Anthem Blue Cross and Blue Shield HP ABA coverage (NY Medicaid Managed Care).

Follows the New York Medicaid rule: ABA is covered for members “under 21 years of age with a diagnosis of Autism Spectrum Disorder (ASD) as defined by… (DSM-5) and/or Rett Syndrome.” No minimum age and no adult pathway — the 21st birthday is a hard cliff. Anthem publishes no age rule of its own for the New York Medicaid line; its Treatment Plan Request Form captures the member’s age at first ABA treatment rather than gating on current age.^[3][1]

Follows the New York Medicaid rule — the 2-year referral is the clock, and no maximum age is set on the diagnostic evaluation. Anthem publishes no recency rule of its own for the Medicaid line; what its form does capture is treatment history, including the age at which ABA was first received.^[3][1]

Follows the New York Medicaid rule: the diagnosis and referral must come from a NYS-licensed, NYS Medicaid-enrolled physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner or physician assistant, following DSM-5 criteria and NYSDOH’s Clinical Practice Guideline on ASD. LBAs and CBAAs sit outside that list — they may not diagnose and may not self-refer. Anthem’s Treatment Plan Request Form requires the treating BCBA/QHCP’s information but names no diagnosing credential of its own for the Medicaid line.^[3][1]

Follows the New York Medicaid rule: no instrument is mandated. What the state requires with the referral is the “DSM-5 Diagnostic Checklist for ASD diagnoses” plus the severity level when the referral comes from an ASD-diagnosing provider; the treatment plan need only record the assessment methodology used and, “as appropriate, identify standardized assessment used (e.g., adaptive behavior scales, symptom inventories, aggression ratings) and results.” Anthem’s New York Medicaid form asks for the Comprehensive-versus-Focused classification and clinical documentation rather than a named instrument battery.^[3][1]

Follows the New York Medicaid rule: the member “must be referred for ABA services by a NYS-licensed and NYS Medicaid-enrolled physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner, or physician assistant,” the referral is “valid for no more than two years,” and it must carry age, the ASD/Rett diagnosis, date of initial diagnosis, co-morbid diagnoses, symptom severity level, a statement the patient needs ABA, and the DSM-5 Diagnostic Checklist. Anthem’s own gate sits on top: treatment authorization runs on the Treatment Plan Request Form for Autism Spectrum Disorders — New York Medicaid (form NY-BCBS-CD-008303-26-GRP2461, June 2026 revision), submitted through Availity.com as the preferred channel, with incomplete forms returned rather than pended. Whether assessment code 97151 needs its own prior authorization is not published.^[3][1]

Anthem’s NY Medicaid manual runs the 7-day ceiling: a standard precertification is decided “within three business days of receipt of the necessary information, but no later than 7 days after the receipt of the request,” an urgent one “no later than 72 hours after receipt of the request,” and a continuing-care (concurrent) request “within one business day of receipt of the necessary information, but no more than 7 days after receipt of the request” (urgent concurrent: one business day, 72 hours at most). “In accordance with the New York State Medicaid contract,” any of these may be extended up to 14 days. ABA goes in through Availity on Anthem’s ASD Treatment Plan Request Form, and the plan should be dated within 30 days of the requested start date. No reauth submission lead time is published.^[4][1]

“We and our providers agree the Medicaid program will be the payer of last resort when third-party resources are available.” If Anthem knows of other coverage it rejects the claim and redirects you “to bill the appropriate insurance carrier”; if it learns later, it recovers after payment. So bill the other plan first, then submit to Anthem with the COB/other-insurance information — “In the case of other insurance, submit the claim within 90 days of receiving a response from the third-party payer.” The manual does not say whether Anthem’s own ABA precertification is still required when it is secondary — confirm with Provider Services (800-450-8753) before starting on the primary plan’s approval alone.^[4]

Not published for the New York Medicaid line. Anthem’s Treatment Plan Request Form does not state which ABA codes may be delivered remotely or under which place-of-service code, and no Anthem New York Medicaid telehealth policy for ABA was retrievable at review time (the plan’s ABA Services FAQ for NY providers, provider news article 13424, was unavailable). The state’s own ABA manual answers telehealth only for supervision.^[1][3]

Blocked on: Availity or Anthem NY provider services — and the plan’s ABA Services FAQ for New York providers; get the telehealth answer in writing per case.

Follows the New York Medicaid rule, which the state applies to FFS and managed care alike: “an LBA can supervise no more than six CBAAs/unlicensed individuals at a time,” “LBAs are required to supervise unlicensed individuals for a minimum of five percent of the hours the unlicensed individual spends providing behavior analysis services each calendar month,” and “supervision must include at least two face-to-face, real-time contacts per month” with the LBA observing service delivery in at least one. Supervision may run over synchronous audio-and-video where on-site is impractical. 97155 counts toward the 5% “only when the LBA joins the patient and the unlicensed individual during a treatment session to direct the unlicensed individual/technician in implementing a new or modified treatment protocol.” CBAAs need direct supervision, and the supervisor “should assess each patient’s/client’s progress at least every 6 months… and review and sign treatment notes and reports prepared by the CBAA supervisee.” Anthem publishes no supervision ratio of its own for the New York Medicaid line; its form requires the treating BCBA/QHCP’s information, which in New York must be an NYSED-licensed LBA (a BCBA credential alone does not qualify).^[3][1]

Follows the New York Medicaid rule: the LBA supervisor must “review and sign treatment notes and reports prepared by the CBAA supervisee,” and documentation of supervision itself “should be recorded in the patient file.” Clinical documentation must carry the treatment plan with assessment and goals, the goal data, total hours of service per week by who delivered them, and the location(s) of services. Records are kept “for a minimum of six years and, for minors, until the patient turns 22 years of age.” Anthem publishes no additional session-note signature rule for its New York Medicaid line.^[3]

Ask the plan: Anthem NY Medicaid provider services for any plan-specific documentation standard beyond the state rule.

Follows the New York Medicaid rule: “LBAs and CBAAs may work in any legally authorized setting. Examples of such settings include private practice, settings where patients/clients reside full-time or part-time, clinics, hospitals, residences, and community settings” — but “NYS Medicaid does not reimburse for ABA services in a school setting.” The treatment plan must record the location(s) of services. Anthem publishes no separate place-of-service rule for the New York Medicaid line; the state’s school bar is the operative constraint.^[3]

Ask the plan: Availity or Anthem NY Medicaid provider services for any plan-specific setting restriction.

Not published for the New York Medicaid line. Anthem’s Medicaid Treatment Plan Request Form is an authorization instrument, not a reimbursement policy, and the state manual is silent on 97153 with 97155.^[1][3]

Ask the plan: Availity or Anthem NY Medicaid provider services, and Anthem’s reimbursement policies for the New York Medicaid line.

No published hour cap for the New York Medicaid line. The form sorts requests into Comprehensive versus Focused ABA — the standard Elevance intensity-review framework — so expect requested hours to be weighed against that model rather than against a stated ceiling. Authorization periods, unit limits and rates are not published.^[1]

Ask the plan: Availity or Anthem NY Medicaid provider services — confirm authorization period, unit limits and any hour-cap logic per case in writing.

Not published for the New York Medicaid line — Anthem’s form collects the treating BCBA/QHCP’s information but states no rendering-versus-supervising NPI convention. At the fee-for-service layer New York is explicit: LBAs bill “using the LBA’s National Provider Identification (NPI) number for the ‘Billing’ provider and/or ‘Supervising’ provider,” with “the NPI number of the CBAA that provided the ABA service… reported as the ‘Rendering’ provider on each claim”; for unlicensed aides and LBA limited-permit holders the supervising LBA’s NPI fills all three roles. CBAAs cannot bill directly and enroll as OPRA providers. Because the state manual directs managed-care providers to their plan for billing guidance, confirm the Anthem claim format in Availity before billing CBAA- or technician-delivered units.^[1][3]

Ask the plan: Availity or Anthem NY Medicaid provider services — confirm the rendering/supervising NPI convention and any modifier requirement in writing.