ABA Weekly Billing

"*" indicates required fields

Clinic Name*

Practice Location*

Patient First Name*

Patient Last Name*

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Phone*

Do not edit. Pre-filled for your convenience.

Hidden

Email*

Do not edit. Pre-filled for your convenience.

Type of Insurance*

Commercial

Medicaid

Commercial + Medicaid

Tricare East - Humana Military

Commercial - Allows Concurrent Billing (Optum-UHC, UMR, others)

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

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

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

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

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

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

Other?

If other, please explain.

Notes

Any additional comments?

97153 Total Units

This is the total 97153 units entered.

97155 Total Units

This is the total 97155 units entered (excluding Solo).

97153 Total Hours

Total Units x 15 ÷ 60

97155 Total Hours

Total Units x 15 ÷ 60

Name

This field is for validation purposes and should be left unchanged.