Autism Diagnosis for ABA Therapy

The first step to beginning ABA Therapy services at PediaPlex is present the written evaluation report from an evaluation with an official diagnosis of autism. All insurance plans, as well as PediaPlex, require a medical diagnosis of autism spectrum disorder (ASD) before authorizing ABA therapy services. An autism evaluation should be administered by a licensed psychologist, a child psychiatrist, or a developmental pediatrician. When starting services at PediaPlex, our intake coordinator will be able to assist you in determining if your child has an official diagnosis that will work for insurance purposes. A school-based diagnosis will not qualify for insurance-covered ABA services.

Defining an Official Diagnosis

To start ABA therapy services your child will need a medical diagnosis of autism. This requires you to  have your child assessed by a qualified health care provider and obtain a full written report assigning the diagnosis of autism and a referral for ABA therapy services. A medical assessment for autism is typically conducted by a psychologist or a developmental pediatrician. They will perform an assessment of symptoms and diagnostic tests and then provide a diagnosis based off of the Diagnostic and Statistical Manual of Mental Disorders – 5 (DSM-5).  One of the specific tests that we highly recommend you ask for is the ADOS-2 (Autism Diagnostic Observation Schedule, 2nd edition). This is the most common test for making a formal diagnosis of autism that will help to accurately assess and diagnose ASD across age, developmental level, and language skills

When we are verifying your diagnosis for insurance purposes, we look for a few major items: whether an ADOS-2 was performed, an official report explaining the tests done, what was found, why the child meets the criteria for an autism diagnosis, and who has performed and signed off on the provided report. If the report submitted at the time of intake does not meet the requirements for insurance, our intake coordinator will be glad to assist you in receiving the proper reports.

Differences in Diagnostic Evaluations

When receiving an evaluation for an autism diagnosis it’s important to get the proper evaluation completed. Between psychologists, neurologists, school psychologists, and developmental pediatricians there are multiple ways to go about getting an evaluation. It’s important to note that not all diagnoses are the same and depending on the professional performing it, it may or may not be a proper diagnosis for insurance standards or the services you are looking to receive.

A medical assessment for autism is typically conducted by a psychologist or a developmental pediatrician. They will perform an assessment of symptoms and diagnostic tests and then give a diagnosis. Based on the DSM-5, an individual needs to have “persistent deficits” in 3 out of 3 areas of social communication and social interaction and at least 2 of 4 restricted or repetitive patterns of behavior, interests, or activities. To meet the diagnostic criteria, these symptoms need to cause a clinically significant impairment in social, occupational, or other important areas of functions. Developmental history is also considered when giving a diagnosis. A medical diagnosis of autism is required for private clinic-based ABA therapy, such as at PediaPlex, as well as for insurance purposes. 

A school-based assessment is typically completed by a multidisciplinary team of professionals at the school and is used to determine educational eligibility for services. The educational eligibility is based on the state requirements, which can vary in every state. Generally speaking, a child has to have differences in verbal communication, nonverbal communication, and social interaction, with other repetitive or sensory based characteristics. For a child to qualify for educational eligibility they must meet the specific state requirements and demonstrate an educational need for services. Just because a child might meet all of the characteristics, they must still demonstrate a need for services to meet eligibility. This assessment is only used within the school district to determine if the child is eligible for special education services.

Additional Information

It’s important to note that an old diagnostic evaluation might not qualify your child for services and you may have to have a new autism evaluation performed. Insurance will often look at when the evaluation was performed and determine if they need a new report. This is common after two years or more, so it’s important we contact your insurance to determine if we need an updated autism evaluation performed.

We know that this is a lot of information which is why we have our intake and billing team on hand to answer questions and contact your insurance for you. Our goal at PediaPlex is to make starting therapy services as seamless as possible! Please contact us with any questions at (817) 442-0222.