QUALIFIED AUTISM PROVIDER CERTIFICATION
OUTPATIENT MENTAL HEALTH CLINIC
Wisconsin Statute 632.895(12m) provides coverage for the treatment of autism spectrum disorders (“ASD”) provided by an outpatient mental health clinic licensed under Wisconsin Administrative Code HFS 35 and that has at least one qualified psychiatrist, psychologist or licensed clinical social worker (“Qualified Provider”) on site. Wisconsin Administrative Code INS 3.36 sets forth the requirements in order for those Qualified Providers and other professionals to be qualified and they are as follows:
- Must be licensed or certified in WI
- Must have completed at least 2080 hours that includes all of the following:
- 1500 hours supervised training involving direct 1:1 work with individuals with ASD using evidenced-based, efficacious therapy models
- Have supervised experience with all of the following:
- Working with families as the primary treating provider and ensuring treatment compliance
- Treating individuals with ASD who function at a variety of cognitive levels and exhibit a variety of skill deficits and strengths.
- Treating individuals with ASD with a variety of behavioral challenges
- Treating individuals with ASD who have shown improvement to the average range in cognitive functioning, language ability, adaptive and social interaction skills
- Designing and implementing progressive treatment programs for individuals with ASD
- Academic coursework from a regionally accredited higher education institution with demonstrated coursework in the application of evidenced-based therapy models consistent with best practice and research on effectiveness for individuals with ASD.
In addition, if a Qualified Provider is going to supervise and bill for services performed by paraprofessionals and professionals, the Qualified Provider must have completed at least 4,160 post-degree hours of experience as a supervisor of less experienced providers, professionals and paraprofessionals.
By signing and returning this form to Anthem Blue Cross and Blue Shield, I hereby certify that the professionals employed by the outpatient mental health clinic meet the requirements set forth above. All Qualified Providers that will bill for services provided by the outpatient mental health clinic shall complete and return to Anthem the Qualified Autism Provider Certification for their specialty. I understand that Anthem may, in its discretion, review its claim history or request supporting information in order to verify the accuracy of this certification.
Signature: Name:
Date: Clinic Name:
NPI Number:Tax Id Number:
Email Address:Phone Number:
If the outpatient mental health clinic will supervise and bill for paraprofessionals, it must also submit a Qualified Autism Paraprofessional Certification.
- Please complete this form for each provider qualified to provide autism services
- Print and have each qualified provider sign the form
- Fax the signed form to 262-523-4783 or scan and attach it to your completed online Provider Maintenance Form.
The Qualified Autism Paraprofessional Certification Form can be found on our public provider website at. Choose Answers@Anthem, and then choose Provider Forms.
Anthem Blue Cross and Blue Shield is the trade name of Blue Cross Blue Shield of Wisconsin ("BCBSWi") whichunderwrites or administersthe PPO and indemnity policies; Compcare Health Services Insurance Corporation ("Compcare")which underwritesor administers the HMO policies; andCompcareand BCBSWicollectively which underwriteor administer thePOS policies.Independent licensees of the Blue Cross and Blue Shield Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross and Blue Shield names and symbols are registered marks of the Blue Cross and Blue Shield Association.
Revision Date December 2013