---
title: Anthem Blue Cross Partnership Plan ABA coverage (Medi-Cal).
url: "https://carelu.com/payers/anthem-blue-cross-partnership-plan-california"
markdown_url: "https://carelu.com/payers/anthem-blue-cross-partnership-plan-california.md"
state: CA (California)
payer: Anthem Blue Cross Partnership Plan (Medi-Cal)
kind: Medicaid managed care plan (MCO)
parent_program: Medi-Cal (California Medicaid)
description: "How Anthem Blue Cross Partnership Plan handles Medi-Cal Behavioral Health Treatment (ABA) — the recommendation-not-diagnosis gate, precertification for assessment and treatment through Availity or fax 855-473-7902, the 30-day treatment-plan rule, 2:10 supervision language and its 7-calendar-day decision clock."
last_reviewed: September 2026
---

# Anthem Blue Cross Partnership Plan ABA coverage (Medi-Cal).

_Payer Guide · Anthem Blue Cross Medi-Cal · Last updated September 2026 · 9 primary sources_

> Anthem Medi-Cal in 15 counties + L.A. Care subcontract; ABA precert via Availity or fax; recommendation, not dx.

Anthem Blue Cross Partnership Plan is Anthem’s Medi-Cal plan: about 745,000 members as prime contractor across 15 counties in August 2026 (Sacramento, Fresno, Tulare, Santa Clara, Kern, San Francisco and the small Regional-model counties among them), plus the members Anthem serves in Los Angeles County under its subcontract with L.A. Care. It follows the state BHT rules closely — a physician or psychologist recommendation opens the door, no autism diagnosis is required — and routes everything, assessment included, through a single precertification form.

This plan administers the **Medi-Cal (California Medicaid)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Medi-Cal (California Medicaid) guide](https://carelu.com/payers/medi-cal-california-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required through the authorization request — Anthem’s Medi-Cal treatment-plan request form covers "initial assessment requests when requesting only 97151/97152 and 0362T," with a diagnostic evaluation, recommendation form, MD progress note or letter "recommending ABA" [2][1]
- **Prior auth for treatment**: Required — ABA is "precertification"; 97153/97154/97155/97158/0373T are requested per week and 97156/97157 per authorization period; the treatment plan "should be dated within 30 days of start date" [2][1]
- **Autism diagnosis required?**: No — Anthem asks for a physician or licensed psychologist recommendation and confirms the diagnosis only "if identified," matching APL 23-010’s "regardless of diagnosis" [2][3][8]

## At a glance

- **Plan type:** Medi-Cal managed care plan — commercial plan in Two-Plan counties, GMC Sacramento, Regional counties; L.A. Care subcontractor
- **Assessment auth:** Yes — 97151/97152/0362T on the ASD Treatment Plan Request Form
- **Treatment auth:** Yes — precertification; plan dated within 30 days of start
- **Diagnosis:** Not required — recommendation from a physician or licensed psychologist; dx "if identified"
- **Submit via:** Availity Essentials (preferred) or fax 855-473-7902
- **Decision clock:** 7 calendar days (up to 14), 72 hours urgent — per the July 2026 manual

## One form for assessment and treatment

Anthem’s Medi-Cal manual says "requests for precertification for ABA should be submitted via fax to 855-473-7902," and the May 2026 Treatment Plan Request Form names Availity Essentials "our preferred method," with the fax as fallback. The same form handles "initial assessment requests when requesting only 97151/97152 and 0362T" — attach a diagnostic evaluation, Anthem’s Recommendation Form, an MD progress note, or a letter confirming "the member’s diagnosis, if identified, and recommending ABA." Treatment requests list 97153, 97154, 97155, 97158 and 0373T per week and 97156/97157 per authorization period, and the plan "should be dated within 30 days of start date." Progress is shown with baseline and updated assessments (the form suggests Vineland, VB-MAPP, ABLLS-R) and cumulative graphs. [1][2][4][10]

Separate from ABA: ASD psychological testing has its own authorization form, to be approved "prior to rendering services." Members can self-refer to network behavioral health providers — "Members do not have to contact Anthem for a referral" — and a family without an agency can be sent to Anthem BH case management via the same fax. [1][2][4][10]

## What Anthem does not publish

No ABA-specific clinical guideline is named for Medi-Cal — Anthem’s UM policy lists Anthem medical and clinical guidelines, MCG (licensed) and Carelon guidelines as its criteria families, available "upon request." Its California behavioral health reimbursement policy page reads "Coming soon," so there is no published rule on concurrent billing or unit edits. Contact details also drift between documents (BH UM 888-831-2246 in the manual, "California Medi-Cal Intake department at 800-407-4627" on the form; Medi-CalBHUM@Anthem.com vs. Medi-calBHUM@wellpoint.com) — record which one gave you an answer. [6][11]

## Intake gates

The questions that decide whether a family can start with Anthem Blue Cross Partnership Plan (Medi-Cal), and what they have to bring.

- **Age limit**: Under 21. The manual’s covered-services grid lists "Applied behavioral analysis (ABA) for members under 21 years of age," and Anthem’s EPSDT policy places ABA under the BHT benefit. [1][7]
- **Diagnosis recency**: Anthem publishes no age limit on the diagnosis or recommendation — its request form and recommendation form carry no recency field, and APL 23-010 sets none. The one date rule is on the treatment plan: it "should be dated within 30 days of start date." [2][3][8]
- **Who may diagnose**: The recommendation or evaluation must come from "a physician, licensed psychologist, or allowable qualified healthcare care provider (QHCP) per state regulations" (request form); the Recommendation Form itself says "A physician or licensed psychologist should complete this form." [2][3]
- **Diagnostic tools required**: None mandated for ABA eligibility. The ASD testing authorization form treats brief screening measures as "an expected part of a routine and complete diagnostic process," and the treatment request suggests "Baseline and updated assessments (for example, Vineland, VB Mapp, ABLLS-R)" for progress. [4][2]
- **Referral required?**: No PCP referral: "Behavioral health providers can be accessed directly by Anthem members. Members do not have to contact Anthem for a referral," and "Members may self-refer to any behavioral healthcare provider in the Anthem network." What is required is the physician/psychologist recommendation, which "The rendering BHT/ABA provider will submit … with a preauthorization request." [10][1][3]
- **Prior-auth decision time**: Anthem’s two documents disagree. The July 2026 manual’s BH timeliness table: routine requests "7 calendar days and up to 14 calendar days when additional information is required," urgent pre-service "Within 72 hours." The older UM policy CA_UMXX_117 (reviewed 2/8/2024) says "within five (5) business days … but no longer than 14 calendar days." Plan against the stricter of the two, and against the state rule (5 business days under APL 21-011, never more than 7 calendar days under 42 CFR 438.210(d) from 2026). Reauthorization: the treatment plan is reviewed at least every six months (APL 23-010). [1][5][12][13]
- **Other insurance (who pays first)**: Anthem follows the Medi-Cal cost-avoidance rule: "If the requested service is covered by the OHC, providers are to instruct the member to seek the service from the OHC carrier," and Anthem "will not process a claim for a member whose Eligibility Record indicates OHC (other than a code F) unless the provider presents proof that all sources of payment have been exhausted"; COB claims without the other carrier’s RA, EOB or denial are "mailed back." "Medicaid is the payer of last resort." Anthem does not say whether its own ABA precertification is needed while it is secondary — get it anyway and confirm with UM. [1][14]
- **Telehealth** _(plan-dependent)_: General rule only: "Utilizing telehealth does not require prior authorization," and Anthem pays live video, audio-only and asynchronous telehealth with the appropriate modifier. For ABA the request form’s place-of-service boxes read "Telehealth (if allowed)" — Anthem publishes no list of which ABA codes it will pay remotely. [1][2]
  - Ask the plan: Anthem Medi-Cal BH UM (888-831-2246) at the time of the request — ask which ABA codes are approved for telehealth on this authorization.

## Delivery and billing rules

Coverage decides whether Anthem Blue Cross Partnership Plan (Medi-Cal) 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 request form describes 97153 as delivered "under the direction of physician/QHCP, receiving 2 hours of supervision for every 10 hours of direct treatment," asks for the supervising BCBA (or other QHCP) and has the signer attest that "any paraprofessional under my supervision has the appropriate education and training." [2]
- **Place of service**: The request form’s setting boxes are Home, Clinic, "School (if allowed)," "Telehealth (if allowed)" and Other. The state rule underneath (APL 23-010) covers home, clinic, community and school settings and bars limiting BHT on school attendance. [2][8]
- **Daily limits / MUEs** _(plan-dependent)_: No Anthem hour cap is published; direct codes are authorized per week on the request form, and APL 23-010 prohibits "caps on number of hours." Claim-level unit edits (MUEs) are not addressed in the documents read. [2][8]
  - Ask the plan: Anthem Medi-Cal provider services or the Availity claim-edit tools — ask whether unit edits apply to 97153/97155 per day.
- **Bill as provider** _(plan-dependent)_: The request form collects the agency’s TIN and NPI and, separately, the "BCBA or rendering care provider" TIN and NPI; the manual says behavioral health services are billed "using behavioral health CPT® codes" to Anthem. No rule on whose NPI goes on a technician’s line is published. [2][1]
  - Ask the plan: Your Anthem Medi-Cal participation agreement or provider services — confirm rendering vs. billing NPI for technician-delivered 97153.
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: Anthem California Medicaid reimbursement policies in Availity, or Anthem Medi-Cal provider services (866-398-1922). [10]

## What intake should collect for Anthem Blue Cross Partnership Plan (Medi-Cal)

- **Recommendation or evaluation:** Anthem Recommendation Form, diagnostic evaluation, MD note or letter recommending ABA — from a physician or licensed psychologist.
- **Plan identity:** Anthem as prime plan vs. L.A. Care member assigned to Anthem — the card decides whose rules and portal apply.
- **Treatment plan date:** Must be within 30 days of the requested start date.
- **Other coverage:** OHC must be billed first; Anthem wants the primary’s RA, EOB or denial on the claim.

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

## Common questions

### Does Anthem Blue Cross Medi-Cal cover ABA?

Yes — for members under 21 as Behavioral Health Treatment, on a recommendation from a physician or licensed psychologist; an autism diagnosis is confirmed only "if identified."

### Does the ABA assessment need prior authorization with Anthem Medi-Cal?

Yes. Anthem runs the assessment (97151/97152/0362T) through the same ASD Treatment Plan Request Form as treatment, via Availity or fax 855-473-7902.

### How fast does Anthem Medi-Cal decide an ABA request?

Its July 2026 manual says 7 calendar days (up to 14 if information is missing) and 72 hours for urgent requests; an older policy says 5 business days. Plan on the shorter clock.

## Primary sources

1. [Anthem Blue Cross Medi-Cal Managed Care Provider Manual (eff. 7/1/2026)](https://providers.anthem.com/docs/gpp/california-provider/CA_CAID_ProviderManual.pdf)
2. [Anthem Blue Cross — Treatment Plan Request Form for Autism Spectrum Disorders, Medi-Cal (May 2026)](https://providers.anthem.com/docs/gpp/california-provider/CA_CAID_ASDTreatmentRequestForm.pdf)
3. [Anthem Blue Cross — BHT/ABA/Autism Services Recommendation Form (Medi-Cal)](https://providers.anthem.com/docs/gpp/california-provider/CA_CAID_Forms_ABAReferral.pdf)
4. [Anthem Blue Cross — Request for Authorization: ASD Testing (Feb 2026)](https://providers.anthem.com/docs/gpp/california-provider/CA_CAID_BHAutismTestingForms.pdf)
5. [Anthem CA_UMXX_117 — Decision and Notification Timeframes (rev. 2/8/2024)](https://mss.anthem.com/california-medicaid/ca_umxx_117.pdf)
6. [Anthem CA_UMXX_118 — Utilization Management Decision and Screening Criteria (rev. 4/18/2024)](https://mss.anthem.com/california-medicaid/ca_umxx_118.pdf)
7. [Anthem CA_PCXX_009 — EPSDT Requirements for Members Under 21 (rev. 12/19/2023)](https://mss.anthem.com/california-medicaid/ca_pcxx_009.pdf)
8. [DHCS APL 23-010 (Revised 11/22/2023) — BHT Coverage for Members Under 21](https://www.dhcs.ca.gov/file/apl23-010-pdf/)
9. [CHHS Open Data — Medi-Cal Managed Care Enrollment Report (August 2026)](https://data.chhs.ca.gov/dataset/medi-cal-managed-care-enrollment-report)
10. [Anthem Blue Cross California — Behavioral Health (provider page)](https://providers.anthem.com/california-provider/patient-care/behavioral-health)
11. [Anthem Blue Cross California — Prior Authorization Requirements (provider page)](https://providers.anthem.com/california-provider/claims/prior-authorization-requirements)
12. [DHCS APL 21-011 (Revised 8/31/2022) — Grievance and Appeals Requirements](https://www.dhcs.ca.gov/file/apl21-011-pdf/)
13. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes](https://www.ecfr.gov/current/title-42/section-438.210)
14. [DHCS APL 22-027 — Cost Avoidance and Post-Payment Recovery for Other Health Coverage](https://www.dhcs.ca.gov/file/apl22-027-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.