---
title: Anthem Blue Cross and Blue Shield HP ABA coverage (NY Medicaid Managed Care).
url: "https://carelu.com/payers/anthem-healthplus-new-york"
markdown_url: "https://carelu.com/payers/anthem-healthplus-new-york.md"
state: NY (New York)
payer: Anthem Blue Cross and Blue Shield HP (NY Medicaid)
kind: Medicaid managed care plan (MCO)
parent_program: New York Medicaid
description: "How Anthem Blue Cross and Blue Shield HP (formerly Empire BCBS HealthPlus) authorizes NY Medicaid ABA — the Treatment Plan Request Form via Availity, the Comprehensive-vs-Focused model classification, and what remains unpublished."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

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

_Payer Guide · Anthem HealthPlus (NY) · Last updated September 2026 · 3 primary sources_

> Treatment Plan Request Form via Availity; Comprehensive-vs-Focused framing; incomplete forms returned.

Anthem HP, LLC — the Elevance plan formerly branded Empire BlueCross BlueShield HealthPlus — carries the NY Medicaid ABA carve-in with an Anthem-specific authorization layer on the state's eligibility baseline. The center of gravity is its Treatment Plan Request Form for Autism Spectrum Disorders (June 2026 revision — proof the plan is an active NY ABA payer), submitted through Availity. Like other Elevance plans, it sorts requests into Comprehensive versus Focused ABA, and it returns incomplete forms rather than pending them.

This plan administers the **New York Medicaid** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [New York Medicaid (NYS DOH / eMedNY) guide](https://carelu.com/payers/new-york-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment:** Not published / unverified. Verify via: Anthem’s ABA Services FAQ for New York providers (provider news article 13424) — the document that would settle whether 97151 itself needs a request. It was unretrievable at review time: the article page returns an empty JS shell and the Wayback Machine holds no capture. Until it can be read, Availity or Anthem NY Medicaid provider services, in writing per case. [1][2]
- **Prior auth for treatment**: Required — Treatment Plan Request Form for ASD (NY Medicaid) via Availity.com, with BCBA/QHCP information; incomplete forms are returned [1]
- **Autism diagnosis required?**: Yes — state baseline: under 21, ASD/Rett per DSM-5, with the state practitioner referral [3][1]

## At a glance

- **Plan type:** Mainstream MMC (Anthem HP, LLC; formerly Empire BCBS HealthPlus)
- **Treatment PA:** Required — Treatment Plan Request Form via Availity (preferred method)
- **Intensity model:** Form distinguishes Comprehensive vs. Focused ABA requests
- **Form details:** Requires BCBA/QHCP information and age of first ABA treatment; incomplete forms returned
- **Clinical criteria:** State eligibility baseline (under 21, ASD/Rett, referral) + Anthem PA overlay
- **Portal:** Availity.com

## The Treatment Plan Request Form workflow

Treatment authorization runs on Anthem's Treatment Plan Request Form for Autism Spectrum Disorders — New York Medicaid (form NY-BCBS-CD-008303-26-GRP2461, June 2026 revision), submitted via Availity.com as the preferred channel. The form requires the treating BCBA/QHCP's information, captures the member's age at first ABA treatment, and classifies the request as Comprehensive or Focused ABA — the standard Elevance intensity-review framework, so expect requested hours to be weighed against that model. The operational rule that costs the most time: incomplete forms are returned, not worked — so treat every field as required and package the clinical documentation with the first submission. [1]

## What Anthem doesn't publish — verify in the portal

Several operational facts have no published answer we could verify: whether the assessment code 97151 itself requires PA (the plan's published process is a treatment-plan-request workflow), whether Carelon Behavioral Health plays a UM role for ABA, and any hour caps or rates. Anthem also maintains an ABA Services FAQ for NY providers (provider news article 13424) that wasn't retrievable at review time. Until the plan confirms otherwise in Availity or through provider services, run assessments on the assumption a request may be needed, and get the answer in writing per case. [2]

## Intake gates

The questions that decide whether a family can start with Anthem Blue Cross and Blue Shield HP (NY Medicaid), and what they have to bring.

- **Age limit**: 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]
- **Diagnosis recency**: 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]
- **Who may diagnose**: 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]
- **Diagnostic tools required**: 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]
- **Referral required?**: 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]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: “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]

## Delivery and billing rules

Coverage decides whether Anthem Blue Cross and Blue Shield HP (NY Medicaid) 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 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]
- **Session-note signature**: 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.
- **Place of service**: 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.
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: 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.
- **Daily limits / MUEs** _(ask the plan)_: 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.
- **Bill as provider** _(ask the plan)_: 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.

## What intake should collect for Anthem Blue Cross and Blue Shield HP (NY Medicaid)

- **BCBA/QHCP details:** The form requires the treating analyst's information — have credentials and NPI ready before submission.
- **ABA treatment history:** The form captures age of first ABA treatment — ask at intake, not at form time.
- **Comprehensive vs. Focused framing:** Classify the request deliberately and align requested hours with the model.
- **Complete state referral packet:** The state eligibility baseline still applies — referral, dx, severity, DSM-5 checklist.

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

## Verification of benefits (VOB) data

How Anthem Blue Cross and Blue Shield HP (NY Medicaid) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (Availity):** 00803 (professional) / 00303 (institutional)
- **Payer ID (Change Healthcare / Optum):** 00303
- **Supports 270/271 eligibility:** Yes

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required — via the Treatment Plan Request Form (Availity preferred). Incomplete forms are returned, not pended. | Not published as a numeric hour/unit ceiling in any Anthem document reviewed — caps are structured by PERIOD (see capPeriod), and the form's Comprehensive-vs-Focused ABA checkbox has no defined hour ranges attached to it in any of the four Anthem documents checked. per per authorization period through 2025; Anthem's Jan 2026 provider newsletter (article 27878) states ALL ABA codes move to a weekly-approved-units cap structure effective 1/1/2026 — treat the pre-2026 period distinction as historical only. | Checkboxes only on the Treatment Plan Request Form: Home / Clinic / School (if allowed) / Telehealth (if allowed) / Other — no POS numeric codes given, "School (if allowed)" on the June 2026 form is in unreconciled tension with the 2023 FAQ's unambiguous "Medicaid does not cover...schools as a place of service" statement | — | — |
| 97152 | Yes | Required — via the Treatment Plan Request Form (Availity preferred). Incomplete forms are returned, not pended. | Not published as a numeric hour/unit ceiling in any Anthem document reviewed — caps are structured by PERIOD (see capPeriod), and the form's Comprehensive-vs-Focused ABA checkbox has no defined hour ranges attached to it in any of the four Anthem documents checked. per per authorization period through 2025; Anthem's Jan 2026 provider newsletter (article 27878) states ALL ABA codes move to a weekly-approved-units cap structure effective 1/1/2026 — treat the pre-2026 period distinction as historical only. | Checkboxes only on the Treatment Plan Request Form: Home / Clinic / School (if allowed) / Telehealth (if allowed) / Other — no POS numeric codes given, "School (if allowed)" on the June 2026 form is in unreconciled tension with the 2023 FAQ's unambiguous "Medicaid does not cover...schools as a place of service" statement | — | — |
| 97153 | Yes | Required — via the Treatment Plan Request Form (Availity preferred). Incomplete forms are returned, not pended. | Not published as a numeric hour/unit ceiling in any Anthem document reviewed — caps are structured by PERIOD (see capPeriod), and the form's Comprehensive-vs-Focused ABA checkbox has no defined hour ranges attached to it in any of the four Anthem documents checked. per per week through 2025; Anthem's Jan 2026 provider newsletter (article 27878) states ALL ABA codes move to a weekly-approved-units cap structure effective 1/1/2026 — treat the pre-2026 period distinction as historical only. | Checkboxes only on the Treatment Plan Request Form: Home / Clinic / School (if allowed) / Telehealth (if allowed) / Other — no POS numeric codes given, "School (if allowed)" on the June 2026 form is in unreconciled tension with the 2023 FAQ's unambiguous "Medicaid does not cover...schools as a place of service" statement | — | — |
| 97154 | Yes | Required — PA effective 4/1/2023 per the 2023 FAQ footnote. | Not published as a numeric hour/unit ceiling in any Anthem document reviewed — caps are structured by PERIOD (see capPeriod), and the form's Comprehensive-vs-Focused ABA checkbox has no defined hour ranges attached to it in any of the four Anthem documents checked. per per week through 2025; Anthem's Jan 2026 provider newsletter (article 27878) states ALL ABA codes move to a weekly-approved-units cap structure effective 1/1/2026 — treat the pre-2026 period distinction as historical only. | Checkboxes only on the Treatment Plan Request Form: Home / Clinic / School (if allowed) / Telehealth (if allowed) / Other — no POS numeric codes given, "School (if allowed)" on the June 2026 form is in unreconciled tension with the 2023 FAQ's unambiguous "Medicaid does not cover...schools as a place of service" statement | — | — |
| 97155 | Yes | Required — via the Treatment Plan Request Form (Availity preferred). Incomplete forms are returned, not pended. | Not published as a numeric hour/unit ceiling in any Anthem document reviewed — caps are structured by PERIOD (see capPeriod), and the form's Comprehensive-vs-Focused ABA checkbox has no defined hour ranges attached to it in any of the four Anthem documents checked. per per authorization period through 2025; Anthem's Jan 2026 provider newsletter (article 27878) states ALL ABA codes move to a weekly-approved-units cap structure effective 1/1/2026 — treat the pre-2026 period distinction as historical only. | Checkboxes only on the Treatment Plan Request Form: Home / Clinic / School (if allowed) / Telehealth (if allowed) / Other — no POS numeric codes given, "School (if allowed)" on the June 2026 form is in unreconciled tension with the 2023 FAQ's unambiguous "Medicaid does not cover...schools as a place of service" statement | — | — |
| 97156 | Yes | Required — via the Treatment Plan Request Form (Availity preferred). Incomplete forms are returned, not pended. | Not published as a numeric hour/unit ceiling in any Anthem document reviewed — caps are structured by PERIOD (see capPeriod), and the form's Comprehensive-vs-Focused ABA checkbox has no defined hour ranges attached to it in any of the four Anthem documents checked. per per authorization period through 2025; Anthem's Jan 2026 provider newsletter (article 27878) states ALL ABA codes move to a weekly-approved-units cap structure effective 1/1/2026 — treat the pre-2026 period distinction as historical only. | Checkboxes only on the Treatment Plan Request Form: Home / Clinic / School (if allowed) / Telehealth (if allowed) / Other — no POS numeric codes given, "School (if allowed)" on the June 2026 form is in unreconciled tension with the 2023 FAQ's unambiguous "Medicaid does not cover...schools as a place of service" statement | — | — |
| 97157 | Yes | Required — PA effective 4/1/2023 per the 2023 FAQ footnote. | Not published as a numeric hour/unit ceiling in any Anthem document reviewed — caps are structured by PERIOD (see capPeriod), and the form's Comprehensive-vs-Focused ABA checkbox has no defined hour ranges attached to it in any of the four Anthem documents checked. per per authorization period through 2025; Anthem's Jan 2026 provider newsletter (article 27878) states ALL ABA codes move to a weekly-approved-units cap structure effective 1/1/2026 — treat the pre-2026 period distinction as historical only. | Checkboxes only on the Treatment Plan Request Form: Home / Clinic / School (if allowed) / Telehealth (if allowed) / Other — no POS numeric codes given, "School (if allowed)" on the June 2026 form is in unreconciled tension with the 2023 FAQ's unambiguous "Medicaid does not cover...schools as a place of service" statement | — | — |
| 97158 | Yes | Required — via the Treatment Plan Request Form (Availity preferred). Incomplete forms are returned, not pended. | Not published as a numeric hour/unit ceiling in any Anthem document reviewed — caps are structured by PERIOD (see capPeriod), and the form's Comprehensive-vs-Focused ABA checkbox has no defined hour ranges attached to it in any of the four Anthem documents checked. per per week through 2025; Anthem's Jan 2026 provider newsletter (article 27878) states ALL ABA codes move to a weekly-approved-units cap structure effective 1/1/2026 — treat the pre-2026 period distinction as historical only. | Checkboxes only on the Treatment Plan Request Form: Home / Clinic / School (if allowed) / Telehealth (if allowed) / Other — no POS numeric codes given, "School (if allowed)" on the June 2026 form is in unreconciled tension with the 2023 FAQ's unambiguous "Medicaid does not cover...schools as a place of service" statement | — | — |
| 0362T | CONFLICTING within Anthem's own current publications — NOT reconciled, verify directly before billing. Anthem's 2023 provider-news FAQ (still live, article 13424) states verbatim: "Medicaid does not cover CPT codes 0362T and 0373T and schools as a place of service." But Anthem's own January 2026 newsletter (article 27878, "Streamlined ABA claim process") lists this code in its "Affected CPT codes" table for the new 2026 weekly-unit billing structure, and the June 2026 Treatment Plan Request Form references 0362T for initial-assessment requests alongside 97151/97152. | Required — via the Treatment Plan Request Form (Availity preferred). Incomplete forms are returned, not pended. | Not published as a numeric hour/unit ceiling in any Anthem document reviewed — caps are structured by PERIOD (see capPeriod), and the form's Comprehensive-vs-Focused ABA checkbox has no defined hour ranges attached to it in any of the four Anthem documents checked. | Checkboxes only on the Treatment Plan Request Form: Home / Clinic / School (if allowed) / Telehealth (if allowed) / Other — no POS numeric codes given, "School (if allowed)" on the June 2026 form is in unreconciled tension with the 2023 FAQ's unambiguous "Medicaid does not cover...schools as a place of service" statement | — | — |
| 0373T | CONFLICTING within Anthem's own current publications — NOT reconciled, verify directly before billing. Anthem's 2023 provider-news FAQ (still live, article 13424) states verbatim: "Medicaid does not cover CPT codes 0362T and 0373T and schools as a place of service." But Anthem's own January 2026 newsletter (article 27878, "Streamlined ABA claim process") lists this code in its "Affected CPT codes" table for the new 2026 weekly-unit billing structure, and the June 2026 Treatment Plan Request Form references 0362T for initial-assessment requests alongside 97151/97152. | Required — via the Treatment Plan Request Form (Availity preferred). Incomplete forms are returned, not pended. | Not published as a numeric hour/unit ceiling in any Anthem document reviewed — caps are structured by PERIOD (see capPeriod), and the form's Comprehensive-vs-Focused ABA checkbox has no defined hour ranges attached to it in any of the four Anthem documents checked. | Checkboxes only on the Treatment Plan Request Form: Home / Clinic / School (if allowed) / Telehealth (if allowed) / Other — no POS numeric codes given, "School (if allowed)" on the June 2026 form is in unreconciled tension with the 2023 FAQ's unambiguous "Medicaid does not cover...schools as a place of service" statement | — | — |

Code notes:

- **97151, 97152:** Lighter documentation path on the same form when "requesting only 97151/97152 and 0362T" — diagnostic evaluation + referral only, vs. the full treatment-initiation packet (baseline/mastery criteria, transition plan, discharge criteria, etc.) required otherwise. Still submitted for authorization — not PA-exempt.

### Contacts

- **Provider services phone:** 800-450-8753
- **Hours:** Mon-Fri 9:00 a.m.-5:00 p.m.
- **Portal:** [Availity Essentials](https://apps.availity.com)
- **Fax:** 800-964-3627

Questions to ask on a verification call:

- Are CPT codes 0362T and 0373T covered under Medicaid — the 2023 FAQ says no, but the 2026 provider-newsletter and treatment-plan-form materials suggest otherwise?
- Does Anthem/Elevance administer ABA/BH in-house, or route through Carelon Behavioral Health — what payer ID applies?
- What is the numeric hour/unit cap for ABA codes now that Anthem moved to a weekly-approved-units cap structure (eff. 1/1/2026)?
- Is ABA billable via telehealth, and if so what modifier/POS code should be used on the claim?
- What billing modifiers does Anthem require for ABA claims?
- Which pVerify payer ID applies specifically to Anthem HealthPlus (Empire BCBS HealthPlus), given three ambiguous candidate entries?
- Which STC bucket does Anthem return ABA benefit detail under, and does the plan's deductible apply to ABA?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/06/pVeify-Payer-List-June-26.pdf (accessed 2026-07-23)
- https://providers.anthem.com/docs/gpp/NY_ABC_CAID_ProviderManual.pdf?v=202501161732 (accessed 2026-07-23)
- https://business.optum.com/content/dam/o4-dam/resources/pdfs/white-papers/institutional-claims-payer-list.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://providers.anthem.com/docs/gpp/NY_ABC_CAID_ABA_AuthReqForm.pdf?v=202411221617 (accessed 2026-07-23)
- https://providernews.anthem.com/new-york/articles/applied-behavior-analysis-services-faq-for-providers-13424 (accessed 2026-07-23)
- https://providernews.anthem.com/new-york/articles/streamlined-aba-claim-process-starts-january-1-2026-27878 (accessed 2026-07-23)
- https://providernews.anthem.com/new-york/articles/aba-reminders-27626 (accessed 2026-07-23)
- https://providers.anthem.com/new-york-provider/contact-us (accessed 2026-07-23)

## Common questions

### Does Anthem HealthPlus cover ABA in New York?

Yes — it carries the NY Medicaid ABA carve-in for members under 21 with ASD/Rett, with treatment authorized via its Treatment Plan Request Form submitted through Availity. The June 2026 form revision confirms it remains an active NY ABA payer.

### Does the ABA assessment need prior authorization at Anthem NY?

No published policy answers that for 97151 specifically — the documented process is the treatment-plan-request workflow. Verify per case in Availity or with provider services, and get the answer in writing.

### Why was our Anthem ABA request returned?

Anthem returns incomplete Treatment Plan Request Forms rather than pending them. Complete every field — including BCBA/QHCP information and the Comprehensive/Focused classification — and attach clinical documentation up front.

## Primary sources

1. [Anthem NY Medicaid ABA Treatment Plan Request Form (June 2026)](https://providers.anthem.com/docs/gpp/NY_ABC_CAID_ABA_AuthReqForm.pdf?v=202411221617)
2. [Anthem NY provider news — ABA Services FAQ (article 13424)](https://providernews.anthem.com/new-york/articles/applied-behavior-analysis-services-faq-for-providers-13424)
3. [eMedNY ABA Provider Policy Manual (state baseline)](https://www.emedny.org/ProviderManuals/ABA/PDFS/ABA_Policy.pdf)
4. [Anthem Blue Cross and Blue Shield HP — NY Medicaid Provider Manual (eff. March 1, 2026), Precertification / Concurrent Review](https://providers.anthem.com/docs/gpp/NY_ABC_CAID_ProviderManual.pdf?v=202501161732)

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.