• Please note that due to claims lag & the bi-annual reconciliation process that the $ amount of paid claims may change over time.

This measure is important because it demonstrates claims trends over time and gives the Department of Vermont Health Access (DVHA) the ability to detect potential areas of concern that directly impact payment for ABA treatment services.

The DVHA Clinical Integrity Unit in collaboration with the DVHA Payment Reform and Policy Units monitors claims data quarterly and reviews results with providers (as needed) to ensure that utilization and payments are closely aligned.  After the end of the performance year, Vermont Medicaid performs an annual reconciliation to identify the differences between payments delivered and services rendered at the member level.

The data indicates that since the implementation of the benefit there has been an increase in the dollar amount of paid claims for ABA services each fiscal year.  The rise in trendline is a good indicator of not only successfully paid treatment services but also an increase in overall treatment.  Beginning 07/01/21, the tiered case rate payment methodology shifted from a prospective model to a retroactive model after claims data was reviewed and showed discrepancies between projected and provided services. This change in methodology has allowed providers to be more accurate in submitting claims for services that have already been provided therefore, more accurately reflecting the dollar amount of paid claims of ABA services.  It is important to note that many providers will continue to actively work SFY24 claims in the 2025 calendar year, which will impact the total SFY24 claims $ amount.

Last updated:  08/01/24

• DVHA Payment Reform Unit
• DVHA Policy Unit
• Gainwell Technology Team