Insurance & coverage

How prior authorization works

Prior authorization (PA or "prior auth") means your insurance company must approve a service before it will pay for it. For autism-related therapy, most insurers require prior auth for ABA — and sometimes for OT and speech therapy as well. The insurer reviews the request and approves or denies coverage, typically within a few business days for standard requests.

What triggers prior auth: ABA therapy almost always requires it. OT and speech may require it depending on your plan. Your pediatrician or therapist will initiate the request with the insurer, but you can call your insurer first to understand what's required before the first appointment.

What you need: the autism diagnosis report, the provider's treatment plan with recommended hours, and the provider's NPI (National Provider Identifier) number. Your insurer may also require a specific prior auth form.

How long approvals last: typically 6 months to 1 year before requiring renewal. Set a calendar reminder — a lapse in authorization means the insurer won't pay for services during the gap.

When coverage is denied

Denial is not final. Insurers are required to give you a specific denial reason in writing. Common reasons: "not medically necessary," "experimental," or "out of network." Each has a response.

1. Request the denial reason in writing — insurers are legally required to provide it.
2. Ask your provider for a letter of medical necessity addressing the specific denial reason.
3. File a written appeal within 30 days — most state laws require this window. Your insurer must tell you the deadline.
4. Request external review if the internal appeal is denied — a third-party independent organization reviews the decision. Most states mandate external review rights for fully insured plans.
5. Contact your state's insurance commissioner if you believe the denial violates your state's ABA mandate.

Keep copies of everything: the original authorization request, the denial letter, your appeal, and all correspondence. Federal and state law protects your right to appeal.

State insurance mandates

As of 2026, all 50 states plus Washington D.C. have enacted ABA insurance mandate laws. However, mandates vary significantly in what they cover: some cap hours per year, some have age limits, and some exempt certain plan types.

Self-funded employer plans — where your employer directly pays claims rather than buying coverage from an insurer — are generally exempt from state mandates under federal ERISA law. Check your plan documents: if it says "self-funded" or "self-insured," your state's ABA mandate may not apply.

ACA marketplace plans are subject to state mandates. Medicaid covers ABA in most states as a required service.

Look up your state's specific mandate using the Autism Speaks insurance coverage guide — it lists each state's law, coverage requirements, and any age or hour caps.

Working with providers on insurance

Finding in-network providers: call your insurer's member services line and ask for their autism provider directory. Ask specifically for BCBAs (for ABA), licensed speech-language pathologists, and occupational therapists. Being in-network reduces your out-of-pocket cost and simplifies prior auth.

NPI numbers: every licensed provider has a National Provider Identifier. Your insurer will ask for this during prior auth. Ask any potential provider for their NPI before they submit an auth request.

If your preferred provider is out-of-network: ask your insurer about out-of-network benefits and whether you can request an in-network exception (sometimes called a "single case agreement"). Providers will often negotiate these directly with insurers if no in-network equivalent exists within a reasonable distance.

Prior auth renewals: build a system for tracking renewal dates. When a renewal is submitted, confirm receipt in writing. Gaps in authorization are a common source of claim denials — the therapy happened, but the insurer won't pay because the prior auth had expired.