At Blue Cross Blue Shield of Michigan, our priority is ensuring members receive high-quality, evidence-based behavioral health care that aligns with clinical and regulatory standards.
Through clinical audits, we have identified instances where services billed did not align with the medical record documentation and/or the services that were authorized. Examples include billing for non-therapy time or for recreational or academic activities that may not be allowable under the benefit.
These findings are the primary reason for reinforcing documentation and billing expectations for Applied Behavior Analysis (ABA) therapy. Providers are expected to follow established documentation guidelines to ensure all services billed are accurate, fully supported and consistent with authorized care.
What audits review
Audits are a standard oversight activity conducted across all provider types, including behavioral health. These reviews verify that services billed were provided, that the services were medically necessary and that the procedure codes used accurately reflect the care delivered. When documentation does not support the services billed or the authorized treatment, overpayments may be identified and recovered in accordance with contractual and regulatory requirements.
What session notes must include
To support billed services, session documentation must clearly support the procedure codes billed, support the number of units reported for ABA services, include valid signatures from the providers who delivered the services and fully disclose what was provided. Documentation should describe the extent of services delivered, including the specific ABA techniques used and the duration of the services. This level of detail is essential to confirm that billed services match both the care delivered and the authorized treatment plan.
Additional requirements that support appropriate care
In addition to documentation standards, providers must ensure that ABA services are delivered by staff with appropriate credentials, that members receive the required diagnostic evaluation before beginning treatment and that appropriate referrals for ABA services are on file. These requirements help ensure care is clinically appropriate, authorized and delivered by qualified professionals.
How accurate documentation helps avoid delays and denials
Incomplete or inconsistent documentation can lead to claim denials, payment delays or compliance issues that may disrupt care. To avoid these outcomes, providers are encouraged to carefully review documentation and coding before submitting claims. This includes confirming that CPT and HCPCS codes, modifiers, and time-based elements accurately reflect the services provided.
Our shared responsibility
Members are best served when behavioral health care is delivered, documented and billed in a way that is accurate, transparent and consistent with clinical and regulatory standards.
Blue Cross Blue Shield of Michigan appreciates the partnership required to uphold these standards and remains committed to working collaboratively to ensure members continue to receive appropriate, high-quality behavioral health services.
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