Autism Spectrum Disorder – Clarification with June 2022 Provider Notice
Posted on October 28, 2022
In the June 2022 Provider Update, we informed our network of some changes to the language within the Commercial Fully Funded Explanation of Coverage (EOC) documents as it relates to what is not covered with Autism Spectrum Disorder. However, without the full description from the EOC, the update may have caused some questions and concerns.
With that stated, Health New England covers medically necessary services that also meets Health New England’s clinical criteria for the diagnosis and treatment of Autism Spectrum Disorder (ASD) as defined by the most recent edition of the Diagnostic and Statistical Manual of Mental Health Disorders. This includes autistic disorder, Asperger’s disorder, and pervasive developmental disorders not otherwise specified. However, what is not covered are services related to ASD whether provided by school personnel or by third party contractors or vendors at the direction of school personnel under an individualized education program (IEP), unless such services are medically necessary and meet Health New England’s clinical criteria for such service.
To learn more, please refer to the Member’s benefit plans at healthnewengland.org/plans or by calling our Member Services Department at (800) 842-4464. You may also call your Provider Relations Representative at (800) 842-4464, ext. 5000, or send an email to providerrelations@hne.com.
