---
title: "Anthem BCBS New York ABA coverage: the intake guide."
url: "https://carelu.com/payers/anthem-bcbs-new-york"
markdown_url: "https://carelu.com/payers/anthem-bcbs-new-york.md"
state: NY (New York)
payer: Anthem BCBS New York (formerly Empire)
kind: Commercial insurance
description: "How Anthem Blue Cross and Blue Shield covers ABA in New York: why the 680-hour cap no longer exists, the Empire rebrand, the 28-county service area, NYSED behavior-analyst licensure, and what intake must verify."
last_reviewed: September 2026
---

# Anthem BCBS New York ABA coverage: the intake guide.

_Payer Guide · Anthem BCBS · New York · Last updated September 2026 · 13 primary sources_

> The 680-hour cap was repealed in 2020; Empire is now Anthem; 28-county service area.

Two things about Anthem in New York are still widely repeated and both are wrong. The first is that the plan is called Empire — Empire BlueCross BlueShield was rebranded Anthem effective January 1, 2024, and the underwriting entities were legally renamed Anthem HealthChoice Assurance, Inc. and Anthem HealthChoice HMO, Inc. Member ID numbers and provider contracts did not change. The second is the 680-hour annual ABA ceiling, which almost every ABA resource on the internet still quotes. It was real, it was in the insurance statute rather than a regulation, and it was repealed by the 2019 budget act effective January 1, 2020.

That repeal changes how you argue a case. There is no statutory hour budget to run out of any more. Any hour limit a New York family actually hits on a fully insured Anthem plan is a medical-necessity determination, which means it goes through Article 49 utilization review and external appeal — not a number you have to accept. Self-funded ERISA plans sit outside the state mandate entirely and answer to federal parity, so plan funding type remains the first fact benefits verification establishes.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Yes — 97151, 97152 and 0362T are authorized per authorization period, with an assessment-only pathway on Anthem's ASD form [10]
- **Prior auth for treatment**: Yes — 97153, 97154, 97155, 97158 and 0373T are authorized per week [10]
- **Autism diagnosis required?**: Yes — and the ABA must be prescribed or ordered by a licensed physician or licensed psychologist; an LBA may not diagnose or self-refer [2][7]

## At a glance

- **Brand:** Empire BCBS became Anthem BCBS effective January 1, 2024 — same member IDs
- **Service area:** 28 New York counties (17 southeastern + 11 northeastern)
- **State mandate:** NY Ins. Law §§ 3216(i)(25) individual, 3221(l)(17) group, 4303(ee) Article 43/HMO
- **680-hour cap:** REPEALED — struck by Ch. 57 of the Laws of 2019, effective 1/1/2020
- **Age / dollar limits:** None in the current statute
- **Criteria applied:** MCG B-806-T — replaced CG-BEH-02 for ABA on June 1, 2024
- **Submit via:** Availity Essentials (preferred) or fax 866-582-2287, on the ASD Treatment Plan Request Form
- **Licensure:** NYSED Licensed Behavior Analyst (LBA) or CBAA — BACB certification alone is not a NY license

## The 680-hour cap is gone. Stop quoting it.

New York's autism mandate did once carry an explicit ABA ceiling. DFS described it plainly in 2014: the mandate "includes coverage for 680 hours of applied behavior analysis ('ABA') treatment per policy or calendar year per covered individual diagnosed with ASD." That sentence lived in the statute itself, in §§ 3216(i)(25)(B), 3221(l)(17)(B) and 4303(ee)(2) — not in a regulation, and not in 11 NYCRR Part 440, which was a short-lived emergency regulation about licensure standards that expired on October 11, 2014. [1][2][5]

The 2019 budget act (S.1507-C / A.2007-C, Part BB, Subpart A, enacted as Chapter 57 of the Laws of 2019) struck the sentence from all three sections. In New York bill drafting, square brackets mark language being deleted, and the bill shows the cap bracketed out. The act took effect on the first of January following enactment and applied to all policies and contracts issued, renewed, modified, altered or amended on or after that date — January 1, 2020. Grep the current statute for "six hundred eighty" and it is not there. [1][2][5]

What replaced it cuts the other way. The current text says a policy "shall not contain any limitations on visits that are solely applied to the treatment of autism spectrum disorder," forbids financial requirements or treatment limitations on ASD benefits more restrictive than those applied to substantially all medical and surgical benefits, and requires coverage consistent at minimum with federal MHPAEA. Bills to put the 680 hours back have been introduced in four consecutive sessions — the current one, A3896, sat in Assembly committee as of January 2026 — and none has passed. One caveat worth carrying: DFS Circular Letter No. 6 (2014) is still live and still authoritative on the licensure point, but its background recital of 680 hours is outdated. Cite it for licensure, never for hours. [1][2][5]

## Empire is Anthem — and only in 28 counties

Anthem's own provider FAQ told New York providers that most communications would move to the Anthem brand beginning January 1, 2024, that members would get a new ID card with the Anthem logo but the member ID number would not change, and that existing agreements and contracts with Empire were unaffected. So an Empire card in a family's folder is an Anthem card; do not treat it as a different payer or re-verify it as one. [8][9]

Geography is the fact that actually saves intake time. Anthem's New York provider manual names its service area as 28 counties: Albany, Bronx, Clinton, Columbia, Delaware, Dutchess, Essex, Fulton, Greene, Montgomery, Kings, Nassau, New York, Orange, Putnam, Queens, Rensselaer, Richmond, Rockland, Saratoga, Schenectady, Schoharie, Suffolk, Sullivan, Ulster, Warren, Washington and Westchester. Seventeen southeastern counties carry the trade name "Anthem Blue Cross and Blue Shield"; eleven northeastern counties carry "Anthem Blue Cross" — so the exact brand wording on the card is itself a geography tell. If a family lives outside those 28 counties, their Blue plan is somebody else — Excellus, Highmark, MVP, CDPHP or Independent Health — and this guide does not govern them. [8][9]

## What the mandate actually requires

- **Three sections, three markets:** § 3216(i)(25) binds individual accident and health policies; § 3221(l)(17) binds group or blanket policies; § 4303(ee) binds Article 43 corporations and HMOs. Between them they cover essentially every state-regulated New York plan. [2][3][4]
- **No age limit, no dollar cap, no hour cap:** The current text carries none of the three. The original 2011 law had a $45,000 annual ABA cap; that gave way to the 680 hours, which is itself now repealed. [2][3][4]
- **A physician or psychologist must prescribe or order it:** Covered treatment is that "prescribed or ordered for an individual diagnosed with autism spectrum disorder by a licensed physician or a licensed psychologist." This is not optional paperwork — it is the definition of what the plan owes. [2][3][4]
- **Utilization review survives:** The statute expressly preserves utilization review and external appeals under Article 49, plus case management and other managed-care provisions. That is the arena an hour dispute now plays out in. [2][3][4]
- **The IEP carve-out:** Coverage may be denied on the basis that the treatment is being provided under an IEP under Article 89 of the Education Law — but services provided on a supplemental basis outside an educational setting stay covered when prescribed. Document the school-day boundary carefully. [2][3][4]

## Licensure: New York does not accept a BCBA alone

New York licenses two credentials through the State Education Department: Licensed Behavior Analyst (LBA) and Certified Behavior Analyst Assistant (CBAA), the latter working under LBA supervision. NYSED is explicit that BACB certification "may be included in advertising in New York State" but "may not be used as a license to practice in New York State," and the grandparenting pathway closed in January 2016. DFS ties this straight to reimbursement: a person providing ABA must be an LBA, or a CBAA supervised by an LBA, for their services to be eligible for health insurance coverage. [6][7][5]

The scope limits matter just as much at intake. An LBA or CBAA may not diagnose the condition ABA is being provided for, and may not prescribe or order ABA for a particular individual. NYSED tells LBAs to verify a client's ASD diagnosis before providing services, precisely because the diagnosis and the order have to come from someone else. Practically: no New York case should open without both the diagnostic report and a physician's or psychologist's order in hand — and the mandate requires the same thing, so the payer and the licensure board are asking for the identical document. [6][7][5]

## Submitting the authorization

Anthem reviews ABA itself — there is no delegated behavioral health vendor in the New York commercial path we could find, and Carelon Medical Benefits Management's New York programme is cardiology, genetic testing, radiology, musculoskeletal, surgical and radiation therapy, not ABA. The instrument is Anthem's Treatment Plan Request Form for Autism Spectrum Disorders, a commercial form explicitly covering New York. Requests go through Availity as the preferred channel, with fax 866-582-2287 as the alternative, and must include BCBA (or other qualified healthcare professional) information plus the form itself. [10][12][13]

The form tells you how the authorization is shaped. You mark the request comprehensive or focused. 97151, 97152, 0362T, 97156 and 97157 are authorized per authorization period; 97153, 97154, 97155, 97158 and 0373T are authorized per week — and 0362T and 0373T each require clinical justification. There is an assessment-only pathway for 97151, 97152 and 0362T, or where the member has new coverage, requiring a diagnostic evaluation by a doctorate-level clinician or allowable qualified healthcare provider showing DSM-5-TR criteria and naming the standardized tools used (the form offers ADI-R, ADOS-2 and CARS-2 as examples). The treatment plan should be dated within 30 days of the start date. [10][12][13]

Two more things to know. The criteria set changed: effective June 1, 2024 Anthem moved ABA reviews from CG-BEH-02 and MCG W0153 to MCG B-806-T, and MCG guidelines are proprietary and unpublished — so the form, not a public policy document, is your best guide to what a complete request looks like. And from January 1, 2026, Anthem reimburses ABA on weekly approved units rather than total authorized units, with units above the approved weekly limit ineligible and adjusted, which is the same per-week structure the form already reflects. [10][12][13]

## Intake gates

The questions that decide whether a family can start with Anthem BCBS New York (formerly Empire), and what they have to bring.

- **Age limit**: None. “The current text carries none of the three” — no age limit, no dollar cap, no hour cap. The original 2011 law carried a $45,000 annual ABA cap; that gave way to the 680-hour ceiling, which Chapter 57 of the Laws of 2019 struck from §§ 3216(i)(25), 3221(l)(17) and 4303(ee) effective for policies issued, renewed, modified, altered or amended on or after January 1, 2020. So an adult ABA case on a fully-insured New York Anthem plan is mandate-covered, in sharp contrast with New York Medicaid’s under-21 rule. Self-funded ERISA plans sit outside the mandate entirely. [2][3][4]
- **Diagnosis recency**: No recency rule on the diagnosis itself — neither the mandate nor Anthem’s ASD form sets a maximum age for the diagnostic evaluation. What Anthem does date is the plan: “the treatment plan should be dated within 30 days of the start date,” and treatment plans must show review or update at least every six months. MCG B-806-T, the criteria set Anthem applies to ABA since June 1, 2024, is proprietary and unpublished, so the form is the best available guide to what a complete request looks like. [10][11]
- **Who may diagnose**: A licensed physician or a licensed psychologist, and this is not optional paperwork — the mandate defines covered treatment as that “prescribed or ordered for an individual diagnosed with autism spectrum disorder by a licensed physician or a licensed psychologist.” NYSED reinforces it from the licensure side: an LBA or CBAA “may not diagnose the condition ABA is being provided for, and may not prescribe or order ABA for a particular individual,” and NYSED tells LBAs to verify a client’s ASD diagnosis before providing services. Anthem’s assessment-only pathway asks for “a diagnostic evaluation by a doctorate-level clinician or allowable qualified healthcare provider.” [2][7][6][10]
- **Diagnostic tools required**: Anthem wants the whole evaluation, not a diagnosis letter. The assessment-only pathway for 97151, 97152 and 0362T — also used where the member has new coverage — requires a diagnostic evaluation by a doctorate-level clinician or allowable qualified healthcare provider showing DSM-5-TR criteria and naming the standardized tools used, with the form offering ADI-R, ADOS-2 and CARS-2 as examples rather than as a required list. Ask for the full report at first contact. [10]
- **Referral required?**: Required by statute, not just by form: the mandate covers treatment “prescribed or ordered… by a licensed physician or a licensed psychologist,” and NYSED bars your LBA from supplying the order or the diagnosis. Both the payer and the licensure board therefore ask for the identical document, so no New York case should open without the diagnostic report and the physician’s or psychologist’s order in hand. Authorization then runs on Anthem’s Treatment Plan Request Form for Autism Spectrum Disorders through Availity (preferred) or fax 866-582-2287, with BCBA or other qualified healthcare professional information included; no referral validity window is published. [2][7][10]
- **Prior-auth decision time**: Anthem’s New York manual publishes its UM clock: a non-urgent pre-service request is decided “within three (3) business days of receipt of all necessary information”; a continued-stay (concurrent) request “within one (1) business day of receipt of all necessary clinical information or 72 hours, whichever is shorter”; urgent requests within one business day of all necessary clinical information or 72 hours, whichever is shorter; post-service within 30 calendar days. A missed deadline is “deemed to be an adverse determination subject to appeal.” These track Insurance Law §4903. For PPO, EPO and indemnity products the precert duty sits on the member, but providers should request it. No ABA reauth lead time is published; the ABA guide expects the treatment plan “reviewed and/or updated at a min of every 6 months.” [8][11][14]
- **Other insurance (who pays first)** _(plan-dependent)_: Anthem’s manual covers what it pays as secondary, not who is primary: it pays in accordance with the agreement and the member’s health benefit plan, the secondary payment plus all other sources “including the Member, shall add up to one hundred percent (100%) of the Plan rate,” and the member owes no more than if Anthem were primary. Bill the primary first and include its EOB on paper COB claims (or submit via Availity). For a child covered through both parents, New York’s COB regulation (binding on fully insured plans) applies 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” (month and day only; same birthday — the plan that covered the parent longer). Divorced or separated parents: the custodial parent’s plan, then the custodial parent’s spouse’s plan, then the other parent’s — unless a court decree assigns health costs to one parent. A plan covering the child as the subscriber pays before a dependent plan. Medicaid is never the primary “plan” (the regulation excludes “a State plan under Medicaid”), so a child with Medicaid as well bills the commercial plan first. [8][15]
  - Ask the plan: the carrier’s eligibility response (Availity or the ID-card number) for an other-insurance record, and both parents’ birth dates and custody arrangements at intake; a self-funded plan follows its own plan document
- **Telehealth** _(ask the plan)_: Anthem names the place-of-service codes but not the code list. For ABA it identifies POS 10 for telehealth with the member at home and POS 02 for telehealth with the member elsewhere, “each subject to the member’s coverage and plan review,” and directs providers to its Virtual Visits reimbursement policy, noting that “allowed codes may vary” and pointing to the allowed virtual services list plus CPT Appendix P for state-by-state eligibility. So which ABA codes are payable by telehealth in New York is a per-plan lookup, not a published rule. [11]
  - Ask the plan: Anthem’s Virtual Visits reimbursement policy and the allowed-virtual-services list for New York — confirm ABA code eligibility before scheduling remote sessions.

## Delivery and billing rules

Coverage decides whether Anthem BCBS New York (formerly Empire) 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 lists who may deliver ABA — “psychiatrists (MDs), psychologists (PhDs), licensed clinical social workers (LCSWs), licensed professional counselors (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 publishes no ratio, cap or observation cadence. In New York that list is narrowed by law rather than by Anthem: NYSED licenses only the LBA and the CBAA (the latter under LBA supervision), says BACB certification “may not be used as a license to practice in New York State,” and DFS has tied reimbursement to exactly that — a person providing ABA must be an LBA, or a CBAA supervised by an LBA, for their services to be eligible for health insurance coverage. The grandparenting pathway closed in January 2016. [11][6][5]
- **Concurrent billing (97153 + 97155)**: 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. [11]
- **Daily limits / MUEs**: No per-day unit ceiling is published. The authorization itself is shaped per code: 97151, 97152, 0362T, 97156 and 97157 are authorized per authorization period, while 97153, 97154, 97155, 97158 and 0373T are authorized per week — and from January 1, 2026 weekly units above the approved limit are ineligible for reimbursement. ABA codes may separately carry CMS MUE limits, administered as NCCI edits under Anthem's Code and Clinical Editing Guidelines policy. [10][13]
- **Session-note signature**: 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. Treatment plans must show review or update at least every 6 months, and the plan submitted with a request should be dated within 30 days of the start date. [11][10]
- **Place of service**: 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. Note the New York mandate separately permits a plan to deny treatment delivered under an IEP while covering supplemental services outside the educational setting, so school-based ABA needs that distinction documented. [11][2]
- **Bill as provider**: 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 New York, DFS additionally requires that the person providing ABA be a NYSED-Licensed Behavior Analyst, or a CBAA supervised by one, for the services to be eligible for insurance coverage. [11][5]

## What intake should collect for Anthem BCBS New York (formerly Empire)

- **Plan funding type, first:** Fully insured New York plan (the mandate and its no-cap rules apply) vs. self-funded ERISA (preempted; federal parity and the plan document govern). Nothing else on this page is reliable until you know which.
- **County of residence:** Anthem New York serves 28 counties. Outside them, an "Anthem" or "Blue Cross" answer means a different carrier — confirm before building the file.
- **The prescribing physician or psychologist:** Both the mandate and NYSED's scope rules require the ABA to be prescribed or ordered by a licensed physician or licensed psychologist. Your LBA cannot supply it.
- **Full diagnostic evaluation, not a diagnosis letter:** Anthem's ASD form wants a doctorate-level evaluation showing DSM-5-TR criteria and the standardized tools used. Ask for the whole report at first contact.
- **NYSED license numbers:** LBA for the supervising analyst, CBAA for assistants. A BCBA credential alone will not support coverage in New York.
- **School hours and IEP services:** The mandate lets a plan deny treatment provided under an IEP while preserving supplemental services outside the educational setting. Capture the school schedule and IEP services so the request draws that line explicitly.

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

## Common questions

### Is ABA still capped at 680 hours a year in New York?

No. The 680-hour ceiling was written into NY Insurance Law §§ 3216(i)(25), 3221(l)(17) and 4303(ee), and Chapter 57 of the Laws of 2019 struck it from all three, effective for policies issued, renewed, modified, altered or amended on or after January 1, 2020. The current statute carries no hour cap, no dollar cap and no age limit, and forbids visit limits applied solely to autism. Bills to reinstate the 680 hours have been introduced repeatedly and none has passed.

### Is Empire BlueCross BlueShield the same as Anthem in New York?

Yes. Empire was rebranded Anthem effective January 1, 2024 and the underwriting entities were renamed Anthem HealthChoice Assurance, Inc. and Anthem HealthChoice HMO, Inc. Member ID numbers did not change and existing provider agreements were unaffected.

### Does Anthem cover all of New York State?

No — 28 counties, split between 17 southeastern counties trading as "Anthem Blue Cross and Blue Shield" and 11 northeastern counties trading as "Anthem Blue Cross." Elsewhere in the state the Blue plan is Excellus, Highmark, MVP, CDPHP or Independent Health.

### Can a BCBA deliver covered ABA in New York?

Not on BACB certification alone. New York requires a NYSED Licensed Behavior Analyst, or a Certified Behavior Analyst Assistant supervised by one, and DFS has said that is what makes the services eligible for insurance coverage. NYSED also bars LBAs and CBAAs from diagnosing or from prescribing or ordering ABA — that has to come from a licensed physician or psychologist.

### Which criteria does Anthem apply to ABA in New York?

MCG B-806-T. Anthem notified commercial providers that effective June 1, 2024 it would transition from CG-BEH-02 and MCG W0153 to MCG B-806-T for medical-necessity and clinical-appropriateness reviews. MCG guidelines are proprietary and not published, so build the request around Anthem's Treatment Plan Request Form for Autism Spectrum Disorders.

## Primary sources

1. [NY S.1507-C (Ch. 57 of the Laws of 2019), Part BB, Subpart A](https://www.nysenate.gov/legislation/bills/2019/S1507/amendment/C)
2. [NY Insurance Law § 3216 (current)](https://law.justia.com/codes/new-york/isc/article-32/3216/)
3. [NY Insurance Law § 3221 (current)](https://law.justia.com/codes/new-york/isc/article-32/3221/)
4. [NY Insurance Law § 4303 (current)](https://law.justia.com/codes/new-york/isc/article-43/4303/)
5. [DFS Insurance Circular Letter No. 6 (2014)](https://www.dfs.ny.gov/industry_guidance/circular_letters/cl2014_06)
6. [NYSED Office of the Professions — Licensed Behavior Analysts FAQ](https://www.op.nysed.gov/professions/licensed-behavior-analysts/frequently-asked-questions)
7. [NYSED — LBA/CBAA assessment and treatment plans](https://www.op.nysed.gov/professions/licensed-behavior-analysts/professional-practice/assessment-and-treatment-plans)
8. [Anthem New York Provider Manual (effective July 1, 2026)](https://www.anthembluecross.com/content/dam/digital/docs/anthembluecross/provider/commercial/manuals/PM_NY_000016.pdf)
9. [Anthem — FAQs: our upcoming rebrand to Anthem (Empire, November 2023)](https://providers.anthem.com/docs/gpp/NYE_FAQs.pdf)
10. [Anthem — Treatment Plan Request Form for Autism Spectrum Disorders (commercial, December 2025)](https://www.anthembluecross.com/content/dam/digital/docs/anthembluecross/provider/commercial/forms/NY_BH_00001.pdf)
11. [Anthem ABA Provider Resource Guide — New York and 10 other states (June 2025)](https://www.anthembluecross.com/content/dam/digital/docs/anthembluecross/provider/commercial/forms/aba-provider-resource-guide-abc-ny.pdf)
12. [Anthem — MCG care guidelines 27th edition update (New York, Commercial, Feb 1 2024)](https://providernews.anthem.com/new-york/articles/mcg-care-guidelines-27th-edition-update-17867-17867)
13. [Anthem New York — Streamlined ABA claim process starts January 1, 2026](https://providernews.anthem.com/new-york/articles/streamlined-aba-claim-process-starts-january-1-2026-27878)
14. [NY Insurance Law §4903 — utilization review determinations](https://www.nysenate.gov/legislation/laws/ISC/4903)
15. [11 NYCRR §52.23 (Regulation 62) — Coordination of benefits](https://www.law.cornell.edu/regulations/new-york/11-NYCRR-52.23)

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.