---
title: Anthem HealthKeepers Plus ABA coverage (Cardinal Care MCO).
url: "https://carelu.com/payers/anthem-healthkeepers-plus"
markdown_url: "https://carelu.com/payers/anthem-healthkeepers-plus.md"
state: VA (Virginia)
payer: Anthem HealthKeepers Plus (VA)
kind: Medicaid managed care plan (MCO)
parent_program: Virginia Medicaid (DMAS)
description: "How Anthem HealthKeepers Plus administers Virginia Medicaid ABA — DMAS standardized forms and criteria, the published code/modifier/POS grid, telehealth and school place-of-service rules, and Availity submission."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Anthem HealthKeepers Plus ABA coverage (Cardinal Care MCO).

_Payer Guide · Anthem HealthKeepers Plus · Last updated September 2026 · 6 primary sources_

> DMAS forms via Availity/ICR; publishes the clearest code/modifier/POS grid in Virginia.

Anthem HealthKeepers Plus administers Virginia's Cardinal Care ABA benefit on the DMAS standardized forms — its own initial SA form carries the DMAS header and admission criteria verbatim. What Anthem uniquely contributes is clarity: a published code/modifier/place-of-service grid that answers the billing questions other plans leave to trial and error, including telehealth combinations and school-setting rules.

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

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Not required — published grid confirms no SA on 97151, 97152, 0362T [1]
- **Prior auth for treatment**: Required — 97153–97158, 0373T on DMAS standardized forms; ≥20 hrs/wk needs the activity schedule [1][2]
- **Autism diagnosis required?**: NO — not autism-restricted, and not category-restricted either. DMAS Appendix D admits a youth under 21 who meets criteria for a primary ICD diagnosis correlating to a DSM diagnosis, OR who has a provisional psychiatric diagnosis developed by an LMHP when no definitive diagnosis has been made, plus at least two functional-impairment criteria. The ABA criteria name no diagnostic category list and never mention autism [3]

## At a glance

- **Plan type:** Cardinal Care MCO (HealthKeepers, Inc.)
- **Clinical rules:** DMAS criteria + standardized forms, verbatim
- **Assessment auth:** None — grid confirms 97151, 97152, 0362T auth-free
- **Submission:** Availity Essentials / Interactive Care Reviewer
- **Telehealth:** GT combos payable on 97151, 97153, 97155, 97156 et al.
- **School setting:** POS 03 allowed for 97151, 97155, 97156

## The grid worth bookmarking

Anthem's February 2023 provider bulletin publishes the full ABA code/modifier/place-of-service grid: no service authorization on 97151, 97152, and 0362T; SA required on 97153–97158 and 0373T; GT telehealth combinations payable on the assessment, direct-treatment, and family-training codes; and school as an allowed place of service (POS 03) for 97151, 97155, and 97156 — useful for IEP-adjacent care coordination. The initial SA form requires an LMHP-level attestation signature and a listing of all ABA or behavior-therapy treatment episodes from the past 12 months across all providers — so prior-treatment history is an intake question, not a billing afterthought. [1][2]

## Submission mechanics

Behavioral-health authorizations submit digitally through Availity Essentials' Interactive Care Reviewer; provider services runs at (800) 901-0020. The DMAS rules apply unchanged: per-code unit requests since October 2025, the ≥20-hours/week activity-schedule requirement (stated on Anthem's own form), and the under-21 EPSDT scope in effect since December 2021. [4]

## Intake gates

The questions that decide whether a family can start with Anthem HealthKeepers Plus (VA), and what they have to bring.

- **Age limit**: Follows the Virginia Medicaid (DMAS) rule: under 21 — Appendix D's ABA admission criteria state it as the first requirement, and the benefit rides EPSDT, so there is no hard hour cap beneath it. [3][1]
- **Diagnosis recency**: Follows the Virginia Medicaid (DMAS) rule: no recency window on the diagnosis. Appendix D admits on a current primary ICD diagnosis correlating to a DSM diagnosis, or on a provisional psychiatric diagnosis developed by an LMHP where no definitive diagnosis has been made — and DMAS states there is no timeframe for the use of a provisional psychiatric diagnosis, expecting the LBA to follow up with the youth's physician or other LMHPs as more information is gathered. What must stay current is the assessment: it is reviewed and updated at least annually by the LBA, LABA or LMHP, and continued-stay criteria test symptoms within the past 30 days. [3][5][1]
- **Who may diagnose**: Follows the Virginia Medicaid (DMAS) rule: two different questions, and Appendix D answers both. The diagnosis: the youth must currently meet criteria for a primary ICD diagnosis that correlates to a DSM diagnosis, or have a provisional psychiatric diagnosis as developed by an LMHP — Appendix D does not restrict the benefit to autism or name a specialty list of diagnosing clinicians. The ABA assessment: it must be completed by an LBA, LABA or LMHP acting within scope (an LMHP-R, LMHP-RP or LMHP-S with completed education and training in ABA may complete it under the supervising LMHP), conducted in person with the youth and the family or caregivers, and an assessment completed by an LABA may be used only for ABA, not as a Comprehensive Needs Assessment for other services. [3][5][1]
- **Diagnostic tools required**: Follows the Virginia Medicaid (DMAS) rule: the initial assessment must include a functional assessment using validated tools, completed by the LBA, LABA or LMHP within scope, and documentation must describe any assessment tools used. DMAS publishes no approved list — the QHP may use clinical judgement to choose the best assessments for the youth — so what is audited is that a validated instrument was used and named, not which one. [3][5][1]
- **Referral required?**: Follows the Virginia Medicaid (DMAS) rule: no physician order. DMAS retired the requirement for an order or letter recommending services signed by a physician, nurse practitioner or physician assistant — what replaced it is a notification duty: the QHP must notify the youth's primary care physician that the child is receiving ABA, providers must communicate the results of the assessment and treatment planning to the PCP, and care coordination with the PCP must be documented in the youth's record. Anthem's initial SA form adds a history question that is an intake question, not a billing one: it requires a listing of all ABA or behavior-therapy treatment episodes from the past 12 months across all providers, plus an LMHP-level attestation signature. [2][5][3]
- **Telehealth**: Follows the Virginia Medicaid (DMAS) rule: initial assessments must be conducted in person with the youth and the family or caregivers. Beyond that, coverage of services delivered by telemedicine is governed by the Telehealth Services Supplement to the Mental Health Services manual, and the use of telemedicine must be documented in the ISP submitted with both the initial and the continued-stay authorization. Care coordination, data analysis and treatment-plan activities billed under 97151 or 97155 do not have to be provided face to face. MCO-contracted providers must consult their contracted MCO for that plan's telehealth policies. Anthem publishes the combinations: GT telehealth pairings are payable on 97151, 97153, 97155 and 97156 among others on its ABA code/modifier/place-of-service grid. [1][3][5]
- **Prior-auth decision time**: Virginia Medicaid rule, applied by Anthem HealthKeepers Plus: since January 1, 2026 DMAS requires FFS and every Cardinal Care MCO to decide standard (non-urgent) requests within 7 calendar days of receipt and expedited requests within 72 hours; the 7-day clock can extend up to 14 calendar days if the member or provider asks, or if the extra time is justified in the member's interest to obtain more medical evidence. Anthem's own manual (effective July 1, 2026) states the same numbers: "Standard authorization decisions are made within seven calendar days following receipt of the request for service," and "Expedited / urgent authorization decisions are made within 72 hours," with behavioral health non-urgent preservice at 7 calendar days in its timeliness table. Timing from Appendix D: submit treatment requests (initial and continued stay) by the requested start date — "If submitted after the required time-frame, the begin date of authorization will be based on the date of receipt," so a late reauthorization leaves an unpaid gap. [7][8][3][9]
- **Other insurance (who pays first)**: Medicaid pays last. Anthem's manual: "Providers must submit coordination of benefits (COB) claims to the primary carrier before submitting to HealthKeepers, Inc." — then bill Anthem the total charges with the primary carrier's remittance advice or a letter explaining the denial; COB claims without one are returned "with a request to submit to the other healthcare program first," and COB filing time frames start on the date of the primary payer's determination. Where Anthem learns of other coverage it rejects the claim and redirects you, except in its listed pay-and-chase cases — "When the services are for preventive pediatric care, including EPSDT," and a child whose primary coverage comes through an absent parent (if unpaid 100 days after service). The manual does not say whether ABA falls in the EPSDT pay-and-chase group, and DMAS's ABA FAQ says claims go to the commercial plan first, so bill primary first. Appendix D makes payment for every non-assessment ABA service conditional on service authorization ("Services other than assessment (97151, 97152 and 0362T) must be service authorized by the FFS service authorization contractor or MCO") and names no exemption for a secondary claim, so get the Medicaid authorization even when the commercial plan pays first. TRICARE and CHAMPVA both pay ahead of Medicaid: TRICARE rules state "Medicaid is not a double coverage plan. In any double coverage situation involving Medicaid, CHAMPUS is always the primary payer," and CHAMPVA "assumes primary payer status" over Medicaid. [7][5][3][10][11]

## Delivery and billing rules

Coverage decides whether Anthem HealthKeepers Plus (VA) 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**: Follows the Virginia Medicaid (DMAS) rule: three separate floors. The LBA, LABA or LMHP must at a minimum observe the youth and supervise services monthly, with supervision documented as a review of progress notes and data plus dialogue with supervised staff about progress and the effectiveness of the ISP. Supervision of unlicensed staff must occur at least twice a month by the LBA, LABA or Licensed Clinical Psychologist, demonstrated by the contemporaneously dated signature of the licensed supervisor. Clinical supervision is required for services rendered by an LABA, LMHP-R, LMHP-RP or LMHP-S, consistent with the scope of practice set by the applicable Virginia Department of Health Professions board — on the nature of supervision DMAS defers to that board and to the BACB. Supervision time without the individual present is not billable; the technician rates were built to include it. [3][5][1]
- **Concurrent billing (97153 + 97155)**: Follows the Virginia Medicaid (DMAS) rule: Appendix D publishes the combinations that may be billed at the same time: 97152 with 97151 (except 97152 HN together with 97151 HN); 97153 with 97155 (except 97153 HN together with 97155 HN) — DMAS adds that 97155 and 97153 may be billed together for supervision activities when the QHP is directing the technician in delivering treatment and the QHP, technician and youth are all present; 97154 and 97158 at the same time for different youth in the same group, with identical professional-level modifiers; 97153 at the same time for two technicians when the reason is documented in a service-authorized ISP; and services with the youth alongside family or group family training when delivered by different qualified staff. What is barred: an additional technician-level code alongside 97158 or 97154. Separately, ABA may not be authorized concurrently with Intensive In-Home, Mental Health Skill Building, Psychosocial Rehabilitation, Partial Hospitalization or Assertive Community Treatment, though short-term authorization overlaps are allowed during transitions. [3][5][1]
- **Daily limits / MUEs**: Follows the Virginia Medicaid (DMAS) rule: no per-day unit ceiling. Assessment codes 97151, 97152 and 0362T carry no service authorization and no unit limit, but may only be billed as part of an initial assessment or a full reassessment. Since dates of service 10/15/2025 every treatment code is authorized with its own predetermined number of units rather than bundled under 97155. Requests at or above 20 hours (80 units) a week must include an individualized schedule of activities that distinguishes therapeutic from recreational time — a general schedule of clinic-based activities is not sufficient. Group sizes follow CPT guidelines. In Residential Treatment Services settings, including therapeutic group homes and PRTFs, the payable ABA set narrows to 97151, 97154 (with modifier HN, HO or TF only), 97155, 97156 and 97157. [3][6][1]
- **Session-note signature**: Follows the Virginia Medicaid (DMAS) rule: documentation must carry the initial assessment completed by the LBA, LABA or LMHP including the assessment instruments used, dates of service and face-to-face contacts, staff and participant names, and staff credentials and signatures. Treatment progress must be documented through daily data collection plus a weekly summary note, with graphical analysis of goals and objectives for those dates of service. Supervision is demonstrated by the contemporaneously dated signature of the licensed supervisor. The ISP must be reviewed at least every 30 calendar days — a progress note satisfies the review if it documents the discussion, any alterations, and the individual's response; the individual's signature is not required, and the 30-day review is held for audit rather than submitted. Anthem's initial SA request form additionally requires an LMHP-level attestation signature (LMHP, LMHP-R, LMHP-S or LMHP-RP). [2][3][5]
- **Place of service**: Follows the Virginia Medicaid (DMAS) rule: ABA may be provided in home or community settings where the targeted behaviors are likely to occur, and in clinic settings — the setting must be justified in the ISP. School is the constrained one: ABA may only be provided in the school setting when the purpose is observation and collaboration by the QHP related to behavior and skill acquisition, not direct therapy, and only when authorized by the school, the parent and the provider and included in the ISP. Technician-level codes may not be billed for school observation and collaboration, and DMAS interprets school as any education setting, private or public; additional school ABA may be available under school health services through the local education agency. Services rendered primarily by a relative or guardian who is legally responsible for the youth's care are not covered. Anthem's published grid allows school as a place of service (POS 03) for 97151, 97155 and 97156 — the assessment, protocol-modification and family-training codes, consistent with the DMAS observation-and-collaboration boundary. [1][3][5]
- **Bill as provider**: Follows the Virginia Medicaid (DMAS) rule: ABA providers must be enrolled with DMAS under the ABA provider types (PCT 156 or 456 with PS 903; PCT 020 or 023; PCT 256 with PS 104), licensed by the applicable Virginia Department of Health Professions board, and credentialed with the youth's Medicaid MCO for managed-care members. Every CPT code is billed with the staff modifier that identifies the professional providing the service: HN for an LABA, HO for an LBA, TF for an LMHP. QHP-level codes must be provided by an LBA or LMHP, with an LABA able to act as a QHP as determined by the supervising LBA under 18VAC85-150-120, and LMHP-Rs, LMHP-RPs and LMHP-Ss with completed ABA education and training able to provide them under the supervising LMHP. Technician-level codes may be delivered by an LMHP-R/RP/S under supervision, an LABA under an LBA, personnel supervised by an LBA or LABA under 18VAC85-150-10 et seq., personnel supervised by a Licensed Clinical Psychologist under § 54.1-3614, or by an LBA or LMHP acting as the technician — LBAs may bill technician-level codes with the appropriate modifier. Unlicensed personnel include but are not limited to RBTs; Virginia does not require the RBT credential. [3][1]

## What intake should collect for Anthem HealthKeepers Plus (VA)

- **Prior ABA episodes (12 months):** The initial SA form requires them across all providers — ask at intake.
- **ASD diagnosis:** Then book the assessment — no authorization needed on assessment codes.
- **Setting preferences:** School delivery is billable for select codes (POS 03) — capture the school picture.
- **LMHP attestation:** The initial SA needs an LMHP/LMHP-R/S/RP signature — line it up before submission.

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

## Verification of benefits (VOB) data

How Anthem HealthKeepers Plus (VA) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 002467 — pVerify 002467 = "Anthem Healthkeepers" (Medical, Eligibility=Yes) on the pVerify Mar-2026 list.
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** none (DMAS pass-through; Anthem administers ABA on DMAS forms via Availity/ICR)
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Not required — Anthem's published grid confirms no service authorization on 97151 | No hard cap — EPSDT medical necessity; the initial behavior-identification assessment sequence follows the DMAS baseline per n/a (no SA on assessment codes) | home, office/clinic (11), community, school (POS 03) — allowed per Anthem's published grid, telehealth (GT) | Yes — GT telehealth combination payable on this code per Anthem's published grid. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97152 | Yes | Not required — Anthem's published grid confirms no service authorization on 97152 | No hard cap — EPSDT medical necessity; the initial behavior-identification assessment sequence follows the DMAS baseline per n/a (no SA on assessment codes) | home, office/clinic (11), community, telehealth (GT) | Yes — GT telehealth combination payable on this code per Anthem's published grid. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97153 | Yes | Required — SA on 97153 per Anthem's published grid; units itemized per CPT code on the DMAS standardized form (eff. 10/15/2025) | No hard cap — per-code units; requests ≥20 hrs/week (80 units) need an individualized activity schedule (stated on Anthem's own form) per per authorization span (~6-month spans typical) | home, office/clinic (11), community, telehealth (GT) | Yes — GT telehealth combination payable on this code per Anthem's published grid. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97154 | Yes | Required — SA on 97154 per Anthem's published grid; units itemized per CPT code on the DMAS standardized form (eff. 10/15/2025) | No hard cap — per-code units; requests ≥20 hrs/week (80 units) need an individualized activity schedule (stated on Anthem's own form) per per authorization span (~6-month spans typical) | home, office/clinic (11), community, telehealth (GT) | Yes — GT telehealth combination payable on this code per Anthem's published grid. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97155 | Yes | Required — SA on 97155 per Anthem's published grid; units itemized per CPT code on the DMAS standardized form (eff. 10/15/2025) | No hard cap — per-code units; requests ≥20 hrs/week (80 units) need an individualized activity schedule (stated on Anthem's own form) per per authorization span (~6-month spans typical) | home, office/clinic (11), community, school (POS 03) — allowed per Anthem's published grid, telehealth (GT) | Yes — GT telehealth combination payable on this code per Anthem's published grid. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97156 | Yes | Required — SA on 97156 per Anthem's published grid; units itemized per CPT code on the DMAS standardized form (eff. 10/15/2025) | No hard cap — per-code units; requests ≥20 hrs/week (80 units) need an individualized activity schedule (stated on Anthem's own form) per per authorization span (~6-month spans typical) | home, office/clinic (11), community, school (POS 03) — allowed per Anthem's published grid, telehealth (GT) | Yes — GT telehealth combination payable on this code per Anthem's published grid. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97157 | Yes | Required — SA on 97157 per Anthem's published grid; units itemized per CPT code on the DMAS standardized form (eff. 10/15/2025) | No hard cap — per-code units; requests ≥20 hrs/week (80 units) need an individualized activity schedule (stated on Anthem's own form) per per authorization span (~6-month spans typical) | home, office/clinic (11), community, telehealth (GT) | Yes — GT telehealth combination payable on this code per Anthem's published grid. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97158 | Yes | Required — SA on 97158 per Anthem's published grid; units itemized per CPT code on the DMAS standardized form (eff. 10/15/2025) | No hard cap — per-code units; requests ≥20 hrs/week (80 units) need an individualized activity schedule (stated on Anthem's own form) per per authorization span (~6-month spans typical) | home, office/clinic (11), community, telehealth (GT) | Yes — GT telehealth combination payable on this code per Anthem's published grid. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 0362T | Yes | Not required — Anthem's published grid confirms no service authorization on 0362T | No hard cap — EPSDT medical necessity; the initial behavior-identification assessment sequence follows the DMAS baseline per n/a (no SA on assessment codes) | home, office/clinic (11), community | Per DMAS state telehealth policy; this code is not listed among Anthem's explicitly GT-payable ABA codes. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 0373T | Yes | Required — SA on 0373T per Anthem's published grid; units itemized per CPT code on the DMAS standardized form (eff. 10/15/2025) | No hard cap — per-code units; requests ≥20 hrs/week (80 units) need an individualized activity schedule (stated on Anthem's own form) per per authorization span (~6-month spans typical) | home, office/clinic (11), community | Per DMAS state telehealth policy; this code is not listed among Anthem's explicitly GT-payable ABA codes. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |

Code notes:

- **97151, 97152, 0362T:** Anthem HealthKeepers Plus publishes the state's clearest ABA code/modifier/POS grid (Feb 2023 bulletin). The initial SA form requires an LMHP-level attestation and a 12-month prior-ABA-episode history.
- **97153, 97154, 97155, 97156, 97157, 97158, 0373T:** Grid worth bookmarking: Anthem's Feb 2023 bulletin publishes the full ABA code/modifier/POS grid; BH authorizations submit via Availity Essentials' Interactive Care Reviewer.

### Medicaid rates

Source: DMAS CPT fee file (cptmedical4.csv for 97151–97158; cptmedical1.csv for 0362T/0373T), read directly from the live file: licensure-tiered per-15-minute ABA rates effective 12/01/2021 (end 12/31/9999), still current in the file that also carries 07/01/2026 rows. Tiers flagged by modifier: no modifier = technician, HN/U1 = LABA, TF/U2 = LMHP, HO/U3/U7 = LBA; ABA rows are the OP (outpatient) place-of-service lines. Trap (confirmed): the file also carries generic "REGULAR & CSB" IP rows for 97151/97152/97156/97157 at a few dollars per unit (e.g. 97151 IP $6.75) — those are the non-ABA physician-fee lines, NOT the ABA program rates. Modifier definitions cross-checked against VirginiaABA's (draft) DMAS billing guidance. No Anthem HealthKeepers Plus-specific ABA fee schedule is publicly posted; the 5 Cardinal Care MCOs run identical DMAS criteria and standardized forms but are not required to match the FFS schedule — this table is the DMAS reference baseline, not a plan-confirmed paid rate. Effective 2021-12-01.

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | $23.48 (LABA) / $39.40 (LMHP) / $46.63 (LBA) | 15min | HN (LABA): $23.48; TF (LMHP): $39.40; HO (LBA): $46.63 |
| 97152 | $15.00 (technician) / $23.48 (LABA) | 15min | technician: $15.00; HN (LABA): $23.48 |
| 97153 | $15.00 (technician) | 15min | technician: $15.00; HN (LABA): $23.48; TF (LMHP): $39.40; HO (LBA): $46.63 |
| 97154 | $12.77 (technician) — group | 15min | technician: $12.77; HN (LABA): $15.60; TF (LMHP): $13.13; HO (LBA): $15.55 |
| 97155 | $23.48 (LABA) / $39.40 (LMHP) / $46.63 (LBA) | 15min | HN (LABA): $23.48; TF (LMHP): $39.40; HO (LBA): $46.63 |
| 97156 | $23.48 (LABA) / $39.40 (LMHP) / $46.63 (LBA) | 15min | HN (LABA): $23.48; TF (LMHP): $39.40; HO (LBA): $46.63 |
| 97157 | $7.83 (LABA) / $13.13 (LMHP) / $15.55 (LBA) — multi-family group | 15min | HN (LABA): $7.83; TF (LMHP): $13.13; HO (LBA): $15.55 |
| 97158 | $22.83 (LABA) / $28.13 (LMHP) / $30.54 (LBA) — group w/ protocol mod | 15min | HN (LABA): $22.83; TF (LMHP): $28.13; HO (LBA): $30.54 |
| 0362T | $53.47 (LABA) / $69.39 (LMHP) / $76.62 (LBA) — team supporting assessment | 15min | HN (LABA): $53.47; TF (LMHP): $69.39; HO (LBA): $76.62 |
| 0373T | $53.47 (LABA) / $69.39 (LMHP) / $76.62 (LBA) — team treatment | 15min | HN (LABA): $53.47; TF (LMHP): $69.39; HO (LBA): $76.62 |

### Contacts

- **Provider services phone:** 800-901-0020 (TTY/TDD: 711)
- **Portal:** [Availity Essentials](https://www.availity.com)

Questions to ask on a verification call:

- For codes other than 97151, 97153, 97155, and 97156, is telehealth reimbursed, or is in-person required?
- Does Anthem HealthKeepers Plus pay these ABA codes at the DMAS fee-schedule rate, or is there a plan-specific rate?

### VOB data sources

- https://providers.anthem.com/docs/gpp/VA_CAID_ABARequirements.pdf?v=202302021327 (accessed 2026-07-23)
- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://www.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23)
- https://vamedicaid.dmas.virginia.gov/sites/default/files/2026-07/MES%20EDI%20270-271%20Companion%20Guide_R100_20220509-PK%202.pdf (accessed 2026-07-23)
- https://providers.anthem.com/docs/gpp/VA_CCC_BH_ABA_InitialStay.pdf?v=202301010312 (accessed 2026-07-23)
- https://www.dmas.virginia.gov/media/cptcodes/cptmedical4.csv (accessed 2026-07-23)
- https://www.dmas.virginia.gov/media/cptcodes/cptmedical1.csv (accessed 2026-07-23)
- https://virginiaaba.org/wp-content/uploads/2021/11/ABA-Billing-Guidance-from-DMAS-Nov21.pdf (accessed 2026-07-23; source document older than 18 months)
- https://providers.anthem.com/virginia-provider/contact-us (accessed 2026-07-23)

## Common questions

### Does Anthem HealthKeepers Plus cover ABA?

Yes — Virginia's Cardinal Care ABA benefit on DMAS criteria and standardized forms: no authorization on assessment codes, SA on treatment codes 97153–97158 and 0373T, submitted via Availity's Interactive Care Reviewer.

### Does Anthem HealthKeepers Plus cover ABA by telehealth or in schools?

Its published grid pays GT telehealth combinations on 97151, 97153, 97155, and 97156, and allows school as a place of service (POS 03) for 97151, 97155, and 97156.

## Primary sources

1. [Anthem VA — ABA requirements bulletin (Feb 2023)](https://providers.anthem.com/docs/gpp/VA_CAID_ABARequirements.pdf?v=202302021327)
2. [Anthem VA — ABA initial SA request form](https://providers.anthem.com/docs/gpp/VA_CCC_BH_ABA_InitialStay.pdf?v=202301010312)
3. [DMAS — MHS manual Appendix D (ABA)](https://vamedicaid.dmas.virginia.gov/sites/default/files/2025-07/MHS%20-%20Appendix%20D%20(updated%207.17.25)_Final.pdf)
4. [Anthem VA — provider news: ABA authorization submission changes](https://providernews.anthem.com/virginia/articles/important-changes-to-applied-behavioral-analysis-aba-authori-26746)
5. [DMAS — Project BRAVO ABA FAQ](https://www.dmas.virginia.gov/media/4271/project-bravo-services-faqs-aba.pdf)
6. [DMAS — ABA service authorization update (eff. 10/15/2025)](https://vamedicaid.dmas.virginia.gov/bulletin/service-authorization-update-applied-behavior-analysis-aba-effective-october-15-2025)
7. [Anthem HealthKeepers Plus — Provider Manual (effective July 1, 2026)](https://providers.anthem.com/docs/gpp/VA_CAID_ProviderManual.pdf)
8. [DMAS bulletin — Interoperability and Prior Authorization Final Rule implementation update](https://vamedicaid.dmas.virginia.gov/bulletin/interoperability-and-prior-authorization-final-rule-implementation-update)
9. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/section-438.210)
10. [32 CFR 199.8 — TRICARE double coverage (eCFR)](https://www.ecfr.gov/current/title-32/section-199.8)
11. [38 CFR 17.272 — CHAMPVA benefit limitations; Medicaid exception (eCFR)](https://www.ecfr.gov/current/title-38/section-17.272)

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.