Anthem BCBS Indiana ABA coverage: the intake guide.

No age limit anywhere in the statute. Reading all five sections of IC 27-8-14.2, the words “age,” “hours,” “visits” and any dollar figure simply do not appear in connection with the autism benefit; the only limit language is a parity clause requiring that dollar limits, deductibles and coinsurance be no less favourable than those applying to physical illness generally (the HMO parallel at IC 27-13-7-14.7 adds copayments). Both the group and individual sections also forbid an insurer from denying, refusing to issue, refusing to renew or otherwise restricting coverage solely because the individual is diagnosed with an autism spectrum disorder. The fork that does matter is group versus individual versus self-funded, not age.^[2][4]

The statute names no credential of its own. Its only gate on who delivers or authorises the service is that the treatment be “prescribed by the insured's treating physician in accordance with a treatment plan” — so the diagnosing-credential requirement comes from the carrier, and Anthem applies the unpublished MCG B-806-T. Anthem's commercial ASD Treatment Plan Request Form, which covers ten states, requires for an initial assessment-only request (97151/97152/0362T) or where the member has new coverage a diagnostic evaluation by a doctorate-level clinician or an allowable qualified healthcare provider per state regulations, showing how the patient meets DSM-5-TR criteria.^[14][2]

Anthem's commercial ASD Treatment Plan Request Form asks the diagnostic evaluation to name the standardized tools used, giving ADI-R, ADOS-2 and CARS-2 as examples rather than as a closed list. The statute names none — it defines autism spectrum disorder as “a neurological condition, including Asperger's syndrome and autism, as defined in the Diagnostic and Statistical Manual of Mental Disorders.” Ask the family for the full evaluation report, not the one-line diagnosis letter.^[14][1]

Yes, and it is statutory rather than administrative. Section 4 limits mandated coverage “to treatment that is prescribed by the insured's treating physician in accordance with a treatment plan” — so the treating physician's prescription and the plan it references are coverage conditions on a fully-insured Indiana group policy. Section 5 requires insurers issuing individual policies only to offer the coverage, and self-funded ERISA plans sit outside the chapter. One scope caveat on the authorization itself: Anthem's precertification list applies to local fully insured members and to self-insured (ASO) members only where the group purchased the medical-management program, and on National Accounts precertification for ABA “applies unless the group specifically opts out of clinical review for this benefit.”^[2][3][9]

Anthem names two telehealth place-of-service codes for ABA — 10 (member at home) and 02 (member elsewhere) — but does not publish a national list of telehealth-eligible ABA codes. Its ABA provider resource guide routes the question to the Virtual Visits reimbursement policy, notes that “allowed codes may vary,” and tells providers to consult the allowed virtual services list in addition to CPT Appendix P “to obtain codes that are eligible for reimbursement in your state.” Treat the answer as per-state and per-plan and confirm before scheduling remote hours.^[10]

Blocked on: Anthem's Virtual Visits reimbursement policy and the Indiana allowed-virtual-services list, or Anthem provider services via Availity Essentials.

Depends on how the plan is funded. A fully insured plan issued in Indiana (group, individual or HMO) falls under IC 27-1-37.5-23, in force since July 1, 2025: urgent PA answered “not later than twenty-four (24) hours after receiving the request,” every other PA “not later than forty-eight (48) hours,” with weekends and state and federal holidays excluded; a missed deadline means the service “shall be automatically deemed authorized” (IC 27-1-37.5-28). A self-funded private-employer plan follows the federal ERISA claims rule instead: urgent within 72 hours; pre-service within a reasonable time “but not later than 15 days after receipt of the claim,” with one 15-day extension; and a request to extend an ongoing course of treatment that involves urgent care must be decided within 24 hours if made at least 24 hours before the authorization expires. On self-insured (ASO) groups that did not buy Anthem's medical-management program there is no preapproval and so no clock (see the precertification-scope note in this guide). Anthem's ABA provider resource guide publishes no reauthorization lead time.^[15][16][17]

Ask the plan: Benefits verification call or the Anthem (Availity) provider portal: ask whether the plan is fully insured and issued in Indiana (state 24/48-business-hour clock) or self-funded ERISA (federal 72-hour / 15-day clock), and what turnaround the plan quotes for ABA.

Depends on the family and on plan funding. For a fully insured Indiana group plan, 760 IAC 1-38.1 sets the order: the plan covering the person as employee or subscriber pays before one covering them as a dependent; for a child whose parents are married or living together, “the plan of the parent whose birthday falls earlier in a calendar year” is primary (same birthday: the plan that has covered that parent longest); for parents who are divorced, separated or do not live together, with no court decree, the order is custodial parent, custodial parent's spouse, noncustodial parent, noncustodial parent's spouse — and a decree that makes one parent responsible for health coverage overrides it. A self-funded ERISA plan sets its COB rules in its plan document instead. TRICARE is always “last pay” behind other health coverage (32 CFR 199.8), so this plan pays before TRICARE. If the child also has Indiana Medicaid, this plan pays first and IHCP pays last — but IHCP still requires its own PA (“must also obtain PA from the appropriate IHCP PA contractor”) and will not pay for services this plan denied as out-of-network, so be in this plan's network and get both authorizations.^{[18][19][20][21][22][23]}

Ask the plan: At intake, collect every coverage the child has, both parents' birthdays and any custody or court-decree terms; then ask Anthem (and the other carrier) on the benefits call whether each plan is fully insured or self-funded and which one they show as primary.

Neither Indiana's mandate nor any published Anthem Indiana document states how recent the ASD diagnostic evaluation must be. Anthem reviews ABA under MCG B-806-T, which is licensed and proprietary and is not published, so the recency rule — if there is one — lives in a document you cannot read. What is published is the treatment-plan side: documentation must show the plan reviewed or updated at least every 6 months.^[10]

In licensed criteria: Availity Essentials → Authorizations and Referrals, or Anthem provider services — ask what evaluation age B-806-T accepts. If a denial turns on recency, ask for the criteria in writing; a denial citing the retired CG-BEH-02 is itself an appeal point. MCG B-806-T is licensed proprietary criteria — it is never published and no document request will produce it, so the plan’s own UM reviewer is the only route to the answer.

Anthem names the approved rendering population rather than a ratio: psychiatrists, psychologists, LCSWs, LPCs and LMFTs with special training or experience in applied behavior analysis, BCBAs and BCBA-Ds, “providers practicing under the direction and supervision of the BCBA,” and other mental health providers licensed or authorized by the state and recognized by the plan. Degree-level modifiers HM (less than bachelor's), HN (bachelor's) and HO (master's) identify the rendering staff level. Anthem publishes no hours-per-hours supervision floor for ABA; the only supervision rule with a number attached is the concurrent-billing condition recorded in that field. In Indiana the supervising analyst must hold the state LBA (or LABA) licence, and direct-contact technicians are exempt from licensure only while acting under the extended authority and direction of a licensed behavior analyst.^[10][6]

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. Supervised or directed services billed alongside a QHP-performed procedure are also subject to Anthem's Incident To Services and Billing reimbursement policy.^[10]

Anthem publishes no Indiana-specific per-day unit ceiling, and Indiana's mandate imposes no hour or visit limit of its own. ABA codes may carry CMS MUE limits, which Anthem administers as NCCI edits under its Code and Clinical Editing Guidelines reimbursement policy. The operative ceiling is the weekly approved units on the authorization.^[10][12]

Each medical-record entry must carry author identification — handwritten signature, unique electronic identifier, or initials — plus rendering provider credentials. Entries are expected 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 require total treatment minutes plus start and stop times in the record. Treatment plans must show review or update at least every 6 months.^[10]

POS codes Anthem names for ABA: 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.^[10]

ABA delivered by therapy assistants, behavior technicians or paraprofessionals must show the supervising BCBA or other QHP in box 31 of the CMS-1500, with degree-level modifiers HM, HN and HO identifying the rendering staff level. In Indiana the supervising analyst must hold the state LBA (or LABA) licence; direct-contact technicians are exempt from licensure only while acting under the extended authority and direction of a licensed behavior analyst or assistant behavior analyst.^[10][6]