Behavioral health treatment for Medi-Cal members under the age of 21
Blue Shield of California Promise Health Plan covers Behavioral Health Treatment (BHT), including Applied Behavior Analysis (ABA) therapy, for Medi-Cal beneficiaries under the age of 21. Blue Shield Promise manages this benefit directly.
Referrals for BHT or ABA treatment for a member should not be sent to the member's medical group or IPA. A primary care physician (PCP) or healthcare provider will follow the screening process below.
If a provider believes the member may have autism spectrum disorder (ASD), based on screening outcomes, the provider should submit a diagnostic evaluation referral for ASD to Blue Shield Promise. If a provider believes a member is likely to benefit from BHT or ABA services, the provider can submit a referral for treatment to Blue Shield Promise.
A diagnosis of autism spectrum disorder is not required for the member to be eligible for BHT or ABA treatment. Please refer to All Plan Letter (APL) 19-014 from Department of Health Care Services (DHCS) for more information.
Steps for referral and evaluation:
Step 1 - Screening
The PCP or healthcare provider completes Early Periodic Screening, Diagnosis, and Treatment (EPSDT), which should include a validated screening tool. The provider then makes a referral to Blue Shield Promise, as appropriate.
Step 2 - Diagnostic evaluation for autism spectrum disorder OR referral for BHT or ABA treatment
- If your screening leads you to believe that the member may have autism spectrum disorder, the Behavioral Health Treatment team at Blue Shield Promise will provide authorization for a diagnostic evaluation with a licensed clinical psychologist.
- If your screening leads you to believe the member is likely to benefit from behavioral health treatment such as ABA, please submit a referral form to the Behavioral Health Treatment team at Blue Shield Promise.
The questions and answers below will help guide you through helping the member to use this benefit.
How can a provider refer a patient for a diagnostic evaluation for autism or Behavioral Health Treatment such as ABA?
Providers should complete a valid screening using one of the suggested tools that indicates the member might need BHT or ABA services. Please review the Blue Shield Promise Referral Steps and Options reference guide to help you determine whether a referral is appropriate.
What happens after the diagnostic evaluation?
After the diagnostic evaluation, if the licensed psychologist will include a recommendation for BHT or ABA in the evaluation, the member's referral will be for a functional assessment to determine which level of treatment would be therapeutic, as described in APL 19-014.
Blue Shield Promise will then make the appropriate referral and provide authorization to obtain those services.
Where can I get more information?
You can call the Blue Shield Promise Behavioral Health Treatment Department:
Phone: (888) 297-1325, 8:30 a.m. to 5 p.m., Monday through Friday.
APL 19-014 (PDF, 75 KB)
Autism spectrum disorder screening tools
Blue Shield Promise Referral Steps and Options (PDF, 117 KB)
Service Authorization Request form (PDF, 206 KB)
Applied Behavioral Analysis Referral form (PDF, 105 KB)
Alcohol and drug screening and services
Learn about the alcohol and drug screening, assessment, brief interventions and referral to treatment (SABIRT) program for Medi-Cal members 11 years of age and older, including pregnant women.
Behavioral Health Services
Blue Shield Promise behavioral health services cover mental health, substance use disorder, and autism spectrum disorder behavioral health treatment.
Health education for Medi-Cal providers
Find information and health education materials for your Medi-Cal patients.
Health assessment guidelines for Medi-Cal providers
Learn how to conduct health assessments, find age-appropriate patient questionnaires and forms, and related provider training materials.
Access network provider tools on Provider Connection website.