Anthem Blue Cross and Blue Shield serves Indiana Medicaid members across Hoosier Healthwise, HIP, and Hoosier Care Connect, and administers ABA under its own UM guideline — which is an explicit restatement of the IHCP rules (405 IAC 5-22-12 and the state bulletins). Clinically you're dealing with state policy; operationally you're dealing with Anthem's documentation package and the Availity/Interactive Care Reviewer pipeline. One caution: Anthem's published guideline predates the April 2026 state changes, so where they differ, the state rules control.
Anthem's stated initial-request requirements are concrete: the PA form, the autism diagnosis coded F84.0, applicable testing results, an intake assessment covering level of functioning, severity, and social/life skills, the treatment plan, and — the one teams miss — the child's daily schedule. Continuation requests need a new PA with an updated treatment plan, developmental testing within 2 months of treatment start, and progress-to-date per goal. Submissions run through Availity's Interactive Care Reviewer, with fax (using the IHCP universal PA form) and phone as alternatives.[1][2]
Members whose care runs through an ACO, PMG, or IPA-contracted group must follow that group's authorization and claims rules rather than Anthem's direct process — worth checking during verification. And because Anthem's guideline hasn't been re-issued since 2021, the 2026 IHCP changes (EPSDT-only, the under-21 cutoff, the 4,000-hour lifetime allocation, mandatory caregiver coaching, and the telehealth restrictions) apply through state policy even though the plan document doesn't mention them.[3]
The questions that decide whether a family can start with Anthem BCBS Indiana (Medicaid), and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the Indiana Medicaid rule: ABA is covered for members 20 years of age and younger. Effective April 1, 2026 coverage runs exclusively through EPSDT, and for dates of service on or after October 1, 2026 IHCP will not authorize or reimburse ABA for members 21 and older — a state policy that binds every MCE.[4][3][5]
Follows the Indiana Medicaid rule: a CDE more than one year old requires an updated statement of need, which must include a referral from an appropriate referring practitioner and an up-to-date behavior assessment completed by the ABA provider. Members continuing current services need no new CDE but do need an updated behavior assessment and treatment plan. A behavior assessment completed within the previous six months should be obtained from the original provider rather than repeated. IHCP states these documentation requirements apply to managed care as well as fee-for-service.[5][4]
Follows the Indiana Medicaid rule: the CDE must be performed by a provider with specialized training in the current DSM autism criteria who is a doctoral-level licensed clinical psychologist endorsed as an HSPP, a licensed physician, a licensed APRN, or a licensed physician assistant. Anthem's own UM guideline asks for the autism diagnosis coded F84.0 with applicable testing results rather than restating the credential list — and because that guideline was last reviewed in 2021, the state list controls where they differ.[5][1]
Two requirements stack. The state's behavior assessment must include three core standardized instruments — the Vineland Comprehensive Parent Interview Form with the Maladaptive Behavior domain, the BASC Parenting Relationship Questionnaire, and an age-appropriate objective direct skills assessment — with the complete scoring report, outcome scores and graphs submitted with the PA. Anthem's own package then asks for “applicable testing results” plus an intake assessment covering level of functioning, severity and social/life skills, and for continuation, developmental testing within 2 months of treatment start. Note the currency switch: only BASC-4 satisfies the state requirement after October 1, 2026.[4][1][6]
Follows the Indiana Medicaid rule: a physician must make a treatment referral recommending ABA therapy, and the CDE’s own required components include a physician’s referral for autism-specific services. Prior authorization is required on top of the referral for every ABA service, through this plan rather than through Acentra Health.[4][5]
Follows the Indiana Medicaid rule: effective April 1, 2026, codes 97151, 97152, 97153, 97154 and 0373T can no longer be billed with telehealth modifier 95 and require in-person delivery. The plan publishes no ABA telehealth policy of its own.[3]
Indiana law sets the binding clock, and it is far faster than the federal one. Since July 1, 2025, IC 27-1-37.5-23 requires a utilization review entity to answer an urgent PA request “not later than twenty-four (24) hours after receiving the request” and every other request “not later than forty-eight (48) hours,” with “weekends and state and federal legal holidays” excluded from both clocks; the chapter's “health plan” expressly includes “the Medicaid risk based managed care program” (IC 27-1-37.5-5), and IC 27-1-37.5-28 makes a missed deadline an automatic approval: the service “shall be automatically deemed authorized.” The federal managed-care floor, 42 CFR 438.210(d), is only a ceiling for states (7 calendar days standard for rating periods starting on or after 1/1/2026, extendable 14 days; 72 hours expedited), so the stricter Indiana clock wins. Anthem's own Indiana Medicaid Provider Manual (INBCBS-CD-PM-070775-24, April 2025) still prints the pre-statute timelines — non-urgent pre-service “within 5 business days (not including weekends and state-approved holidays) from receipt of the request,” urgent pre-service and concurrent reviews within 48 hours — so hold Anthem to the statute, not the manual. Neither the manual nor Anthem's Indiana Medicaid ABA guidelines publish a reauthorization submission lead time.[9][10][11][12][13]
Anthem pays last. Its Indiana Medicaid manual: “Anthem is the payer of last resort per Federal and State guidelines,” and a COB claim must carry the other payer's remittance advice/EOP or a letter explaining the denial — paper claims without one are mailed back, electronic ones denied — and must reach Anthem “within 90 days from the date on the other program’s RA/EOP or letter of denial of coverage.” Anthem pays “up to the IHCP allowed amount” and “adjudicates COB claims in alignment with the IHCP Third Party Liability Module” — the module that refuses claims the primary denied as out-of-network, so be in the commercial plan's network. If commercial coverage turns up after Anthem paid, Anthem recovers from the other carrier rather than from you. Get this plan's ABA PA even when it is secondary: the IHCP Prior Authorization module says that when the member has primary coverage, the provider “must follow the primary insurer's requirements for obtaining PA and must also obtain PA from the appropriate IHCP PA contractor (based on the program assignment of the member) to receive payment from the IHCP for the balance of charges not paid by the primary insurance.” The Anthem manual adds nothing of its own on PA-when-secondary beyond Medicare. TRICARE is not a problem here: 32 CFR 199.8 excludes Medicaid from the “double coverage plans” TRICARE pays after, so for a child with both, TRICARE pays before Medicaid.[12][14][15][16]
Coverage decides whether Anthem BCBS Indiana (Medicaid) 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.
Follows the Indiana Medicaid rule: ABA performed by a BCaBA or credentialed RBT must be under the direct supervision of a BCBA, BCBA-D or HSPP, and since April 1, 2026 at least 1 hour of BCBA (or IHCP-approved qualifying clinician) supervision is required per 8 hours of technician-delivered therapy. Behavior assessments may only be performed by a psychologist, BCBA-D or master's-level BCBA. IHCP states that its ABA documentation requirements apply to both fee-for-service and managed care, and this plan publishes no supervision standard of its own.[4][3][5]
Follows the Indiana Medicaid limits: up to 40 hours per week may be requested with anything beyond that needing an additional PA; each prior authorization is capped at six months; and since April 1, 2026 comprehensive ABA (16+ hours/week, modifier UA) draws from a 4,000-hour (16,000-unit) lifetime allocation per member, with 97155 and 97156 excluded and targeted ABA (≤15 hours/week) exempt. No per-day MUE ceiling is published at either level.[4][3]
Follows the Indiana Medicaid rule: the treatment plan must be built around the member's school attendance (including homeschooling) and other daily activities, while services focusing solely on recreational or educational outcomes are not covered, and neither are services duplicative of an IEP that address the same goals using the same techniques as the treatment plan.[4]
Follows the Indiana Medicaid rule: ABA rendered by a BCaBA or RBT must be billed under the NPI of an IHCP-enrolled ABA therapist or school corporation, on a professional claim. Since July 1, 2025 the rendering practitioner must be enrolled under ABA specialty 615, 624 or 625, and since April 1, 2025 the rendering NPI must align with the credential-level modifier (U1 RBT / U2 BCaBA / U3 BCBA-HSPP). Plan-level claim formatting may still differ — MCEs publish their own billing requirements.[4][3]
Not published by Indiana Medicaid or by this plan. IHCP is explicit that within managed care “individual managed care entities (MCEs) establish and publish their own billing and reimbursement requirements,” so unlike the clinical criteria, code-pair rules are not inherited from the state by default.[5]
Ask the plan: The MCE directly — ask whether 97155 pays alongside 97153 for the same clock time, and request the plan's billing and reimbursement requirements in writing.
Neither Indiana Medicaid nor this plan publishes a session-note signature rule. The state's published signature requirements attach to the plan documents — the behavior assessment and the treatment plan must each be signed by the lead analyst and the parent or guardian — and BT202562, the bulletin titled for ABA documentation requirements, does not reach the individual session note. IHCP states its documentation requirements apply to managed care as well as fee-for-service, but also that MCEs establish and publish their own billing and reimbursement requirements, so the gap is not automatically filled at the state level.[4][5]
Ask the plan: The MCE directly — ask for its ABA documentation and session-note standard in writing. BT202562 also promises a future bulletin clarifying documentation requirements under the updated ABA State Plan Amendment; check for it before relying on this.
Yes — under Anthem's UM guideline, which restates IHCP criteria: all ABA prior-authorized, 6-month max authorizations, up to 40 hours/week requestable, members 20 and younger.
The PA form, F84.0 diagnosis, testing results, an intake assessment (functioning, severity, social/life skills), the treatment plan, and the child's daily schedule — via Availity's Interactive Care Reviewer, fax, or phone.
Yes — EPSDT-only coverage, the under-21 cutoff, the 4,000-hour lifetime allocation, and telehealth restrictions are state policy that binds every MCE, even though Anthem's published guideline predates them.
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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