Purpose

Every claim ABAS submits is a representation that the service was delivered, documented, and coded correctly. This policy sets the standards for accurate coding and billing: services billed as rendered, correct service codes, accurate time and units, accurate rendering-provider information, and documentation completed before a claim is submitted. It exists so that ABAS is paid only for work it actually performed and so that billing errors are found and corrected, not repeated.

Scope

This policy applies to all ABAS employees whose work creates, supports, or becomes a claim. That includes BCBAs and Behavior Technicians who deliver and document services, the Billing & Recovery Specialist who prepares, submits, and reconciles claims, the Compliance Officer who audits coding and billing practices, and the Director of Operations and Executive Director in their oversight roles. It covers all services ABAS bills to any payer, regardless of service location.

Definitions

Policy Statement

5.1 Services Billed as Rendered

ABAS bills only for services that were actually delivered to the member and documented at the time of service. A claim must match what happened: the service, the date, the duration, and the person who delivered it. Employees must not create, modify, or sign documentation for the purpose of supporting a claim that does not reflect the service as it occurred.

5.2 Correct Coding

Each claim must use the service code that accurately describes the service delivered. ABA services are billed primarily under the adaptive behavior services CPT code family (97151 through 97158); some payers, including MassHealth, also use certain HCPCS Level II codes for ABA or related services. Code selection must follow the coding and billing requirements of the payer billed, including the code set, rate, and unit definitions it requires (for MassHealth, those set in 101 CMR 358.00), and the member's authorized treatment plan. Code selection is driven by what was delivered, never by which code pays more. When a coding question cannot be resolved from payer guidance, the Billing & Recovery Specialist holds the claim and escalates to the Compliance Officer.

5.3 Time and Unit Accuracy

Billed units must be calculated from the documented start and end times of the service, using the payer's unit definitions and rounding rules. Employees must not bill for travel, documentation time, cancellations, or any other non-billable time unless the payer expressly allows it. Documented session times must reflect actual face-to-face or otherwise billable service time.

5.4 Rendering Provider and Supervision Accuracy

Every claim must correctly identify the rendering provider. Services delivered by a Behavior Technician must be billed as technician-delivered services, and services requiring BCBA delivery or supervision must be billed only when the BCBA actually delivered or supervised the service as the payer requires. Employees must not misrepresent credentials, bill one person's work under another person's identity, or share signatures or login credentials.

5.5 Documentation Before Billing

No claim may be submitted until the supporting documentation is complete and signed, including any required BCBA review or cosignature. The Billing & Recovery Specialist holds any claim that lacks complete supporting documentation until the documentation is completed through a dated and attributed entry. Missing documentation is corrected by the person who delivered the service, never by billing employees. If documentation is not completed within the timeframe ABAS sets for timely, accurate claim submission, the Billing & Recovery Specialist notifies the Compliance Officer, who follows up with the responsible provider and the supervising BCBA.

5.6 Prohibited Practices

The following are prohibited. This list is illustrative, not exhaustive:

1. Upcoding, or billing at a higher level, intensity, or duration than was delivered and documented.
2. Unbundling services to increase total payment.
3. Billing for missed or cancelled sessions as if they were delivered.
4. Submitting duplicate claims for the same service.
5. Misrepresenting the rendering provider, the provider's credentials, or the supervision provided.
6. Altering, backdating, or fabricating documentation to support a claim.

5.7 Billing Errors and Overpayments

Routine billing reconciliation, including denials, underpayments, and ordinary claim corrections, is handled by the Billing & Recovery Specialist through the payer's correction process. An overpayment is different: it is money ABAS is not entitled to keep, and once identified it must be reported and returned within the 60-day federal deadline (42 U.S.C. § 1320a-7k(d)), whatever its cause. Employees who identify a suspected overpayment must report it promptly to the Compliance Officer, who oversees its investigation, documentation, and return as required by POL-004 (Fraud, Waste, and Abuse Prevention), Section 5.5, and POL-006 (False Claims Acts), Section 5.4. Suspected intentional misconduct, such as overbilling or billing for services not rendered, is reported and handled under POL-003 (Compliance Reporting, Investigation, and Resolution).

Procedures

Responsibilities

Steps

1. The rendering provider documents the session at the time of service, capturing the documentation fields listed in the Responsibilities table above (member, date, start and end times, service delivered, and signature), and completes any correction through a dated and attributed entry.
2. The BCBA completes any required review or cosignature and confirms the service is consistent with the authorized treatment plan.
3. The Billing & Recovery Specialist confirms documentation is complete and signed before preparing the claim. Claims without complete documentation are held and the responsible provider is notified.
4. The Billing & Recovery Specialist assigns the service code and units directly from the documentation, following the coding and unit rules of the payer billed (for MassHealth, per 101 CMR 358.00), and submits the claim.
5. The Billing & Recovery Specialist reconciles payer remittances against submitted claims and investigates denials, underpayments, and overpayments.
6. Routine errors, denials, and underpayments are corrected through the payer's correction process by the Billing & Recovery Specialist. A suspected overpayment goes to the Compliance Officer, who oversees its return within the 60-day deadline under POL-004 and POL-006. Suspected intentional misconduct is reported under POL-003.
7. The Compliance Officer audits a sample of claims against documentation on the schedule set in the annual compliance work plan and reports results to the Compliance Committee.

Training Requirements

All ABAS employees who deliver, document, or bill services must complete training on this policy during onboarding and at least annually thereafter. Clinical employees training covers documentation standards, session time recording, and the documentation-before-billing rule. The Billing & Recovery Specialist must complete role-specific training on the coding, unit, and claim correction requirements of the payers ABAS bills (including MassHealth), refreshed when payer requirements change. The Compliance Officer tracks completion and reports completion rates to the Compliance Committee.

Reporting and Enforcement

Employees who become aware of a potential violation of this policy, including a billing error that has not been corrected, must report it through the channels described in POL-003 (Compliance Reporting, Investigation, and Resolution), including the anonymous web form and the compliance ticketing system. Reports are investigated under POL-003 and its Compliance Ticket Management SOP. A confirmed violation may result in corrective action up to and including termination, repayment of improperly received funds, and referral to the relevant payer or program, or other authorities, where required by law. ABAS will not retaliate against any person who reports a concern in good faith.