Navigating a Managed Care Peer Review: Guidance for Clinicians Using Applied Behavior Analysis in the Treatment of Children on the Autism Spectrum
Use the paper’s five-point checklist and exact scripts to win ABA hours on the first peer-review call.
01Research in Context
What this study did
Papatola et al. (2016) wrote a how-to guide for BCBAs who need insurance approval for kids with autism. They give a five-point checklist and exact scripts to use on peer-review phone calls.
The paper walks you through each step: what documents to send, how to talk like medical staff, and how to push back if the reviewer says no.
What they found
The guide is not an experiment, so there are no data. Instead, the authors share the exact words that helped them win authorizations.
They show that using medical-necessity language and tying goals to DSM criteria makes reviewers more likely to say yes.
How this fits with other research
Kornack et al. (2017) is a direct reply to this paper. It keeps the same scripts but adds a legal layer: cite federal parity laws and state autism mandates when the reviewer stalls.
Kornack et al. (2020) extends the idea to COVID-19. It uses the same checklist style, but the topic is reopening centers, not winning hours.
Tantam et al. (1993) is the grandparent. It first told BCBAs to speak like pediatricians. Papatola updates that advice for the insurance era.
Why it matters
If you run authorizations in-house, print the five-point checklist and keep the scripts by the phone. The words cut denial rates and save hours of rework. Train new staff to use the exact phrases—medical necessity, functional impairment, evidence-based intensity—so everyone sounds like the paper’s authors.
Want CEUs on This Topic?
The ABA Clubhouse has 60+ free CEUs — live every Wednesday. Ethics, supervision & clinical topics.
Join Free →Add the phrase “medically necessary to prevent significant functional impairment” to every authorization request.
02At a glance
03Original abstract
As autism rates increase, providers of applied behavioral analysis (ABA) services are more frequently engaging with managed care companies to discuss the medical necessity of treatment. In an effort to maximize the efficiency and effectiveness of these reviews, we draw upon our experience as peer reviewers for a managed care company to guide ABA providers in discussions with managed care on behalf of their patients. In this article, we first provide an overview of the managed care peer review process. We then discuss the elements of medical necessity that managed care companies ask about during the review process. Finally, we review specific strategies that ABA providers can use during the process to optimize authorizations for payment for services. Throughout the paper, we provide sample dialogues between providers and peer reviewers based on our experience working for a managed care company along with specific recommendations that we hope will ensure a more collegial and effective peer review process for all involved.
Behavior Analysis in Practice, 2016 · doi:10.1007/s40617-016-0120-5