Anthem in Colorado is Rocky Mountain Hospital and Medical Service, Inc., with HMO products underwritten by HMO Colorado, Inc. Three things make Colorado different from the rest of Anthem's footprint, and all three are worth knowing before the first authorization goes out: Anthem publishes a Colorado-specific ABA provider resource guide rather than folding the state into its multi-state one; Colorado's autism mandate lost its dollar caps years ago and never had a small-group carve-out; and since March 1, 2026 Anthem authorizes ABA in weekly approved units, so a claim that exceeds the weekly number gets adjusted even when the total authorization still has room.
As always, plan funding type is the first fact to establish. Colorado's mandate binds health benefit plans issued or renewed in the state; self-funded ERISA plans are outside state insurance law entirely and answer to federal parity instead. Anthem's own Colorado precertification list says as much in its scope note — it applies to local fully-insured members and only to those self-insured (ASO) members whose group purchased the medical-management program.
Anthem's Colorado precertification list carries an explicit "Responsible party" column, and it spells out how to read it: if Anthem is listed, Anthem reviews; if Carelon Medical Benefits Management is listed, Carelon reviews; if CarelonRx is listed, CarelonRx reviews. The behavioral health row reads "Behavioral Health Services — Inpatient and Outpatient," responsible party Anthem, with the criteria column pointing to a phone number: Behavioral Health at 800-424-4014. The general care-provider precertification line on the same document is 800-832-7850.[1][4]
That matters because the Colorado list is full of Carelon references, and they are the wrong Carelon. Carelon Medical Benefits Management runs Anthem's imaging, genetic testing, cardiology, musculoskeletal, sleep, oncology and rehabilitative-therapy programs — it owns 97150 (group therapeutic procedures) and the PT/OT/speech codes, but not ABA. Carelon Behavioral Health is a different Elevance company; nothing in the current Colorado commercial precertification list assigns it ABA utilization review. Route an ABA request to providerportal.com and it goes to a vendor that does not handle it.[1][4]
Since September 1, 2025 Anthem has asked that behavioral health authorizations be submitted through Availity Essentials — log in, select Authorizations and Referrals, then the Patient Registration tab. Treat that as the front door and the 800-424-4014 line as the escalation path.[1][4]
Plenty of ABA billing playbooks still say Anthem reviews ABA under clinical guideline CG-BEH-02, "Adaptive Behavioral Treatment." For Colorado commercial that stopped being true in 2024. A signed Anthem letter to Colorado providers, dated February 1, 2024 and flagged as a material adverse change, states that beginning with dates of service on or after June 1, 2024, Anthem and its subsidiary HMO Colorado, Inc. would transition from CG-BEH-02 and MCG W0153 to MCG B-806-T, Behavioral Health Care Applied Behavioral Analysis (Original MCG Guideline), for medical necessity and clinical appropriateness reviews.[8]
The practical consequence is that there is no public criteria document to write your treatment plan against. MCG guidelines are licensed and proprietary; Anthem does not publish them. So the leverage moves to the things Anthem does publish — the Colorado ABA provider resource guide below, the documentation standards, and a clean, data-anchored treatment plan. If a denial letter still cites CG-BEH-02, that is worth flagging on appeal.[8]
Effective March 1, 2026, Anthem reimburses ABA in Colorado based on weekly approved units rather than total authorized units. Anthem's own framing of the consequence is blunt: claims should reflect the units rendered within each week, up to the weekly medically necessary limit as approved by prior approval, and claims submitted with units exceeding the weekly limit will be considered ineligible for reimbursement and will be adjusted accordingly.[3]
Practically, this ends the common pattern of banking unused hours and running a heavy make-up week after a vacation or a staffing gap. It also changes what intake needs to capture: a family's realistic, sustainable weekly availability is now a billing input, not just a scheduling nicety. The change applies across the whole ABA code set — 97151, 97152, 0362T, 97153, 97154, 97155, 97156, 97157, 97158 and 0373T.[3]
Colorado's mandate — C.R.S. § 10-16-104(1.4), added by SB 09-244 — requires all health benefit plans issued or renewed in the state to cover the assessment, diagnosis and treatment of autism spectrum disorders, and it names applied behavior analysis explicitly in the definition of covered treatment. It is one of the stronger mandates in this directory for three reasons.[5]
First, the caps are gone. The pre-2017 text tied coverage to a rule from the commissioner requiring services actuarially equivalent to the old dollar limit; SB 15-015 struck that language effective January 1, 2017. What replaced it is a parity clause: coverage may not be subject to dollar limits, deductibles or coinsurance less favorable to the insured than those applying to physical illness generally. Second, there is no small-employer exemption anywhere in subsection (1.4) — the only carve-outs written into the definition of "health benefit plan" for this subsection are short-term limited-duration policies and individual grandfathered plans. Third, the statute forbids plans from excluding ASD or imposing additional authorization requirements that operate to exclude coverage.[5]
The limit on all of this is the familiar one: self-funded ERISA plans are preempted from state insurance law, so a Colorado family on a self-funded employer plan gets whatever the plan document and federal parity give them, not the mandate. Establish funding type before you quote anything from this section.[5]
The statute says treatment for autism spectrum disorders shall be prescribed or ordered by a licensed physician or licensed psychologist. A BCBA's recommendation alone does not satisfy it — capture the ordering clinician at intake, not at appeal.[5][2]
Colorado requires the treatment plan to be developed in accordance with the patient-centered medical home as defined in C.R.S. § 25.5-1-103(5.5). Anthem's Colorado ABA guide reproduces this requirement and footnotes the statute, so it is a plan-document expectation, not just a statutory curiosity.[5][2]
The statute lists six qualification pathways, from a doctoral-level clinician licensed by the Colorado medical board down to a BACB Registered Behavior Technician working under the supervision of one of the higher tiers. The ladder is broader than "BCBA only," which matters when you are staffing a case.[5][2]
Colorado has historically not licensed behavior analysts, leaning instead on the statutory "autism services provider" ladder and BACB certification. That changed in 2026: HB26-1425 became law and creates the Colorado Behavior Analyst Licensing Board under the Division of Professions and Occupations at DORA, with authority to license behavior analysts and assistant behavior analysts. The operative date is not now — on and after July 1, 2028, practising or offering applied behavior analysis without a board-issued license is prohibited, and doing so is a class 2 misdemeanor.[6][7]
As of this writing the board seats are still listed as vacant on the DORA program page and no license is being issued, so today's credentialing conversation with Anthem still runs on national certification plus the statutory ladder. The planning consequence is real, though: every analyst you expect to still be supervising Colorado cases in mid-2028 needs a licensure path, and the regulation carries a sunset review scheduled for September 1, 2031.[6][7]
The questions that decide whether a family can start with Anthem BCBS Colorado, and what they have to bring. Each maps onto something intake should ask on the first call.
No age limit. C.R.S. § 10-16-104(1.4) requires all health benefit plans issued or renewed in Colorado to cover the assessment, diagnosis and treatment of autism spectrum disorders, naming applied behavior analysis in the definition of covered treatment, and carries no age terms — the dollar-cap language that once framed coverage was struck effective January 1, 2017 and replaced with a parity clause. The only carve-outs written into the subsection are short-term limited-duration policies and individual grandfathered plans; self-funded ERISA plans are preempted out.[5]
Required, and it is a Colorado-specific gate that catches files at appeal. The treatment plan must be "developed for an individual by an autism services provider and prescribed by a licensed physician or a licensed psychologist pursuant to a comprehensive evaluation or reevaluation," and must state the individual's diagnosis, the proposed treatment by type, frequency and anticipated duration, the anticipated outcomes stated as goals, and how often the plan will be updated. Capture the ordering clinician's name, credential and order date at intake.[2][5]
Payable, with the code list held elsewhere. Anthem names two telehealth places of service for ABA in Colorado — "10 = Telehealth (member located in home while receiving services)" and "02 = Telehealth (member located outside of home while receiving services)" — each "subject to the member's coverage and reviews by the plan." Which codes are eligible is governed by Anthem's Virtual Visits reimbursement policy: "allowed codes may vary. Refer to the Allowed virtual services in addition to CPT Appendix P to obtain codes that are eligible for reimbursement in your state."[2]
Depends on how the plan is funded. Fully insured Colorado plans follow C.R.S. § 10-16-112.5: within five business days after receipt the carrier must say the request is "approved, denied, or incomplete" (naming the missing information), then decide within five business days after receiving it; urgent requests within "two business days but not longer than seventy-two hours." If the carrier misses those deadlines the request "is deemed granted" — but the provider must send any requested information within two business days of the notice or loses that protection. An approval "is valid for at least one hundred eighty days after the date of approval and continues for the duration of the authorized course of treatment." Self-funded (ERISA) plans follow the federal claims rule instead: pre-service decisions within 15 days of receipt (one 15-day extension), urgent within 72 hours. Anthem's Colorado precertification list and ABA resource guide publish no separate decision clock or submission lead time.[9][10]
Ask the plan: Benefits verification: fully insured Colorado policy (5-business-day clock, 180-day approvals, deemed-granted rule) vs. self-funded ERISA plan (15 days / 72 hours).
For a child on two parents' plans, Colorado's group coordination-of-benefits regulation (fully insured plans): parents married or living together — "The plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (same birthday → the plan that covered the parent longer); otherwise a court decree controls, and without one the order is custodial parent, custodial parent's spouse, non-custodial parent, then the non-custodial parent's spouse. Self-funded plans set their own order in the plan document. Anthem's Colorado ABA documents publish no coordination-of-benefits rule of their own. If the child also has TRICARE, this plan pays first — TRICARE is the secondary payer to other health insurance under its double-coverage rule (Medicaid is the only coverage it pays ahead of). CHAMPVA likewise pays last: "In double coverage situations, CHAMPVA would be the last payer." If the child also has Medicaid, this plan is primary and Medicaid pays last.[11][12][13][14]
Ask the plan: Benefits verification with both plans: funding type, which is primary for the child, and whether the secondary plan requires its own authorization.
Not published. Anthem reviews ABA in Colorado against MCG B-806-T, which is licensed and proprietary, and the Colorado ABA provider resource guide states no recency rule for the diagnostic evaluation. The nearest published anchor is structural rather than temporal: the treatment plan must be prescribed "pursuant to a comprehensive evaluation or reevaluation," which contemplates re-evaluation without naming a clock.[2][5]
Blocked on: Anthem Behavioral Health at 800-424-4014, or the authorization request itself through Availity Essentials — MCG B-806-T is not publicly available.
Who may make the ASD diagnosis is not published — the criteria set is MCG B-806-T, which Anthem does not publish. What Colorado does fix is the prescriber: the treatment plan is "developed for an individual by an autism services provider and prescribed by a licensed physician or a licensed psychologist pursuant to a comprehensive evaluation or reevaluation," and the statute requires treatment for ASD to be prescribed or ordered by a licensed physician or licensed psychologist. A BCBA's recommendation alone does not satisfy it.[2][5]
Blocked on: Anthem Behavioral Health at 800-424-4014 for the diagnostic-credential standard applied under MCG B-806-T.
Not published. Anthem's Colorado ABA provider resource guide covers credentialing, coding, documentation, place of service and supervision, but names no diagnostic or assessment instrument, and the operative criteria set (MCG B-806-T) is proprietary.[2]
Blocked on: Anthem Behavioral Health at 800-424-4014 — ask which instruments MCG B-806-T expects behind the diagnosis and behind the requested intensity.
Coverage decides whether Anthem BCBS Colorado pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
No ratio is published — Anthem sets a supervision structure instead. Approved ABA service providers include "providers practicing under the direction and supervision of the BCBA," and the statutory autism-services-provider ladder Anthem reproduces ends with a BACB registered behavior technician who "provides direct services to a person with an autism spectrum disorder under the supervision of an autism services provider" in one of the five higher tiers. Anthem's own supervision paragraph is a billing rule rather than a dosage rule: supervised or directed services billed with a QHP-performed procedure are subject to its Incident To Services and Billing reimbursement policy.[2][5]
Allowed only in the narrow case: a physician or other QHP billing 97155 can add 97153 only if both the technician and the QHP are face-to-face with the patient at the same time and the QHP is directing the technician.[2]
No Anthem-specific daily unit ceiling is published for Colorado. ABA codes may carry CMS MUE limits, which Anthem administers as NCCI edits under its Code and Clinical Editing Guidelines reimbursement policy and refreshes when CMS publishes. The binding practical ceiling is instead the weekly approved units on the authorization (effective March 1, 2026).[2][3]
Each entry must carry author identification — handwritten signature, unique electronic identifier, or initials — plus rendering provider credentials. Entries should be made at the time of service or shortly thereafter and should not exceed 30 days, with a signature date within 30 days of the date of service. Timed codes need total treatment minutes plus start and stop times in the record. Treatment plans must show review or update at least every 6 months.[2]
POS codes Anthem names for ABA in Colorado: 12 home, 11 office/clinic, 99 community, 03 school, 10 telehealth with the member at home, 02 telehealth with the member elsewhere — each subject to the member's coverage and plan review.[2]
ABA performed by therapy assistants, behavior technicians or paraprofessionals must show the supervising BCBA or other qualified healthcare professional in box 31 of the CMS-1500. Degree-level modifiers HM (less than bachelor's), HN (bachelor's) and HO (master's) identify the rendering staff level.[2]
Yes. Colorado's mandate (C.R.S. § 10-16-104(1.4)) names applied behavior analysis as covered treatment for autism spectrum disorders in all health benefit plans issued or renewed in the state, and Anthem precertifies ABA as a behavioral health service. Self-funded ERISA plans sit outside the mandate, so confirm funding type first.
To Anthem. Anthem's Colorado precertification list names Anthem as the responsible party for behavioral health services and points to its Behavioral Health line, 800-424-4014; submit through Availity Essentials. The Carelon names that appear throughout that list are Carelon Medical Benefits Management (imaging, genetics, cardiology, MSK, rehab therapy) and CarelonRx — neither handles ABA.
From March 1, 2026 reimbursement is based on weekly approved units rather than total authorized units. Units rendered above the approved weekly limit are ineligible for reimbursement and get adjusted, so banking hours across weeks no longer works.
No. The cap language was struck effective January 1, 2017, and the statute now requires that coverage not be subject to dollar limits, deductibles or coinsurance less favorable than those applied to physical illness generally. There is also no small-employer exemption in the autism subsection.
Not yet, but it will. HB26-1425 became law in 2026 and creates the Colorado Behavior Analyst Licensing Board; on and after July 1, 2028 practising applied behavior analysis without a board-issued license is prohibited. Until then the statutory "autism services provider" ladder, built on BACB certification, is the operative standard.
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.
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