(1) For a member to qualify for initial ABA services, the member must meet the functional impairment criteria and one of the following: 

(a) have a provisional qualifying diagnosis of ASD and be under 21 years of age;

(b) be DD eligible and under 21 years of age; or

(c) have a provisional qualifying diagnosis of SED and be either:

(i) 17 years of age or younger; or

(ii) up to 20 years of age and enrolled in an accredited secondary school.

(2) A physician, licensed mental health professional, nurse practitioner, or psychologist must deem ABA services medically necessary to alleviate the symptoms of the stated provisional qualifying diagnosis and must document the medical necessity of the service in the form of a prescription. The prescription must state the diagnosis for which the member is being referred and that the referral is for ABA services.

(3) The BCBA must complete, and submit to the department, the ABA Services Intent to Initiate Treatment form.