Anthem BCBS Missouri ABA coverage: the intake guide.

A six-month ceiling on plan review

Outside inpatient services, the statute gives the carrier the right to review the treatment plan "not more than once every six months" unless the carrier and the treating physician or psychologist agree more frequent review is necessary — and the cost of obtaining any review or treatment plan is borne by the plan, not the provider. If an Anthem Missouri authorization is being re-reviewed more often than that on a fully insured plan, that is a cite-able objection.^[1][6]

Line therapists are reimbursable

The statute directs reimbursement to the autism service provider or to the entity or group the supervising board-certified behavior analyst works for, and expressly includes line-therapist services delivered under that supervision when they are in the treatment plan and medically necessary.^[1][6]

National Accounts can opt out of ABA precert

On Anthem National Accounts business, "precertification for ABA is recommended and applies unless the group specifically opts out of clinical review for this benefit. Retrospective review is allowed." A national-account family may need no precert at all — worth one phone call before you build a file.^[1][6]

Anthem's form sets a doctorate-level bar with a state-law escape hatch: for an initial assessment-only request (97151/97152/0362T) or where the member has new insurance coverage, you must include “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. Missouri's mandate then adds the ordering requirement, which is narrower: ABA must be ordered by the treating licensed physician or psychologist in a treatment plan. Ask for the full evaluation report, not a one-line diagnosis letter.^[11][1]

The diagnostic evaluation must name the standardized tools used — Anthem's commercial ASD Treatment Plan Request Form gives ADI-R, ADOS-2 and CARS-2 as examples rather than as a closed list — and must show how the patient meets DSM-5-TR criteria. Missouri's mandate names no instrument. Capture the tool, the administration date and the administering clinician at intake; the form asks for all three in the same breath as the diagnosis.^[11][1]

Anthem's Missouri manual covers the mechanics, not the order: when Anthem is secondary, its payment "plus the amounts owed by all other sources, including the Member, shall add up to one hundred percent (100%) of the Plan rate"; "Include Explanation of Benefit (EOB) from primary insurance carrier with Coordination of Benefits (COB) Claims submitted for secondary payment," matched to each service line and charge, with CMS-1500 fields 9–9d completed. The order of benefits comes from state law for fully insured plans. Missouri's COB rule (20 CSR 400-2.030) governs fully insured group plans: when parents are not separated or divorced, "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" (same birthday: the plan that covered the parent longer); for divorced or separated parents a court decree naming the responsible parent controls. Self-funded plans follow their plan document. If the child also has Medicaid, this plan pays first: Medicaid is payer of last resort (42 CFR 433.139) — bill here, then send the EOB or denial to Medicaid, and get Medicaid's own prior auth too if the state requires it. TRICARE is secondary to this plan ("TRICARE shall be last pay," 32 CFR 199.8), and "CHAMPVA is the last payer to OHI" (38 CFR 17.276(d)).^{[12][15][16][17][18]}

The mandate sets no overall age limit on autism coverage — what it ages out is the dollar cap. RSMo § 376.1224 subjects ABA to “a maximum benefit of forty thousand dollars per calendar year for individuals through eighteen years of age,” a statutory base that is CPI-indexed (the Department of Commerce and Insurance publishes the adjusted figure annually). Coverage required under the section other than ABA “shall not be subject to the age and dollar limitations described in this subsection,” so OT, PT, speech, psychiatric and pharmacy care for autism carry no age cut-off and no dollar cap. Self-funded private ERISA plans are preempted from all of it; note Missouri's unusual reach into the state consolidated health care plan, self-insured governmental plans, MEWAs and self-insured school-district plans established on or after 1/1/2020.^[1]

Ask the plan: Benefits verification on the specific plan, via the payer portal or the number on the member’s card — ask whether RSMo § 376.1224 reaches this plan (it reaches fully-insured plans, the state consolidated health care plan, self-insured governmental plans, MEWAs and self-insured school-district plans established on or after 1/1/2020, but not private self-funded ERISA plans), and what the plan applies as this year’s dollar cap. The Missouri Department of Commerce and Insurance publishes the CPI-adjusted figure annually — quote that year’s number, never the $40,000 statutory base.

Yes on a plan the mandate reaches, and the statute is specific about who writes it: ABA “must be ordered by the treating licensed physician or psychologist” in a treatment plan, and must be supervised by a board-certified behavior analyst licensed under chapter 337. Capture the ordering physician or psychologist and the treatment plan they signed. Two Missouri rules work in the provider's favour once the order exists: the carrier may review the treatment plan no more than once every six months unless the provider agrees otherwise, and the cost of obtaining any review or treatment plan is borne by the plan. Self-funded private ERISA plans are outside the statute.^[1]

Ask the plan: Benefits verification on the specific plan, via the payer portal or the number on the member’s card — confirm first whether RSMo § 376.1224 reaches this plan. Where it does, capture the ordering licensed physician or psychologist and the treatment plan they signed, and the supervising chapter 337 licensed behavior analyst. Where it does not (a private self-funded ERISA plan), ask the carrier whether it requires a physician or psychologist order and in what form.

Anthem names two telehealth place-of-service codes for ABA — 10 (member at home) and 02 (member elsewhere) — but publishes no 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 directs providers to the allowed virtual services list in addition to CPT Appendix P “to obtain codes that are eligible for reimbursement in your state.” Confirm per state and per plan before scheduling remote hours — and remember that weekly approved units since March 1, 2026 bound the week regardless of how the hours are delivered.^[7]

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

Anthem publishes no number of its own: "UM review timeframes follow Federal, State, and accreditation requirements as applicable to the review," and providers "shall make best efforts to supply requested information within twenty-four (24) hours of request." No ABA reauthorization lead time is published; the ASD treatment-plan form says only that the "Treatment plan should be dated within 30 days of start date." Missouri fully insured plans are bound by RSMo 376.1363: a carrier "shall make the determination within thirty-six hours, which shall include one working day, of obtaining all necessary information," with an approval phoned or sent electronically to the provider within 24 hours; concurrent review (continuing an approved course) is decided "within one working day of obtaining all necessary information." The clock starts when the file is complete, not when the form lands. Self-funded ERISA plans are outside state law and follow 29 CFR 2560.503-1: a pre-service decision "not later than 15 days after receipt of the claim" (one 15-day extension), 72 hours for urgent care, and an urgent extension request decided within 24 hours if made at least 24 hours before the approval expires.^{[12][11][13][14]}

Ask the plan: Anthem / Carelon behavioral health UM (number on the member ID card): confirm fully insured vs. self-funded, and how far before expiry Anthem wants the ABA reauthorization — no lead time is published.

The rule Anthem does publish attaches to the treatment plan, not the diagnosis: the ASD Treatment Plan Request Form requires the treatment plan to be dated within 30 days of the start date. On the diagnosis itself Anthem reviews under MCG B-806-T, which is licensed, proprietary and unpublished, so any recency criterion is in a document you cannot read. What triggers a fresh diagnostic evaluation is a request type rather than a date: an initial assessment-only request covering 97151, 97152 and 0362T, or a member with new insurance coverage, must include a diagnostic evaluation. On a fully-insured Missouri plan the statute caps re-review of the treatment plan at once every six months.^[11][1]

In licensed criteria: Availity Essentials → Authorizations and Referrals, or fax 866-582-2287 with the ASD Treatment Plan Request Form — ask what evaluation age B-806-T accepts. 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, and Anthem publishes no hours-per-hours supervision floor for ABA. Missouri supplies the binding credential instead, and writes it into the mandate itself: ABA must be supervised by a board-certified behavior analyst licensed under chapter 337, and an “autism service provider” is defined by that licence rather than by BACB certification alone.^[7][1][3]

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.^[7]

Anthem publishes no Missouri-specific per-day unit ceiling. ABA codes may carry CMS MUE limits, which Anthem administers as NCCI edits under its Code and Clinical Editing Guidelines reimbursement policy and realigns when CMS updates them. The ceiling that actually bites is the weekly approved units on the authorization (effective March 1, 2026).^[7][8]

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 — and on fully insured Missouri plans the carrier may not compel that review more than every 6 months.^[7][1]

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.^[7]

ABA delivered by therapy assistants, behavior technicians or paraprofessionals must show the supervising BCBA or other QHP in box 31 of the CMS-1500. Degree-level modifiers HM, HN and HO identify the rendering staff level. Missouri's mandate separately directs reimbursement to the autism service provider or to the entity the supervising board-certified behavior analyst works for, and expressly covers line-therapist services under that supervision.^[7][1]