Anthem BCBS Georgia ABA coverage (+ Ava's Law).

Codes & modifiers

97151–97158 plus 0362T/0373T, with degree-level modifiers (HM/HN/HO). Technician-rendered services must show the supervising BCBA in Box 31 of the CMS-1500.^[1]

Concurrent billing

97155 alongside 97153 only when technician and QHP are both face-to-face and the QHP is directing.^[1]

Hour limits

Direct treatment ≤40 hours/week; protocol modification up to 2 hours per 10 direct hours, max 8/week.^[1]

Documentation

Timed codes need total minutes and start/stop times; notes entered within 30 days with signature and credentials; plans must include caregiver training, mastery dates, generalization, and discharge planning.^[1]

Anthem’s commercial ABA provider resource guide publishes no age criterion — it covers credentialing, coding, place of service, documentation and telehealth, not eligibility age. The age term that bites in Georgia comes from Ava’s Law, which requires state-regulated individual and group plans to cover ASD treatment for individuals 20 years of age or under. Two carve-outs and one federal override matter: employers with 10 or fewer employees are exempt, self-funded ERISA plans are preempted, and federal mental-health parity generally makes the mandate’s age and dollar caps hard to enforce against covered large-group plans — so an age-based decline on a large-group member is an escalation, not an answer.^[1][2]

Ask the plan: Plan funding type and employer size first, then a live benefits verification; clinical guideline CG-BEH-02 in the Anthem provider portal for any age criterion the guideline itself carries.

No referral precondition is published for ABA. The resource guide treats “physician orders” and “referrals” as elements that must be present in the medical record when they exist, not as an entry gate, and Anthem gates ABA through prior authorization instead — assessment and treatment reviewed against CG-BEH-02, with the initial behavior-identification assessment capped at 20 combined hours. Whether the member’s specific plan requires a PCP referral is a benefit-design question.^[1][2]

Ask the plan: The member’s benefit document and Anthem provider services — ask whether a PCP referral is required in addition to the prior authorization.

Anthem publishes the place-of-service half outright but makes the code list plan- and state-specific. Telehealth POS codes for ABA are “10 = Telehealth (member located in home while receiving services)” and “02 = Telehealth (member located outside of home while receiving services),” all “subject to member’s coverage and reviews by the plan.” For which codes actually pay, the guide redirects: “please visit our Virtual Visits reimbursement policy that outlines our standard rules. 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.” So the POS mechanics are settled and the payable code set is not.^[1]

Blocked on: Anthem’s Virtual Visits reimbursement policy and the Georgia “Allowed virtual services” list, plus the member’s benefit document, before scheduling remote ABA.

It depends on how the plan is funded. A fully insured Anthem Blue Cross and Blue Shield plan sold in Georgia follows the Ensuring Transparency in Prior Authorization Act. A standard request gets notice "within 7 calendar days of obtaining all necessary information to make such authorization or adverse determination" (O.C.G.A. 33-46-26). Urgent requests get notice "no later than 72 hours after receiving all information needed" (33-46-27). A missed deadline means "automatic authorization" of the service (33-46-29), with a narrow de minimis exception. Both clocks start only once the plan has everything it needs, so send a complete packet. The Act also binds DCH contracts under the State Health Benefit Plan. A self-funded employer plan is governed by ERISA instead: "not later than 15 days after receipt of the claim," with one 15-day extension, and 72 hours for urgent care. No reauthorization lead time is published for Anthem Blue Cross and Blue Shield ABA in Georgia.^[4][5][6]

Ask the plan: Benefits verification with Anthem Blue Cross and Blue Shield: ask whether the plan is fully insured (Georgia prior-authorization law), self-funded (ERISA), or the State Health Benefit Plan, and the plan's reauthorization lead time.

Between two parents' group plans, Georgia's coordination-of-benefits rule uses the birthday rule: "The benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year." "Birthday" means month and day only. If the birthdays match, the plan that has covered the parent longer pays first. For separated or divorced parents, the order is the custodial parent's plan, then the step-parent's, then the non-custodial parent's, unless a court decree assigns health costs to one parent. That rule governs fully insured group plans. A self-funded employer plan sets its own order in its plan document. The Anthem Blue Cross and Blue Shield plan pays before Georgia Medicaid, which is payer of last resort and still wants its own ABS PA when secondary. It also pays before TRICARE, which pays only after other coverage. When the child also has CHAMPVA, the Anthem Blue Cross and Blue Shield plan pays first: "If you have any other type of other health insurance, CHAMPVA will pay secondary."^{[7][8][9][10]}

Ask the plan: Anthem Blue Cross and Blue Shield member services / benefits verification: confirm funding type and the COB order in the plan document, and collect the other parent's plan, each parent's date of birth and any custody decree at intake.

Anthem’s ABA provider resource guide sets a treatment-plan clock rather than a diagnosis clock: “documentation must show that the treatment plan was reviewed and/or updated at a minimum of every six months. Providers should review their guidelines if treatment plans are required more frequently.” It publishes no recency window on the ASD diagnostic evaluation itself, and no re-diagnosis interval.^[1]

Blocked on: Anthem clinical guideline CG-BEH-02 in the Anthem provider portal, and Anthem provider services — the public resource guide does not carry the medical-necessity criteria text.

The ABA provider resource guide lists who may RENDER ABA, not who may diagnose: “approved service providers include psychiatrists (MDs), psychologists (PhDs), licensed clinical social workers (LPCs), licensed marriage and family therapists (LMFTs) with special training and/or experience in applied behavior analysis, Board Certified Behavior Analysts (BCBA/BCBA-D), providers practicing under the direction and supervision of the BCBA, and other mental health service providers licensed or authorized by the state in which they practice and recognized by the Anthem affiliated health plan to be eligible for reimbursement.” The diagnosing-provider requirement lives in clinical guideline CG-BEH-02 rather than in this document. Georgia adds a licensure layer either way: HB 412 (2022) created O.C.G.A. Title 43, Chapter 7A, so the supervising analyst must hold a Georgia Behavior Analyst Licensing Board licence.^[1]

Blocked on: Anthem clinical guideline CG-BEH-02 in the Anthem provider portal for the credentials Anthem requires of the diagnosing professional.

Anthem names no required instrument. Its resource guide defines applied behavior analysis as including “a detailed behavioral history, patient observation, administration of standardized and nonstandardized tests and structured guardian/caregiver interview to identify and describe deficient adaptive or maladaptive behaviors,” and behavioral follow-up assessments as using “structured observation and/or standardized and nonstandardized tests to determine levels of adaptive behavior” across cooperation, motivation, visual understanding, receptive and expressive language, imitation, requests, labeling, play and leisure, and social interactions. Which instruments satisfy that is not published.^[1]

Blocked on: Anthem clinical guideline CG-BEH-02 for any required or preferred instrument list, and Anthem provider services.

Anthem’s commercial ABA guide — which names Georgia (Blue Cross Blue Shield Healthcare Plan of Georgia, Inc.) on its cover — defines supervision through what is billable rather than through a ratio: “A QHP can only bill for 97155 if both the technician and QHP are face-to-face with the patient at the same time and the QHP is directing the technician.” Approved ABA renderers include BCBA/BCBA-D and “providers practicing under the direction and supervision of the BCBA.” No percentage floor or caseload cap is published.^[1]

Yes, on Anthem’s own terms: where the technician and the QHP are both face-to-face with the patient at the same time and the QHP is directing the technician, “codes 97153 and 97155 can be billed together.” The permission is conditional on that simultaneous face-to-face direction — 97155 for analyst work away from the patient is outside it.^[1]

Anthem publishes no Anthem-specific per-day ceiling and defers to CMS. “ABA codes may have associated MUE limits”; Anthem administers NCCI edits under its Code and Clinical Editing Guidelines reimbursement policy, and “NCCI edits are revised to align with CMS MUE updates once published.” The guide points providers to CMS for the current MUE list — so the operative regime is the CMS table Anthem’s editor loads, not a published Anthem number.^[1]

Ask the plan: Which CMS MUE table (Practitioner vs. Medicaid NCCI) Anthem’s editor applies to a given Georgia product — confirm with Anthem provider services before modelling units.

Anthem signs by author identification and puts a clock on it. Each entry in the medical record must include author identification of the physician or other QHP — “a handwritten signature, unique electronic identifier, or initials and rendering provider credentials” — entered at the time of service or shortly thereafter and “not exceed[ing] 30 days,” with the signature date within 30 days of the date of service. All documentation must be legible to someone other than the writer and must support the services billed on each unique date. For timed ABA codes the record must carry total treatment time in minutes plus start and stop times.^[1]

Anthem publishes the POS code list for ABA outright: 12 home, 11 office/clinic, 99 community, 03 school, 10 telehealth with the member at home, 02 telehealth with the member outside the home — all “subject to member’s coverage and reviews by the plan.” School and community are therefore codeable places of service, not excluded ones; group home is not listed.^[1]

Ask the plan: Whether POS 03 school is payable on a specific Georgia member’s benefit — the code list is explicitly subject to plan review.

The supervising analyst goes in box 31. “ABA therapy performed by therapy assistants, behavioral technicians, or paraprofessionals must show the supervising BCBA or other QHP in box 31 of the CMS claim form.” Credential level rides as a modifier: HM for less than bachelor’s level, HN bachelor’s level, HO master’s level.^[1]