Virginia is the most legible of Anthem's commercial states for an ABA intake team, because Anthem publishes the code-level answer. Its two Virginia precertification lists — one for HMO and EPO, one for PPO, both updated September 1, 2026 — name 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T and 0373T as individual rows, each with Anthem as the responsible party. That means the assessment is separately authorized, and it means nothing is routed to a delegated vendor.
It also means the product type on the card changes the rulebook. On the HMO/EPO list the criteria column for every ABA row reads "Anthem Applied Behavioral Analysis"; on the PPO list it reads "MCG Guidelines." The force of the requirement differs too: HMO services "require prior approval and will not be eligible for reimbursement if rendered without the appropriate prior authorization," while on EPO and PPO prior approval is "highly recommended" and skipping it triggers a pre-payment claim review that may end in denial. Establish product and funding type before anything else — self-funded ERISA plans are outside Virginia's mandate and answer to federal parity instead.
Both Virginia lists carry a responsible-party column, and for all ten ABA codes it reads Anthem. Carelon Medical Benefits Management appears throughout both documents — it owns imaging, genetic testing, musculoskeletal, oncology and the rehabilitative-therapy codes such as 97140, 97150 and 97161 — but never an ABA code. Carelon Behavioral Health does not appear in either list at all. Send an ABA request to providerportal.com and it lands with a vendor that does not handle it.[1][2]
The criteria split is the detail most guides miss. Every ABA row on the HMO/EPO list points to a criteria set Anthem calls "Anthem Applied Behavioral Analysis." Every ABA row on the PPO list points to "MCG Guidelines" instead — consistent with Anthem's move to MCG B-806-T for ABA reviews in June 2024. Neither criteria set is published, so what you can control is the completeness of the submission.[1][2]
Submission mechanics, from the lists themselves: request prior authorization through Availity, and for mental health and substance use disorder prior authorizations call 800-755-0851, staffed 24/7. For non-urgent requests, submit all required clinical information 14 calendar days before the proposed service where possible. The ordering or rendering provider is responsible for completing the prior-authorization process. Since September 1, 2025 Availity Essentials has been Anthem's stated preferred channel for behavioral health authorizations.[1][2]
Virginia's mandate binds insurers issuing expense-incurred hospital, medical and surgical or major medical policies, corporations issuing subscription contracts, and HMOs, and it extends to state employee coverage and to local-government, teacher and retiree coverage. Since January 1, 2020 it applies to individuals "of any age" — note that the change removed not just the upper age limit but the old age-2 floor as well, so a very young child is squarely inside the mandate.[3]
The cap is still there. Subsection K reads: "Coverage for applied behavior analysis under this section will be subject to an annual maximum benefit of $35,000, unless the insurer, corporation, or health maintenance organization elects to provide coverage in a greater amount." Separately, the statute says coverage "will not be subject to any visit limits." The $35,000 figure is a quantitative treatment limit on a mental-health benefit, which makes its enforceability against a large-group plan a live parity question rather than a settled fact — a plan applying it hard is worth escalating, not accepting on sight.[3]
What Virginia does not have is a small-employer carve-out. The current text contains no employee-count threshold anywhere; the opposite is true, since subsection G expressly extended the mandate to the individual and small group markets for policies delivered, issued for delivery, reissued or extended on or after January 1, 2021. The real exclusions are narrow: short-term travel, accident-only, limited or specified-disease policies; short-term non-renewable policies of not more than six months; and Medicare-eligible policies. There is also a one-year actuarial waiver an insurer may claim, with the Commissioner of Insurance's approval, if behavioral-health-treatment costs exceeded one percent of premiums over the experience period. Self-funded ERISA plans are outside the statute by omission — it reaches insurers, subscription-contract corporations and HMOs, not employers who fund their own benefits.[3]
Covered ABA is "applied behavior analysis when provided or supervised by a board certified behavior analyst who shall be licensed by the Board of Medicine. The prescribing practitioner shall be independent of the provider of applied behavior analysis." A referral written by a clinician inside your own practice can fail this test — capture who ordered it, and their relationship to you.[3]
The statute defines the treatment plan as one developed by a licensed physician or licensed psychologist following a comprehensive evaluation or reevaluation performed consistently with the most recent clinical report or recommendation of the AAP or AACAP. Treatment must likewise be prescribed or ordered by a licensed physician or psychologist who determines the care medically necessary.[3]
The insurer may review the treatment plan "not more than once every 12 months unless the insurer … and the individual's licensed physician or licensed psychologist agree that a more frequent review is necessary," and the cost of any such review is covered under the policy. Virginia's ceiling is twice as generous as Missouri's six months — worth knowing when an Anthem reviewer asks for an off-cycle update on a fully insured plan.[3]
Virginia makes it unlawful to practise as, or hold oneself out as, a behavior analyst or assistant behavior analyst without a licence from the Board of Medicine, which issues the titles Licensed Behavior Analyst and Licensed Assistant Behavior Analyst. Licensure is layered on top of national certification: the application requires documentation of current BACB certification as a Board Certified Behavior Analyst (or Board Certified Assistant Behavior Analyst), and an assistant must document supervision by a licensed behavior analyst under the Board's requirements. The regulations sit at 18VAC85-150, under the authority of §§ 54.1-2400 and 54.1-2957.16.[4][5]
This is where Anthem's own multi-state guidance can mislead. Its ABA provider resource guide lists a broad set of approved service providers — psychiatrists, psychologists, LCSWs, LPCs, LMFTs with ABA training, BCBAs, people working under BCBA direction, and "other mental health service providers licensed or authorized by the state in which they practice." In Virginia the insurance statute narrows that considerably: covered ABA must be provided or supervised by a board certified behavior analyst licensed by the Board of Medicine. Credential to the statute, not to the guide.[4][5]
Anthem's Virginia entity is Anthem Health Plans of Virginia, Inc., and its own boilerplate is precise about geography: Anthem and its affiliate HealthKeepers, Inc. "serve all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123." Anthem's commercial prior-authorization page puts it more colloquially — Virginia "excluding the Northern Virginia suburbs of Washington, D.C." So a family in Fairfax City, Vienna, or east of Route 123 who says they have "Anthem" or "Blue Cross" needs a second question about which Blue plan, because it is not this one and none of the rules on this page govern them.[7][10]
The other current change: effective January 1, 2026, Anthem reimburses ABA on weekly approved units rather than total authorized units. Claims should reflect units rendered within each week up to the weekly medically necessary limit as approved by prior approval, and units above it are ineligible for reimbursement and get adjusted. The affected code set is all ten. Together with the 14-calendar-day lead time on non-urgent requests, that makes a realistic weekly schedule an intake question with direct billing consequences.[7][10]
The questions that decide whether a family can start with Anthem BCBS Virginia, and what they have to bring. Each maps onto something intake should ask on the first call.
Any age. Virginia's mandate has applied to individuals of any age since 1/1/2020 — 2019's HB 2577 removed the old age-2 floor as well as the upper limit — for individual and group policies and HMO contracts, extended to the individual and small group markets for policies delivered, issued, reissued or extended on or after 1/1/2021. ABA remains subject to a $35,000 annual maximum benefit unless the insurer elects more, with no visit limits; as a quantitative treatment limit on a mental-health benefit that cap is a live parity question for large-group plans rather than a settled rule. Self-funded ERISA plans sit outside the statute. Anthem's own Virginia precertification lists carry no age column for the ABA rows.[3][1]
Virginia writes the gate into the benefit itself: covered ABA must be provided or supervised by a board certified behavior analyst licensed by the Board of Medicine, and the prescribing practitioner must be independent of the ABA provider. The treatment plan is defined as one developed by a licensed physician or licensed psychologist following a comprehensive evaluation or reevaluation performed consistently with the most recent clinical report or recommendation of the AAP or AACAP, and treatment must be prescribed or ordered by a licensed physician or psychologist who determines it medically necessary. A referral written by a clinician inside your own practice can fail the independence test. This is where Anthem's own multi-state ABA provider resource guide can mislead: it lists a broad approved set including psychiatrists, psychologists, LCSWs, LPCs, LMFTs with ABA training, BCBAs and people working under BCBA direction. In Virginia the statute is the narrower and controlling standard — credential to the statute, not to the guide.[3][7]
Yes, and it is statutory rather than a carrier rule: treatment must be prescribed or ordered by a licensed physician or licensed psychologist who determines the care medically necessary, and that prescribing practitioner must be independent of the ABA provider. The insurer may review the treatment plan not more than once every 12 months unless the insurer and the individual's licensed physician or psychologist agree more frequent review is necessary, with the cost of any such review covered under the policy. Anthem layers its own process on top: prior authorization is requested through Availity, the mental health and substance use prior-authorization line is 800-755-0851 staffed 24/7, and for non-urgent requests all required clinical information should be submitted 14 calendar days before the proposed service. The ordering or rendering provider is responsible for completing the prior-authorization process. On HMO products services rendered without prior authorization are not eligible for reimbursement; on EPO and PPO prior approval is highly recommended and skipping it triggers a pre-payment claim review that may end in denial.[3][1]
Anthem names the telehealth places of service for ABA directly: 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, alongside POS 12 home, 11 office/clinic, 99 community and 03 school.[7]
Depends on how the plan is funded. Fully insured Virginia plans: Virginia's utilization-review statute requires the entity to "communicate its utilization review decision no later than two business days after receipt by the entity of all information necessary to complete the review" — the clock starts only once the file is complete. Self-funded (ERISA) plans are excluded from that article and follow the federal claims rule instead: a pre-service decision within 15 days of receipt (one 15-day extension allowed, with notice; if the extension is for missing information you get at least 45 days to supply it) and an urgent-care decision within 72 hours; a request to extend an ongoing course of treatment that is urgent is decided within 24 hours if made at least 24 hours before the current authorization expires. Anthem's Virginia precertification lists add a submission lead time: "For non-urgent requests, submit all required clinical information 14 calendar days before the proposed service when possible."[12][13][14][1]
Ask the plan: Benefits verification: ask whether the plan is fully insured (Virginia UR statute applies) or self-funded ERISA (federal 15-day/72-hour rule), and the carrier's turnaround for its behavioral health reviewer.
Anthem's Virginia ABA documents publish no coordination-of-benefits rule; order of benefits follows the plan document. If the child also has TRICARE, this plan pays first — TRICARE is the secondary payer to other health insurance under its double-coverage rule (Medicaid is the only coverage it pays ahead of). CHAMPVA likewise pays last: "In double coverage situations, CHAMPVA would be the last payer." If the child also has Medicaid, this plan is primary and Medicaid pays last. When the child has two parents' plans, the plan's own coordination-of-benefits provision decides the order — a self-funded plan writes its own rules. For Virginia HMO contracts, 14VAC5-211-80 lets the plan coordinate but says it "shall not be relieved of its duty to provide a covered health care service" because of other coverage, must "provide or arrange for the service first and then, at its option, seek coordination of benefits," and "Until a coordination of benefits determination is made, the enrollee shall not be held liable."[15][16][17][18]
Ask the plan: Benefits verification with each plan: which is primary for the child (order-of-benefits rule, custody/court order), and whether the secondary plan needs its own authorization.
No recency window is published. Neither Virginia's statute nor Anthem's Virginia precertification lists date the diagnosis, and neither of the two criteria sets the lists point to — Anthem Applied Behavioral Analysis for HMO and EPO, MCG Guidelines for PPO — is published. What Virginia does date is review: the insurer may review the treatment plan not more than once every 12 months unless the insurer and the individual's licensed physician or psychologist agree more frequent review is necessary.[3][1]
In licensed criteria: Anthem behavioral health prior authorization at 800-755-0851 or via Availity — the criteria sets behind the ABA rows (Anthem Applied Behavioral Analysis; MCG B-806-T) are not published.
No instrument list is published for Virginia. The statute names none; it requires the treatment plan to follow a comprehensive evaluation or reevaluation performed consistently with the most recent clinical report or recommendation of the AAP or AACAP. Anthem's HMO/EPO and PPO criteria sets for ABA are not published, so what you can control is the completeness of the submission.[3][1]
In licensed criteria: Anthem behavioral health prior authorization at 800-755-0851 or via Availity — neither the Anthem Applied Behavioral Analysis criteria nor MCG B-806-T is published.
Coverage decides whether Anthem BCBS Virginia pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Anthem publishes no numeric supervision ratio for Virginia, and neither criteria set its ABA rows point to — Anthem Applied Behavioral Analysis for HMO/EPO, MCG Guidelines for PPO — is published. What does bind is statutory: covered ABA must be provided or supervised by a board certified behavior analyst who is licensed by the Virginia Board of Medicine, making licensure a coverage condition rather than only a credentialing one, and the Board's regulations at 18VAC85-150 make the licensed behavior analyst responsible for care rendered under that supervision, with an assistant behavior analyst required to document supervision by an LBA. Anthem's own ABA provider resource guide reflects the structure on the claim side: work by therapy assistants, behavior technicians or paraprofessionals must show the supervising BCBA or other QHP, with HM, HN and HO identifying the rendering staff level.[3][4][6][7]
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]
No per-day unit ceiling is published for Virginia. Every ABA code carries its own precertification row, and from January 1, 2026 reimbursement runs on weekly approved units — units rendered above the approved weekly limit are ineligible and adjusted. ABA codes may separately carry CMS MUE limits, administered as NCCI edits under Anthem's Code and Clinical Editing Guidelines reimbursement policy.[2][10]
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; separately, Virginia law caps insurer-initiated plan review at once every 12 months absent agreement with the treating physician or psychologist.[7][3]
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, with degree-level modifiers HM, HN and HO identifying the rendering staff level. In Virginia the supervising analyst must additionally be a board certified behavior analyst licensed by the Virginia Board of Medicine, and the prescribing practitioner must be independent of the ABA provider.[7][3]
Yes, and for every code. Anthem's Virginia HMO/EPO and PPO precertification lists name 97151 through 97158 plus 0362T and 0373T as individual rows with Anthem as the responsible party. On HMO, services without prior authorization are not eligible for reimbursement; on EPO and PPO, prior approval is "highly recommended" and skipping it triggers a pre-payment claim review that may end in denial.
Yes. It appears as its own row on both Virginia lists rather than being folded into a treatment authorization, so request it in its own right.
The statute still carries it: Va. Code § 38.2-3418.17(K) subjects ABA to an annual maximum benefit of $35,000 unless the insurer elects to provide more, while separately barring visit limits. As a quantitative treatment limit on a mental-health benefit, its enforceability against a large-group plan is a parity question worth raising rather than conceding.
Any age, for policies delivered, issued for delivery, reissued or extended on or after January 1, 2020. The amendment removed the old lower bound of age two as well as the upper limit.
No. Anthem and its affiliate HealthKeepers, Inc. serve all of Virginia except the City of Fairfax, the Town of Vienna, and the area east of State Route 123. A family in that Northern Virginia sliver holding a Blue card is on a different plan.
A board certified behavior analyst who is also licensed by the Virginia Board of Medicine, or someone under that person's supervision — and the practitioner prescribing the ABA must be independent of the ABA provider. Anthem's multi-state ABA guide lists a broader set of approved providers; in Virginia the statute is the narrower and controlling standard.
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.
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