Unfortunately, insurance companies are getting more and more picky when it comes to Autism Services. To ensure you don’t run into any issues with getting approval for services, here are some key pieces of information / sections that should be present in every diagnostic report and re-evaluation report. If your report is missing any of these sections, bring it up with the provider ASAP so they can make any necessary edits/addendums before you receive a denial for services.
FROM YOU
1) Identifying Information
Ensure any/all reports have the basic info included, such as:
Child’s Name & Date of Birth
Age at Evaluation
Date(s) of Evaluation
Evaluator’s Name & Credentials
Reason for Referral
FROM YOU
2) Developmental & Medical History
Reports should contain a detailed review of your child’s development over time. Specifically look for:
Pregnancy & Birth History
Early Milestones
Language and Motor Development
Medical History
Feeding, Sleep, Toileting
Sensory Differences
School or Daycare History
Previous Evaluations
FROM PEOPLE WHO KNOW YOUR CHILD
3) Behavioral Concerns
The report should include concerns and observations shared by you, other parent/caregivers, teachers or daycare staff, and other providers or therapists. These real-life observations help the evaluator understand what your child is experiencing across different settings.
FROM THE EVALUATOR
4) Behavioral Observations (Provider)
The evaluation should include direct observation of your child, including how they communicate, interact with others, play or engage with activities, and respond to their environment.
FROM THE EVALUATOR
5) Autism-Specific Diagnostic Tools
This is an important section to check.
Many insurance plans require the evaluation to include a validated autism diagnostic assessment tool. ADOS-2 and CARS-2 are two commonly recognized tools, although exact requirements vary by insurance plan, state, age, and clinical situation.
FROM THE EVALUATOR
6) DSM-5-TR Criteria
The report should explain how the child’s history and observed behaviors support the diagnostic criteria (called DSM-5), not simply list out the diagnosis. Ensure this section clearly explains how your child meets each area of the criteria (with examples), therefore supporting the diagnosis.
FROM THE EVALUATOR
7) Diagnostic Impression
The report should clearly state the final diagnosis, along with specific support-level information (Level 1, 2 or 3).
FROM THE EVALUATOR
8) Recommendations & Next Steps
If your provider diagnoses Autism during the appointment, please ensure the report includes an official recommendation for ABA Therapy (and other therapies, if necessary). This will be helpful when seeking services!
FROM THE EVALUATOR OR PEDIATRICIAN
9) Referral for Services
Some insurance plans require a separate referral before ABA or other recommended services can begin.
If your insurance requires a referral from your child’s pediatrician or primary care provider rather than the provider who completed the diagnostic evaluation, call their office and ask if they can send you a referral for the recommended services.
Please Note: Your pediatrician may ask you to schedule a follow-up appointment to review the diagnostic evaluation and discuss your child’s new diagnosis before writing referrals for ABA or other recommended services.
We are here to make complicated services a little easier to navigate. Send us the questions you're running into—from ABA authorizations and insurance to Medicaid, IEPs, and planning for adulthood—and we'll continue breaking down the information you need. Send us an email at: [email protected]
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