---
title: "Anthem BCBS Georgia ABA coverage (+ Ava's Law)."
url: "https://carelu.com/payers/anthem-bcbs-georgia"
markdown_url: "https://carelu.com/payers/anthem-bcbs-georgia.md"
state: GA (Georgia)
payer: Anthem BCBS Georgia
kind: Commercial insurance
description: "How Anthem Blue Cross Blue Shield covers ABA in Georgia: CG-BEH-02 medical-necessity criteria, documentation and billing rules, 6-month reauthorization — plus how Ava's Law and parity protections apply."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

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

_Payer Guide · Anthem BCBS Georgia · Last updated September 2026 · 3 primary sources_

> CG-BEH-02 criteria + Ava’s Law mandate; caps, parity, billing rules.

Anthem Blue Cross Blue Shield of Georgia covers ABA under clinical guideline CG-BEH-02, layered on top of Georgia's autism insurance mandate — Ava's Law. The combination matters: the policy defines what's medically necessary, while the mandate (and federal parity law) defines what plans must offer and which caps are actually enforceable. Intake teams that understand both catch coverage that others write off.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment:** Not published / unverified. Verify via: Anthem clinical guideline CG-BEH-02 — or its successor, since Anthem moved commercial ABA reviews to MCG B-806-T for dates of service on or after 6/1/2024 — in the Anthem provider portal. The cited ABA Provider Resource Guide was downloaded and read in full and contains no occurrence of “prior authorization” or “precertification,” and no 20-combined-hour assessment cap.
- **Prior auth for treatment:** Not published / unverified. Verify via: Anthem clinical guideline CG-BEH-02, or its successor MCG B-806-T, in the Anthem provider portal. The cited ABA Provider Resource Guide carries only the plan-review clock — “documentation must show that the treatment plan was reviewed and/or updated at a minimum of every six months” — and states no prior-authorization requirement.

## At a glance

- **Covers ABA?:** Yes — per CG-BEH-02 medical-necessity criteria
- **State mandate:** Ava's Law: state-regulated plans, age 20 and under
- **Assessment cap:** Initial behavior-identification assessment ≤20 combined hours
- **Direct-care ceiling:** ≤40 hrs/week adaptive behavior treatment
- **Reauth:** Updated plan every 6 months; standardized assessment ≥ every 2 years
- **Parity note:** $35K/year cap generally unenforceable vs. large groups (MHPAEA)

## Medical-necessity criteria

CG-BEH-02 requires all of the following: an ASD diagnosis from a licensed, qualified professional; a person-centered treatment plan with measurable, baseline-anchored goals; a provider licensed or certified per state law; completed functional assessments across motor, language, social, and adaptive domains; and age-appropriate goals targeting the deficits that matter. The initial behavior-identification assessment is capped at 20 combined hours — enough for a thorough assessment, not an open-ended one. [1]

## Ava's Law — and its limits

Georgia's autism mandate (O.C.G.A. § 33-24-59.10) requires state-regulated individual and group plans to cover ASD treatment — including ABA — for individuals 20 and under, with ABA nominally cappable at $35,000/year. Two big caveats every intake team should know: employers with 10 or fewer employees and self-funded ERISA plans are exempt from the state mandate; and federal mental-health parity (MHPAEA) generally makes the dollar and age caps unenforceable against covered large-group plans. A payer applying the $35K cap to a large-group member is a parity red flag worth escalating, not accepting. [2]

## Billing and documentation rules

- **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]

## Reauthorization rhythm

Expect an updated treatment plan every 6 months, interim progress assessment at least every 6 months, standardized developmental assessments at minimum every 2 years, and documented clinically significant progress in adaptive functioning, communication, language, or social skills. Intake sets this clock: the baseline data collected at the start is what every future review gets measured against. [1]

## Intake gates

The questions that decide whether a family can start with Anthem BCBS Georgia, and what they have to bring.

- **Age limit** _(plan-dependent)_: 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.
- **Referral required?** _(plan-dependent)_: 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.
- **Telehealth** _(plan-dependent)_: 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.
- **Prior-auth decision time** _(plan-dependent)_: 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.
- **Other insurance (who pays first)** _(plan-dependent)_: 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.

## Delivery and billing rules

Coverage decides whether Anthem BCBS Georgia 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.

- **Supervision**: 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]
- **Concurrent billing (97153 + 97155)**: 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]
- **Daily limits / MUEs**: 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.
- **Session-note signature**: 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]
- **Place of service**: 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.
- **Bill as provider**: 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]

## What intake should collect for Anthem BCBS Georgia

- **Member ID + plan funding type:** Fully insured (mandate applies) vs. self-funded ERISA (exempt) vs. small group (≤10 employees, exempt) — this determines what the plan owes.
- **Employer size:** Directly relevant to both the mandate and parity analysis.
- **Diagnosis + functional assessments:** ASD diagnosis from a qualified professional, plus any existing motor/language/social/adaptive assessments.
- **Age:** The mandate covers 20 and under; parity may extend practical coverage — flag edge cases for benefits verification.
- **Baseline data expectations:** Set up the measurable, baseline-anchored goals CG-BEH-02 requires from day one.

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

## Verification of benefits (VOB) data

How Anthem BCBS Georgia ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 01347 — pVerify also separately lists "00032 BCBS of Georgia" — confirm which code applies to this specific plan family before automating routing.
- **Payer ID (Availity):** 00601
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** Carelon Behavioral Health
- **BH administrator payer ID:** BEACON963116116 — Resolved to the eligibility/270 second-hop ID: a 270 sent directly to Carelon's EDI gateway uses payer ID BEACON963116116 (Carelon's own 270/271 Companion Guide, Loop 2100A NM109 "Use 'BEACON963116116'"). The two IDs previously in conflict are Carelon's CLAIMS/ERA clearinghouse IDs, not eligibility IDs: BHOVO is the 837 claims ID (Optum ERA list annotates "Beacon Health Options (837I & 837P)" → BHOVO) and CHCBH is the ERA-835 ID (Optum ERA list "Carelon Behavioral Health" → CHCBH). Neither BHOVO nor CHCBH appears on Optum's real-time eligibility list. NOTE: the direct Carelon eligibility feed returns only STC 30 active/inactive per Carelon's own guide — ABA cost-share detail comes from the Anthem MEDICAL 271 (MH bucket), not this feed.

### How the 271 reports ABA benefits

- **ABA benefit bucket (service type code):** MH — Anthem/Elevance's own real-time EDI 270/271 Companion Guide (Release AV-3, GA-inclusive — cover names "Blue Cross Blue Shield Healthcare Plan of Georgia, Inc.") lists MH (Mental Health) in its "Individual Service Types Supported" table as a service-type-specific response; ABA/autism has no dedicated STC (CAQH CORE), so ABA cost-share rides the MH bucket. No A4-A8 codes appear in the guide. CAVEAT: if the 270 is addressed to the Carelon carve-out gateway rather than Anthem's medical payer ID, Carelon's own companion guide states it "treats all inquiries as Service Type Code 30" and returns only active/inactive — so MH-level cost-share comes back from the Anthem MEDICAL 271, not the Carelon feed.
- **Deductible applies to ABA:** plan-dependent — Plan-dependent — the companion guide is an EDI transaction-format document, not a plan-benefit document; whether the deductible applies to ABA is set by the member's specific plan. Confirm via plan summary or Anthem GA provider services.
- **Cost-share type:** plan-dependent — Plan-dependent — copay (EB*C) and coinsurance (EB*A) are both structurally supported; which applies is plan-specific.
- **Copay unit:** plan-dependent — Plan-dependent — not addressed by the companion guide; ABA bills multiple sessions/day, so per-visit vs per-day materially changes the family's number. Confirm via plan summary.
- **271 response quality for ABA:** medium — Seeded 'medium' (inferred from companion-guide structure): the guide commits to returning "specific eligibility and benefit information" for supported service-type codes and distinguishes MH from the generic "30 Health Benefit Plan Coverage" summary bucket, so MH is a genuine service-level response — but it does NOT enumerate copay/coinsurance/deductible amounts (deferred to the X12 TR3), short of the explicit financial-detail commitment that earns Cigna/UHC a 'high'.

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required — part of the ≤20-combined-hour initial behavior-identification assessment | — | 12 = Home, 11 = Office/Clinic, 99 = Community, 03 = School, 10 = Telehealth (member in home), 02 = Telehealth (member outside home) | Allowed via POS 10/02 per the ABA Provider Resource Guide's general POS list; code-specific modifier (95/GT) and per-code telehealth eligibility aren't published — the guide defers to a separate Virtual Visits reimbursement policy / CPT Appendix P. | HM (less than bachelor's), HN (bachelor's), HO (master's) |
| 97152 | Yes | Required — part of the ≤20-combined-hour initial behavior-identification assessment | — | 12 = Home, 11 = Office/Clinic, 99 = Community, 03 = School, 10 = Telehealth (member in home), 02 = Telehealth (member outside home) | Allowed via POS 10/02 per the ABA Provider Resource Guide's general POS list; code-specific modifier (95/GT) and per-code telehealth eligibility aren't published — the guide defers to a separate Virtual Visits reimbursement policy / CPT Appendix P. | HM (less than bachelor's), HN (bachelor's), HO (master's) |
| 97153 | Yes | Required — treatment plan, reviewed every 6 months | — | 12 = Home, 11 = Office/Clinic, 99 = Community, 03 = School, 10 = Telehealth (member in home), 02 = Telehealth (member outside home) | Allowed via POS 10/02 per the ABA Provider Resource Guide's general POS list; code-specific modifier (95/GT) and per-code telehealth eligibility aren't published — the guide defers to a separate Virtual Visits reimbursement policy / CPT Appendix P. | HM (less than bachelor's), HN (bachelor's), HO (master's) |
| 97154 | Yes | Required — treatment plan, reviewed every 6 months | — | 12 = Home, 11 = Office/Clinic, 99 = Community, 03 = School, 10 = Telehealth (member in home), 02 = Telehealth (member outside home) | Allowed via POS 10/02 per the ABA Provider Resource Guide's general POS list; code-specific modifier (95/GT) and per-code telehealth eligibility aren't published — the guide defers to a separate Virtual Visits reimbursement policy / CPT Appendix P. | HM (less than bachelor's), HN (bachelor's), HO (master's) |
| 97155 | Yes | Required — treatment plan, reviewed every 6 months | — | 12 = Home, 11 = Office/Clinic, 99 = Community, 03 = School, 10 = Telehealth (member in home), 02 = Telehealth (member outside home) | Allowed via POS 10/02 per the ABA Provider Resource Guide's general POS list; code-specific modifier (95/GT) and per-code telehealth eligibility aren't published — the guide defers to a separate Virtual Visits reimbursement policy / CPT Appendix P. | HM (less than bachelor's), HN (bachelor's), HO (master's) |
| 97156 | Yes | Required — protocol modification, up to 2 hrs per 10 direct hours, max 8/week | — | 12 = Home, 11 = Office/Clinic, 99 = Community, 03 = School, 10 = Telehealth (member in home), 02 = Telehealth (member outside home) | Allowed via POS 10/02 per the ABA Provider Resource Guide's general POS list; code-specific modifier (95/GT) and per-code telehealth eligibility aren't published — the guide defers to a separate Virtual Visits reimbursement policy / CPT Appendix P. | HM (less than bachelor's), HN (bachelor's), HO (master's) |
| 97157 | Yes | Required — treatment plan, reviewed every 6 months | — | 12 = Home, 11 = Office/Clinic, 99 = Community, 03 = School, 10 = Telehealth (member in home), 02 = Telehealth (member outside home) | Allowed via POS 10/02 per the ABA Provider Resource Guide's general POS list; code-specific modifier (95/GT) and per-code telehealth eligibility aren't published — the guide defers to a separate Virtual Visits reimbursement policy / CPT Appendix P. | HM (less than bachelor's), HN (bachelor's), HO (master's) |
| 97158 | Yes | Required — treatment plan, reviewed every 6 months | — | 12 = Home, 11 = Office/Clinic, 99 = Community, 03 = School, 10 = Telehealth (member in home), 02 = Telehealth (member outside home) | Allowed via POS 10/02 per the ABA Provider Resource Guide's general POS list; code-specific modifier (95/GT) and per-code telehealth eligibility aren't published — the guide defers to a separate Virtual Visits reimbursement policy / CPT Appendix P. | HM (less than bachelor's), HN (bachelor's), HO (master's) |
| 0362T | Yes | Required — part of the ≤20-combined-hour initial behavior-identification assessment | — | 12 = Home, 11 = Office/Clinic, 99 = Community, 03 = School, 10 = Telehealth (member in home), 02 = Telehealth (member outside home) | Allowed via POS 10/02 per the ABA Provider Resource Guide's general POS list; code-specific modifier (95/GT) and per-code telehealth eligibility aren't published — the guide defers to a separate Virtual Visits reimbursement policy / CPT Appendix P. | HM (less than bachelor's), HN (bachelor's), HO (master's) |
| 0373T | Yes | Required — treatment plan, reviewed every 6 months | — | 12 = Home, 11 = Office/Clinic, 99 = Community, 03 = School, 10 = Telehealth (member in home), 02 = Telehealth (member outside home) | Allowed via POS 10/02 per the ABA Provider Resource Guide's general POS list; code-specific modifier (95/GT) and per-code telehealth eligibility aren't published — the guide defers to a separate Virtual Visits reimbursement policy / CPT Appendix P. | HM (less than bachelor's), HN (bachelor's), HO (master's) |

Code notes:

- **97151, 97152, 97153, 97154, 97156, 97157, 97158, 0362T, 0373T:** Verify via: CMS's current MUE list (unit caps — the guide defers to it) and Anthem's Virtual Visits reimbursement policy / CPT Appendix P (telehealth mechanics).
- **97155:** Billable alongside 97153 only when the technician and the QHP are both face-to-face and the QHP is directing (per the ABA Provider Resource Guide, which contains an apparent typo — "971555" — in this rule). Verify via: CMS's current MUE list (unit caps — the guide defers to it) and Anthem's Virtual Visits reimbursement policy / CPT Appendix P (telehealth mechanics).

### Contacts

- **Provider services phone:** 800-676-2583
- **Portal:** [Availity Essentials](https://apps.availity.com/web/onboarding/availity-fr-ui/#/login)

Questions to ask on a verification call:

- Does ABA route to Carelon Behavioral Health or stay on Anthem's medical claims system — and what payer ID do you use for eligibility checks?
- Which pVerify payer ID is correct for this Anthem BCBS Georgia plan family — 01347 or the separately listed 00032 BCBS of Georgia?
- What Change Healthcare payer ID do you use for Anthem BCBS Georgia — 00101 or 00601?
- Does eligibility checking return real-time or batch-only 271 responses?
- Is the ABA cost share a copay or coinsurance, and is it charged per visit or per day?
- What's the current daily/session unit cap for 97151-97158, 0362T, and 0373T — the ABA Provider Resource Guide defers to "the current CMS MUE list" without stating the number?
- Which service-type-code bucket does Anthem return ABA benefit detail under, and does the deductible apply to it?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months)
- https://files.providernews.anthem.com/5585/MULTI-BCBS-CM-072378-24-CPN72366-EXPRESS-ABA-prov-resource-gd-FINAL-V3.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.carelonbehavioralhealth.com/content/dam/digital/carelon/cbh-assets/documents/global/guides/270-271-companion-guide.pdf (accessed 2026-07-23; source document older than 18 months)
- https://business.optum.com/content/dam/o4-dam/resources/pdfs/white-papers/electronic-remittance-advice-payer-list.pdf (accessed 2026-07-23)
- https://business.optum.com/content/dam/o4-dam/resources/pdfs/white-papers/real-time-eligibility-payer-list.pdf (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://www.anthem.com/content/dam/digital/docs/provider/commercial/general/EDI_CE_NE_W_VA_00016.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.anthem.com/provider/individual-commercial/contact-us (accessed 2026-07-23)

## Common questions

### Does Anthem BCBS Georgia cover ABA therapy?

Yes — under clinical guideline CG-BEH-02, requiring an ASD diagnosis, functional assessments, a measurable treatment plan, and a licensed/certified provider. Georgia's Ava's Law also mandates coverage in state-regulated plans for individuals 20 and under.

### Is the $35,000 ABA cap in Ava's Law enforceable?

Against large-group plans covered by federal parity law, generally not — MHPAEA prohibits treatment limits on mental-health benefits that are stricter than medical/surgical benefits. Treat a payer applying the cap to a large-group member as a red flag to escalate.

### Which plans are exempt from Ava's Law?

Self-funded ERISA plans (federal preemption) and employers with 10 or fewer employees. That's why intake should always capture the employer and funding type, not just the insurance card.

## Primary sources

1. [Anthem ABA Provider Resource Guide (Oct 2024)](https://files.providernews.anthem.com/5585/MULTI-BCBS-CM-072378-24-CPN72366-EXPRESS-ABA-prov-resource-gd-FINAL-V3.pdf)
2. [Ava's Law — O.C.G.A. § 33-24-59.10](https://law.justia.com/codes/georgia/title-33/chapter-24/article-1/section-33-24-59-10/)
3. [Georgia Behavior Analyst Licensing Board](https://sos.ga.gov/georgia-behavior-analyst-licensing-board)
4. [Georgia SB 80 (2021) — O.C.G.A. 33-46-26, -27, -29, -30 (Ensuring Transparency in Prior Authorization Act)](https://gov.georgia.gov/document/2021-signed-legislation/sb-80/download)
5. [O.C.G.A. 33-46-26 — prior authorization notice within 7 calendar days (FindLaw)](https://codes.findlaw.com/ga/title-33-insurance/ga-code-sect-33-46-26/)
6. [29 CFR 2560.503-1 — ERISA claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
7. [Ga. Comp. R. & Regs. 120-2-48-.05 — Group Coordination of Benefits, order of benefits](https://www.law.cornell.edu/regulations/georgia/Ga-Comp-R-Regs-R-120-2-48-.05)
8. [GA DCH — Part I Policies and Procedures for Medicaid/PeachCare for Kids (version date July 1, 2026), 104.3 and 303 (GAMMIS copy retrieved via web.archive.org)](https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Part%201%20Policies%20and%20Procedures%20for%20Medicaid%20PeachCare%20for%20Kids%20Q3%20July%202026%2020260706155614.pdf)
9. [10 U.S.C. 1079(i)(1) — TRICARE pays after other coverage, Medicaid excepted](https://www.govinfo.gov/content/pkg/USCODE-2023-title10/html/USCODE-2023-title10-subtitleA-partII-chap55-sec1079.htm)
10. [CHAMPVA Guidebook (updated Jan. 1, 2025) — Other Health Insurance](https://www.va.gov/COMMUNITYCARE/docs/pubfiles/programguides/CHAMPVA-Guide.pdf)

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.