Medicaid and may bill independently or under a group practice. The provider rendering the service may not bill under another provider type. Claims may be submitted on the DHS designated form or electronically transmitted to the DHS fiscal agent and must include all information required by DHS to process the claim for the timely filing of a payment. Medicaid will reimburse according to its established fee schedule for ABA services provided. Applied Behavior Analysis Manual | January 2026 16 8.0 Glossary Table 1 lists the acronyms that appear throughout this policy chapter. Table 1: Acronym Glossary Acronym Description ABA Applied Behavioral Analysis ASD Autism Spectrum Disorder BCAT Board Certified Autism Technician BCaSA Board Certified Assistant Behavior Analyst BCBA Board Certified Behavior Analyst CMS Centers for Medicare & Medicaid Services DHS Department of Human Services DSM Diagnostic and Statistical Manual EPSDT Early and Periodic Screening, Diagnostic, and Treatment ICD International Classification of Diseases IEP Individualized Education Plan LBSW Licensed Bachelor Social Worker LCSW Licensed Certified Social Worker LCISW Licensed Certified Independent Social Worker LPC Licensed Professional Counselor LMFT Licensed Marriage and Family Therapist LSAC Licensed Substance Abuse Counselor RBT Registered Behavior Technician PA Prior Authorization SSA Social Security Act USVI United States Virgin Islands Applied Behavior Analysis Manual | January 2026 17 Revision History The revision history identifies the document version number, date, changes made to the document, and a brief description of revisions applied. Table 1: Revision History/Change Log Document Version # Date Revisions Applied 1.0 TBD Initial Publication *Disclaimer: This chapter does not address all the complexities of Medicaid policies and procedures and must be supplemented with all Federal and Territory Laws and Regulations