OHCA Policies and Rules
317:30-5-312. Treatment plan components and documentation requirements
[Revised 10-25-24]
(a) Treatment plan. The treatment plan is developed by a BCBA or a licensed psychologist from the clinical assessment, and if applicable, the Functional Behavior Assessment (FBA). The treatment plan shall:
(1) Be person-centered and individualized;
(2) Delineate the baseline levels of target behaviors;
(3) Specify long-term and short-term objectives that are defined in observable, measurable behavioral terms;
(4) Specify criteria that will be used to determine achievement of objectives;
(5) Clearly relate to the identified maladaptive behavior and/or should include functional goals and those related to core deficits of ASD as defined by the DSM, both important to and relevant to the child/youth, family, and directly related to the core deficits of ASD as defined by the DSM.
(6) Include specific functional goals to the child/youth, objectively measurable within a specific time frame, attainable in relation to the child/youth prognosis and developmental level.
(7) Include an operational, behavior definition of the target behavior excesses and deficits, prevention and intervention strategies, schedules of reinforcement, and functional alternative responses to the identified function of the target behavior in the BSP.
(8) Include goals that match the setting for services and include a specific titration plan to fade services over time.
(9) Clearly identify the schedule of services planned and the individuals responsible for delivering the services, including frequent review of data on target behaviors and adjustments in the treatment plan and/or protocols by the BCBA or licensed psychologist as needed.
(10) Include training and supervision to enable board certified assistant behavior analysts (BCaBAs) and registered behavior technicians (RBTs) to implement assessment and treatment protocols, not to include the functional behavior assessment.
(11) Include date of training, techniques utilized, and supports used to enable parents and other caregivers to participate in treatment planning and successfully reinforce the established treatment plan in the home, clinic, community, and other settings.
(12) Include signatures of the BCBA and parent/legal guardian that reflect an actual date including month, day, and year to be considered valid.
(13) Contain the dates of the PA span for which the ABA services have been approved and include the specific date it was created in the treatment plan.
(14) Include care coordination involving the parents or caregiver(s), school, state disability programs, and others as applicable; and
(15) Ensure that services are consistent with applicable professional standards and guidelines relating to the practice of applied behavior analysis as well as state Medicaid laws and regulations.
(b) Assessments and treatment plans. Initial assessments allow ABA providers to develop a treatment plan that is unique to the member and include all treatment recommendations and goals.
(1) The clinical assessment serves as a critical component of the treatment plan and is conducted by a board-certified behavior analyst (BCBA) to identify the specific behavioral needs of the member. The clinical assessment may include validated measures such as the Vineland Adaptive Behavior Scales or other appropriate assessments that assist in identifying the child/youth’s current skill level, aid in development of the treatment plan, and support medical necessity for ABA services.
(2) The FBA related to specific behaviors of concern, to be addressed in a BSP, as clinically indicated. The FBA consists of:
(A) An operational definition of the problematic behavior (topography, onset/offset, cycle, intensity, and severity);
(B) History of the problematic behavior (long-term and recent);
(C) Antecedent analysis (setting, people, time of day, and events);
(D) Consequence analysis; and
(E) Impression and analysis of the function of the problematic behavior.
(3) Assessments must be completed by the BCBA.
(c) Documentation requirements. ABA providers must:
(1) Document all ABA services in the member's record. Refer to OAC 317:30-5-248;
(2) Retain the member's records necessary to disclose the extent of services. Refer to OAC 317:30-3-15; and
(3) Release the medical information necessary for payment of a claim upon request. Refer to OAC 317:30-3-16.
(4) All assessment and treatment services must include the following:
(A) Date;
(B) Start and stop time for each session/unit billed and physical location where service was provided;
(C) Signature of the provider(s) rendering services;
(D) Credentials of provider(s) rendering services;
(E) Specific problem(s), goals, and/or objectives addressed;
(F) Methods used to address problem(s), goals, and objectives;
(G) Progress made toward goals and objectives;
(H) Patient response to the session or intervention; and
(I) Any new problem(s), goals, and/or objectives identified during the session.
(J) Initial treatment plans or plan updates are not valid until all signatures are present. As used in this subsection, all signatures mean:
(i) The signature and date of acknowledgement of the supervising BCBA or licensed psychologist; and
(ii) The signature and date of consent of any minor who is age fourteen (14) or older; and
(iii) The signature of consent of:
(I) A parent or legal guardian of any minor; or
(II) If the minor documents a legal exception to parent or legal guardian consent, the excepted minor.
(iv) All signatures:
(I) Must clearly indicate that the signatories approve of and consent, assent, or acknowledge the treatment plan; and
(II) May be provided on a signature page applicable to both the assessment and the treatment plan, if the signed page clearly indicates approval of and consent, assent, or acknowledgment of both the assessment and the treatment plan.
(III) If member is age fourteen (14) or older and is unable to sign and date documentation, please document this in the record.
Disclaimer. The OHCA rules found on this Web site are unofficial. The official rules are published by the Oklahoma Secretary of State Office of Administrative Rules as Title 317 of the Oklahoma Administrative Code. To order an official copy of these rules, contact the Office of Administrative Rules at (405) 521-4911.
