---
title: AmeriHealth Caritas Ohio ABA coverage (Next Gen MCO).
url: "https://carelu.com/payers/amerihealth-caritas-ohio"
markdown_url: "https://carelu.com/payers/amerihealth-caritas-ohio.md"
state: OH (Ohio)
payer: AmeriHealth Caritas Ohio
kind: Medicaid managed care plan (MCO)
parent_program: Ohio Medicaid
description: "How AmeriHealth Caritas Ohio administers Medicaid ABA — state-rule-driven criteria, the NaviNet/Jiva authorization workflow, UM contacts, and what to verify directly in the portal."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# AmeriHealth Caritas Ohio ABA coverage (Next Gen MCO).

_Payer Guide · AmeriHealth Caritas (OH) · Last updated September 2026 · 2 primary sources_

> State-rule-driven UM; NaviNet/Jiva workflow — thinnest public ABA paper trail of the OH plans.

AmeriHealth Caritas Ohio — the newest of Ohio's Next Generation plans — publishes no distinct ABA clinical policy, so expect utilization management driven by the state rule (OAC 5160-34). Like its North Carolina sibling, the plan's site blocks automated access, which makes its portal the source of truth: this guide covers the verified structure and flags what to confirm directly.

This plan administers the **Ohio Medicaid** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Ohio Medicaid guide](https://carelu.com/payers/ohio-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment:** Not published / unverified. Verify via: AmeriHealth Caritas Ohio's behavioral-health prior-authorization guidance, downloaded from NaviNet — the plan's public site blocks automated retrieval, and the state rule behind it (OAC 5160-34-02) is itself unreachable.
- **Prior auth for treatment:** Not published / unverified. Verify via: The decision clock is sourced (manual + OAC 5160-26-03.1); the Jiva/NaviNet channel, UM phone line and 6-month period still need AmeriHealth Caritas Ohio's behavioral-health prior-authorization guidance, via NaviNet or carelu.com/sources. [3][4]

## At a glance

- **Plan type:** Ohio Next Generation MCO (newest entrant)
- **Clinical rules:** State OAC 5160-34 framework — no distinct plan policy found
- **Prior auth:** Required before ABA begins; 6-month auth periods
- **UM contact:** (833) 735-7700
- **Portal:** Jiva via NaviNet
- **Decision time:** 7 calendar days standard / 48 hours expedited (OAC 5160-26-03.1); plan manual still prints 10 calendar days

## How AmeriHealth Caritas runs ABA authorization

The clinical baseline is the state rule: PA on ABA services, DSM-5-TR diagnosis via comprehensive evaluation, 6-month review cycles. Authorization requests flow through the Jiva UM system via NaviNet, with UM at (833) 735-7700 and a standard decision due “no later than seven calendar days following receipt of the request for service” under OAC 5160-26-03.1 (effective 1/1/2026) — the plan’s January 2026 manual still prints “no later than 10 calendar days,” so 7 is the binding outer limit and 48 hours applies to expedited requests. Approved intensities in the 10–40 hours/week range track clinical necessity per the state framework. Because the plan's public documents can't be pulled programmatically, download the current behavioral-health PA guidance from the portal and re-check it quarterly; the OhioRISE rule applies as everywhere — ABA bills to AmeriHealth Caritas, never to OhioRISE. [2][1][3][4]

## Intake gates

The questions that decide whether a family can start with AmeriHealth Caritas Ohio, and what they have to bring.

- **Who may diagnose**: Follows the Ohio Medicaid framework: the ASD diagnosis comes from a documented comprehensive diagnostic evaluation by a licensed physician, psychologist, or other clinician qualified to diagnose autism, demonstrating DSM-5-TR criteria. [2][1]
- **Referral required?**: No referral or service order requirement is published, and AmeriHealth Caritas Ohio publishes no distinct ABA clinical policy — expect utilization management driven by the OAC 5160-34 framework. Authorization requests flow through the Jiva UM system via NaviNet, with UM at (833) 735-7700; standard decisions are due “no later than seven calendar days following receipt of the request for service” under OAC 5160-26-03.1 (the plan’s January 2026 manual still prints 10 calendar days), and authorization periods run 6 months. Because the plan’s public documents cannot be pulled programmatically, download the current behavioral-health PA guidance from the portal and re-check it quarterly. [2][1][1][4][3]
- **Prior-auth decision time**: AmeriHealth Caritas Ohio’s January 2026 manual still prints the older standard clock: notice “no later than 10 calendar days after AmeriHealth Caritas Ohio receives the request,” extendable up to 14 calendar days. Expedited decisions: “no later than 48 hours after receipt of the request for service.” The manual points to OAC 5160-26-03.1, which has required 7 calendar days for standard decisions since 1/1/2026, so 7 days is the binding outer limit. No ABA reauthorization lead time is published. Ohio’s MCO rule sets the clock. For a standard request the MCO “must provide notice to the provider and member as expeditiously as the member’s health condition requires but no later than seven calendar days following receipt of the request for service,” extendable by up to fourteen calendar days (an MCO-requested extension needs ODM’s prior approval). An expedited decision is due “no later than forty-eight hours after receipt of the request for service” (OAC 5160-26-03.1, effective 1/1/2026). The 48 hours is stricter than the federal 72-hour managed-care cap. [4][3]
- **Other insurance (who pays first)**: AmeriHealth Caritas Ohio’s manual: “before billing AmeriHealth Caritas Ohio when there is a Primary Insurer, healthcare providers are required to bill the Primary Insurer first and obtain an Explanation of Benefits (EOB) statement.” Then bill the balance with the EOB attached, within 180 days of the date the other insurer paid. Pay-first exception: providers “are not required to bill the third party” first when “the claim is for preventive pediatric services (including EPSDT/Healthchek) that are covered by the Medicaid program.” The plan then recovers from the other payer. The manual does not say whether ABA qualifies, or whether its own authorization is needed when a commercial plan pays first. Ohio’s MCO rule: “The MCE is the payer of last resort when a member has third party resources available.” Providers must “take reasonable measures to obtain all third party payments and file claims with all TPPs prior to billing the MCE.” That means a remittance from the other payer showing a valid non-payment reason (service not covered, applied to the deductible or copay, benefit maximum reached), a partial payment with its remittance, or no response within ninety days of submitting to the other payer. The MCO pays at most its allowed amount minus the other payments, and must allow at least ninety days from the other payer’s remittance to file. Exception: “The MCE, except SPBM, pays first for preventive pediatric services before seeking reimbursement from any liable third party.” Children in the custody of a county children’s services agency are exempt from TPL cooperation (OAC 5160-26-09.1). [3][5]
  - Ask the plan: AmeriHealth Caritas Ohio Provider Services (1-833-644-6001): whether ABA claims fall under the EPSDT/Healthchek pay-first exception, and whether a plan authorization is required when a commercial plan pays first.
- **Telehealth** _(ask the plan)_: No plan-specific ABA telehealth rule found; ODM’s Telehealth Services guidance for managed care entities and the Telehealth Billing Guidelines set the underlying rules. [2][1]
  - Ask the plan: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.

## Delivery and billing rules

Coverage decides whether AmeriHealth Caritas Ohio pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Bill as provider**: Follows the Ohio Medicaid framework: independent practitioners are Certified Ohio Behavior Analysts (ORC Chapter 4783) or BACB BCBAs and BCBA-Ds enrolled with ODM as Provider Type 19, Specialty 190, with BCaBAs and RBTs delivering under supervision. The routing rule holds everywhere in Ohio: OhioRISE does not pay for ABA — ODM’s Mixed Services Protocol assigns ABA claims to the member’s MCO or fee-for-service even for OhioRISE-enrolled youth. [2][1]
- **Supervision** _(ask the plan)_: Follows the Ohio framework, which sets no fixed ratio: OAC 4783-6-02 requires the COBA to write a supervision plan into each client’s treatment plan, consult before plan initiation and modification, and observe directly on a periodic basis, with frequency left to documented clinical judgment and assessment, plan development and efficacy review non-delegable. No plan-specific numeric ratio was found for this MCO — note that other Ohio plans do publish one (Optum 1–2 hours per 10 direct hours weekly; Buckeye 97155 at 10–20% of direct hours). [2][1]
  - Ask the plan: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02. [2][1]
- **Place of service** _(ask the plan)_: No plan-specific place-of-service rule found. The confirmed Ohio boundary is the school one: the MCO is not responsible for payment of services provided through the Medicaid School Program under OAC Chapter 5160-35, 5160-35-04 and 5160-26-03. [2][1]
  - Ask the plan: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.

## What intake should collect for AmeriHealth Caritas Ohio

- **NaviNet/Jiva access:** The working authorization channel — confirm registration before the first case.
- **ASD diagnosis (DSM-5-TR):** Comprehensive evaluation per the state baseline.
- **Timeline expectations:** Standard decisions due within 7 calendar days of receipt (OAC 5160-26-03.1), 48 hours if expedited — communicate it to families up front.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How AmeriHealth Caritas Ohio ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 01548
- **Payer ID (Change Healthcare / Optum):** 842435374 — ODM FI MCE claims payer ID 842435374 (companion guide, verified); a distinct Change Healthcare CPID was not separately confirmed.
- **Supports 270/271 eligibility:** Yes
- **Real-time eligibility:** Yes
- **Behavioral health administrator:** none (state-rule-driven; BH administrator not named on the plan's BH PA page) — The plan's BH PA page confirms ABA needs PA but names no BH administrator — confirm in-house vs. delegated via the ACO provider manual.
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes — "Behavioral Analysis Therapy for Autism Spectrum Disorder" (AmeriHealth Caritas OH BH PA page); administered on the OAC 5160-34 state framework, no distinct plan ABA policy published | Required before ABA begins; 6-month authorization periods. Jiva UM via NaviNet; UM (833) 735-7700, fax (833) 329-6411. Initial decisions commonly reported at 10-14 business days. | 32 units/day (CMS MUE ceiling — no distinct plan table; state/CMS default) per day | — | — | — |
| 97152 | Yes — "Behavioral Analysis Therapy for Autism Spectrum Disorder" (AmeriHealth Caritas OH BH PA page); administered on the OAC 5160-34 state framework, no distinct plan ABA policy published | Required before ABA begins; 6-month authorization periods. Jiva UM via NaviNet; UM (833) 735-7700, fax (833) 329-6411. Initial decisions commonly reported at 10-14 business days. | 16 units/day (CMS MUE ceiling — no distinct plan table; state/CMS default) per day | — | — | — |
| 97153 | Yes — "Behavioral Analysis Therapy for Autism Spectrum Disorder" (AmeriHealth Caritas OH BH PA page); administered on the OAC 5160-34 state framework, no distinct plan ABA policy published | Required before ABA begins; 6-month authorization periods. Jiva UM via NaviNet; UM (833) 735-7700, fax (833) 329-6411. Initial decisions commonly reported at 10-14 business days. | 32 units/day (CMS MUE ceiling — no distinct plan table; state/CMS default) per day | — | — | — |
| 97154 | Yes — "Behavioral Analysis Therapy for Autism Spectrum Disorder" (AmeriHealth Caritas OH BH PA page); administered on the OAC 5160-34 state framework, no distinct plan ABA policy published | Required before ABA begins; 6-month authorization periods. Jiva UM via NaviNet; UM (833) 735-7700, fax (833) 329-6411. Initial decisions commonly reported at 10-14 business days. | 18 units/day (CMS MUE ceiling — no distinct plan table; state/CMS default) per day | — | — | — |
| 97155 | Yes — "Behavioral Analysis Therapy for Autism Spectrum Disorder" (AmeriHealth Caritas OH BH PA page); administered on the OAC 5160-34 state framework, no distinct plan ABA policy published | Required before ABA begins; 6-month authorization periods. Jiva UM via NaviNet; UM (833) 735-7700, fax (833) 329-6411. Initial decisions commonly reported at 10-14 business days. | 24 units/day (CMS MUE ceiling — no distinct plan table; state/CMS default) per day | — | — | — |
| 97156 | Yes — "Behavioral Analysis Therapy for Autism Spectrum Disorder" (AmeriHealth Caritas OH BH PA page); administered on the OAC 5160-34 state framework, no distinct plan ABA policy published | Required before ABA begins; 6-month authorization periods. Jiva UM via NaviNet; UM (833) 735-7700, fax (833) 329-6411. Initial decisions commonly reported at 10-14 business days. | 16 units/day (CMS MUE ceiling — no distinct plan table; state/CMS default) per day | — | — | — |
| 97157 | Yes — "Behavioral Analysis Therapy for Autism Spectrum Disorder" (AmeriHealth Caritas OH BH PA page); administered on the OAC 5160-34 state framework, no distinct plan ABA policy published | Required before ABA begins; 6-month authorization periods. Jiva UM via NaviNet; UM (833) 735-7700, fax (833) 329-6411. Initial decisions commonly reported at 10-14 business days. | 16 units/day (CMS MUE ceiling — no distinct plan table; state/CMS default) per day | — | — | — |
| 97158 | Yes — "Behavioral Analysis Therapy for Autism Spectrum Disorder" (AmeriHealth Caritas OH BH PA page); administered on the OAC 5160-34 state framework, no distinct plan ABA policy published | Required before ABA begins; 6-month authorization periods. Jiva UM via NaviNet; UM (833) 735-7700, fax (833) 329-6411. Initial decisions commonly reported at 10-14 business days. | 16 units/day (CMS MUE ceiling — no distinct plan table; state/CMS default) per day | — | — | — |
| 0362T | Yes — "Behavioral Analysis Therapy for Autism Spectrum Disorder" (AmeriHealth Caritas OH BH PA page); administered on the OAC 5160-34 state framework, no distinct plan ABA policy published | Required before ABA begins; 6-month authorization periods. Jiva UM via NaviNet; UM (833) 735-7700, fax (833) 329-6411. Initial decisions commonly reported at 10-14 business days. | 16 units/day (CMS MUE ceiling — no distinct plan table; state/CMS default) per day | — | — | — |
| 0373T | Yes — "Behavioral Analysis Therapy for Autism Spectrum Disorder" (AmeriHealth Caritas OH BH PA page); administered on the OAC 5160-34 state framework, no distinct plan ABA policy published | Required before ABA begins; 6-month authorization periods. Jiva UM via NaviNet; UM (833) 735-7700, fax (833) 329-6411. Initial decisions commonly reported at 10-14 business days. | 32 units/day (CMS MUE ceiling — no distinct plan table; state/CMS default) per day | — | — | — |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** Approved intensities generally 10-40 hrs/wk per clinical necessity (state framework). The plan's BH PA page is NOT bot-blocked this pass (contrary to the original compile) but publishes no code-level table. OhioRISE rule applies: ABA bills to AmeriHealth Caritas, never to OhioRISE. Verify code-level detail via the plan portal / provider manual.

### Contacts

- **Provider services phone:** (833) 735-7700
- **Portal:** [NaviNet (Jiva UM)](https://navinet.navimedix.com/)
- **Fax:** (833) 329-6411

Questions to ask on a verification call:

- What POS codes are accepted for ABA billing (home, clinic, school, telehealth)?
- Is telehealth approved for any ABA code, and if so what modifier is required?
- Do you require a licensure-tier billing modifier for RBT- vs. BCBA-delivered codes?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://dam.assets.ohio.gov/image/upload/medicaid.ohio.gov/Providers/MITS/HIPAA%205010%20Implementation/CompanionGuide/OMES/FFS/Ohio270-271.pdf (accessed 2026-07-23)
- https://www.amerihealthcaritasoh.com/provider/resources/behavioral-prior-auth (accessed 2026-07-23)
- https://www.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23)
- https://codes.ohio.gov/ohio-administrative-code/rule-5160-34-02 (accessed 2026-07-23)
- https://navinet.navimedix.com/ (accessed 2026-07-23)

## Common questions

### Does AmeriHealth Caritas Ohio cover ABA therapy?

Yes — under the Ohio Medicaid framework, with prior authorization before services begin and 6-month authorization periods, managed through Jiva via NaviNet.

### How long do AmeriHealth Caritas Ohio ABA authorizations take?

Standard decisions are due “no later than seven calendar days following receipt of the request for service” under OAC 5160-26-03.1 (effective 1/1/2026), and expedited decisions within 48 hours. The plan’s January 2026 provider manual still prints “no later than 10 calendar days” — treat 7 as the binding outer limit.

## Primary sources

1. [AmeriHealth Caritas OH — BH prior authorization page (verify via portal)](https://www.amerihealthcaritasoh.com/provider/resources/behavioral-prior-auth)
2. [Ohio Administrative Code — rule 5160-34-02](https://codes.ohio.gov/ohio-administrative-code/rule-5160-34-02)
3. [AmeriHealth Caritas Ohio — Provider Manual (January 2026, version six)](https://www.amerihealthcaritasoh.com/content/dam/amerihealth-caritas/acoh/pdf/provider/provider-manual.pdf)
4. [OAC 5160-26-03.1 — MCO utilization management and authorization timeframes (eff. 1/1/2026)](https://codes.ohio.gov/ohio-administrative-code/rule-5160-26-03.1)
5. [OAC 5160-26-09.1 — MCO third party recovery and coordination of benefits](https://codes.ohio.gov/ohio-administrative-code/rule-5160-26-09.1)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.