ABA Weekly Billing – Advocate Insurance Billing

Clinic Name*

Patient First Name*

Patient Last Name*

Phone*

Do not edit. Pre-filled for your convenience.

Email*

Do not edit. Pre-filled for your convenience.

Type of Insurance*

Supervising BCBA for this patient?

Supervising BCBA for this patient.

Date of Care*

Care Received*

Please select ALL the codes this patient received on this date.

97151 - Units Received

1 Unit = 15 minutes

Who Performed 97151?

Please list first and last name of provider AND the number of units each provider performed.

Who Performed 97152?

Please list first and last name of provider AND the number of units each provider performed.

97152 - Units Received

1 Unit = 15 minutes

Who Performed 97153?

Please list first and last name of provider.

97153 - Units Received

1 Unit = 15 minutes

97153 - Adjusted Units to Bill

Who Performed 97155 Supervision?

Please list first and last name of provider.

97155 Supervision - Units Received

1 Unit = 15 minutes

Who Performed 97155 Solo?

Please list first and last name of provider AND the number of units each provider performed.

97155 Solo - Units Received

1 Unit = 15 minutes

Who Performed 97156 Family ABT Guidance?

Please list first and last name of provider AND the number of units each provider performed.

97156 Family ABT Guidance - Units Received

1 Unit = 15 minutes

Who Performed 97156 AM Team Meeting?

Please list first and last name of provider AND the number of units each provider performed.

97156 AM Team Meeting - Units Received

1 Unit = 15 minutes

Who Performed 97154?

Please list first and last name of provider AND the number of units each provider performed.

97154 - Units Received

1 Unit = 15 minutes

Who Performed 97158?

Please list first and last name of provider AND the number of units each provider performed.

97158 - Units Received

1 Unit = 15 minutes

Who Performed 0373T?

Please list first and last name of provider AND the number of units each provider performed.

0373T - Units Received

1 Unit = 15 minutes

Is there another date of service for this patient?

Yes
No

Date of Care*

Care Received

Please select ALL the codes this patient received on this date.

Who Performed 97151?

Please list first and last name of provider AND the number of units each provider performed.

97151 - Units Received

1 Unit = 15 minutes

Who Performed 97152?

Please list first and last name of provider AND the number of units each provider performed.

97152 - Units Received

1 Unit = 15 minutes

Who Performed 97153?

Please list first and last name of provider.

97153 - Units Received

1 Unit = 15 minutes

97153 - Adjusted Units to Bill

Who Performed 97155 Supervison?

Please list first and last name of provider.

97155 Supervision - Units Received

1 Unit = 15 minutes

Who Performed 97155 Solo?

Please list first and last name of provider AND the number of units each provider performed.

97155 Solo - Units Received

1 Unit = 15 minutes

Who Performed 97156 Family ABT Guidance?

Please list first and last name of provider AND the number of units each provider performed.

97156 Family ABT Guidance - Units Received

1 Unit = 15 minutes

Who Performed 97156 AM Team Meeting?

Please list first and last name of provider AND the number of units each provider performed.

97156 AM - Team Meeting - Units Received

1 Unit = 15 minutes

Who Performed 97154?

Please list first and last name of provider AND the number of units each provider performed.

97154 - Group ABT by Protocol

1 Unit = 15 minutes

Who Performed 97158?

Please list first and last name of provider AND the number of units each provider performed.

97158 - Group ABT with Protocol Modification-Social Skills Group

1 Unit = 15 minutes

Who Performed 0373T?

Please list first and last name of provider AND the number of units each provider performed.

0373T - Units Received

1 Unit = 15 minutes

Is there another date of service for this patient?

Yes
No

Date of Care*

Care Received

Please select ALL the codes this patient received on this date.

Who Performed 97151?

Please list first and last name of provider AND the number of units each provider performed.

97151 - Units Received

1 Unit = 15 minutes

Who Performed 97152?

Please list first and last name of provider AND the number of units each provider performed.

97152 - Units Received

1 Unit = 15 minutes

Who Performed 97153?

Please list first and last name of provider.

97153 - Units Received

1 Unit = 15 minutes

97153 - Adjusted Units to Bill

Who Performed 97155 Supervision?

Please list first and last name of provider.

97155 Supervision - Units Received

1 Unit = 15 minutes

Who Performed 97155 Solo?

Please list first and last name of provider AND the number of units each provider performed.

97155 Solo - Units Received

1 Unit = 15 minutes

Who Performed 97156 Family ABT Guidance?

Please list first and last name of provider AND the number of units each provider performed.

97156 Family ABT Guidance - Units Received

1 Unit = 15 minutes

Who Performed 97156 AM - Team Meeting?

Please list first and last name of provider AND the number of units each provider performed.

97156 AM - Team Meeting - Units Received

1 Unit = 15 minutes

Who Performed 97154?

Please list first and last name of provider AND the number of units each provider performed.

97154 - Group ABT by Protocol

1 Unit = 15 minutes

Who Performed 97158?

Please list first and last name of provider AND the number of units each provider performed.

97158 - Group ABT with Protocol Modification-Social Skills Group

1 Unit = 15 minutes

Who Performed 0373T?

Please list first and last name of provider AND the number of units each provider performed.

0373T - Units Received

1 Unit = 15 minutes

Is there another date of service for this patient?

Yes
No

Date of Care*

Care Received

Please select ALL the codes this patient received on this date.

Who Performed 97151?

Please list first and last name of provider AND the number of units each provider performed.

97151 - Units Received

1 Unit = 15 minutes

Who Performed 97152?

Please list first and last name of provider AND the number of units each provider performed.

97152 - Units Received

1 Unit = 15 minutes

Who Performed 97153?

Please list first and last name of provider.

97153 - Units Received

1 Unit = 15 minutes

97153 - Adjusted Units to Bill

Who Performed 97155 Supervision?

Please list first and last name of provider.

97155 Supervision - Units Received

1 Unit = 15 minutes

Who Performed 97155 Solo?

Please list first and last name of provider AND the number of units each provider performed.

97155 Solo - Units Received

1 Unit = 15 minutes

Who Performed 97156 Family ABT Guidance?

Please list first and last name of provider AND the number of units each provider performed.

97156 Family ABT Guidance - Units Received

1 Unit = 15 minutes

Who Performed 97156 AM Team Meeting?

Please list first and last name of provider AND the number of units each provider performed.

97156 AM - Team Meeting - Units Received

1 Unit = 15 minutes

Who Performed 97154?

Please list first and last name of provider AND the number of units each provider performed.

97154 - Group ABT by Protocol

1 Unit = 15 minutes

Who Performed 97158?

Please list first and last name of provider AND the number of units each provider performed.

97158 - Group ABT with Protocol Modification-Social Skills Group

1 Unit = 15 minutes

Who Performed 0373T?

Please list first and last name of provider AND the number of units each provider performed.

0373T - Units Received

1 Unit = 15 minutes

Is there another date of service for this patient?

Yes
No

Date of Care*

Care Received

Please select ALL the codes this patient received on this date.

Who Performed 97151?

Please list first and last name of provider AND the number of units each provider performed.

97151 - Units Received

1 Unit = 15 minutes

Who Performed 97152?

Please list first and last name of provider AND the number of units each provider performed.

97152 - Units Received

1 Unit = 15 minutes

Who Performed 97153?

Please list first and last name of provider.

97153 - Units Received

1 Unit = 15 minutes

97153 - Adjusted Units to Bill

Who Performed 97155 Supervision?

Please list first and last name of provider.

97155 Supervision- Units Received

1 Unit = 15 minutes

Who Performed 97155 Solo?

Please list first and last name of provider AND the number of units each provider performed.

97155 Solo- Units Received

1 Unit = 15 minutes

Who Performed 97156 Family ABT Guidance?

Please list first and last name of provider AND the number of units each provider performed.

97156 Family ABT Guidance - Units Received

1 Unit = 15 minutes

Who Performed 97156 AM Team Meeting?

Please list first and last name of provider AND the number of units each provider performed.

97156 AM - Team Meeting - Units Received

1 Unit = 15 minutes

Who Performed 97154?

Please list first and last name of provider AND the number of units each provider performed.

97154 - Group ABT by Protocol

1 Unit = 15 minutes

Who Performed 97158?

Please list first and last name of provider AND the number of units each provider performed.

97158 - Group ABT with Protocol Modification-Social Skills Group

1 Unit = 15 minutes

Who Performed 0373T?

Please list first and last name of provider AND the number of units each provider performed.

0373T - Units Received

1 Unit = 15 minutes

Is there another date of service for this patient?

Yes
No

Date of Care*

Care Received

Please select ALL the codes this patient received on this date.

Who Performed 97151?

Please list first and last name of provider AND the number of units each provider performed.

97151 - Units Received

1 Unit = 15 minutes

Who Performed 97152?

Please list first and last name of provider AND the number of units each provider performed.

97152 - Units Received

1 Unit = 15 minutes

Who Performed 97153?

Please list first and last name of provider.

97153 - Units Received

1 Unit = 15 minutes

97153 - Adjusted Units to Bill

Who Performed 97155 Supervision?

Please list first and last name of provider.

97155 Supervision- Units Received

1 Unit = 15 minutes

Who Performed 97155 Solo?

Please list first and last name of provider AND the number of units each provider performed.

97155 Solo- Units Received

1 Unit = 15 minutes

Who Performed 97156 Family ABT Guidance?

Please list first and last name of provider AND the number of units each provider performed.

97156 Family ABT Guidance - Units Received

1 Unit = 15 minutes

Who Performed 97156 AM Team Meeting?

Please list first and last name of provider AND the number of units each provider performed.

97156 AM - Team Meeting - Units Received

1 Unit = 15 minutes

Who Performed 97154?

Please list first and last name of provider AND the number of units each provider performed.

97154 - Group ABT by Protocol

1 Unit = 15 minutes

Who Performed 97158?

Please list first and last name of provider AND the number of units each provider performed.

97158 - Group ABT with Protocol Modification-Social Skills Group

1 Unit = 15 minutes

Who Performed 0373T?

Please list first and last name of provider AND the number of units each provider performed.

0373T - Units Received

1 Unit = 15 minutes

Were these charges performed via telehealth?*

Yes
No
Other?

If other, please explain.

Notes

Any additional comments?