Anthem Blue Cross and Blue Shield administers Ohio Medicaid ABA by adopting its corporate Clinical UM Guideline CG-BEH-02 (Adaptive Behavioral Treatment) on top of the state rule — the same guideline family it applies in Georgia and elsewhere, bringing hour parameters and supervision ratios the state rule doesn't specify. The provider manual frames ASD services for under-21 members squarely under EPSDT: medically necessary services can exceed adult plan limits.
Anthem's Ohio Medicaid Clinical UM Guidelines list confirms CG-BEH-02 (and CG-BEH-15 for activity therapy) as the adopted criteria for adaptive behavioral treatment, layered on the OAC 5160-34 baseline. The CG-BEH-02 family of guidelines carries the familiar Anthem parameters — total requested treatment at or under 40 hours/week, protocol modification around 2 hours per 10 direct hours — though the Ohio-specific published delta is thinner than at CareSource or Buckeye, so verify current hour rules in the guideline text or the PA lookup tool at providers.anthem.com/oh before finalizing a request. UM submissions run through Availity Essentials' Interactive Care Reviewer, per the October 2025 provider manual, which also confirms the EPSDT framing and that under-21 inpatient psychiatric care routes to OhioRISE while ABA remains Anthem's responsibility.[1][2]
The questions that decide whether a family can start with Anthem BCBS Ohio (Medicaid), and what they have to bring. Each maps onto something intake should ask on the first call.
No state-level age bound could be verified, but Anthem’s Ohio Medicaid provider manual (10/2025) frames ASD services for members under 21 squarely under EPSDT: medically necessary services can exceed adult plan limits. Under-21 inpatient psychiatric care routes to OhioRISE while ABA remains Anthem’s responsibility.[3][1][2][2]
Follows the Ohio Medicaid framework: the ASD diagnosis comes from a documented comprehensive diagnostic evaluation by a licensed physician, psychologist, or other clinician qualified to diagnose autism, demonstrating DSM-5-TR criteria.[3][1][2]
No referral or service order requirement is published on the Medicaid side. Anthem adopts Clinical UM Guideline CG-BEH-02 (Adaptive Behavioral Treatment), with CG-BEH-15 for activity therapy, on top of the OAC 5160-34 baseline, and utilization-management requests run through Availity Essentials’ Interactive Care Reviewer. The assessment-versus-treatment PA split is not published — run the codes through the PA lookup tool at providers.anthem.com/oh per case.[3][1][2][1][2]
Anthem’s Ohio Medicaid manual, citing OAC 5160-26-03.1 and R.C. 5160.34: “For non-urgent pre-service requests: 7 calendar days. For urgent pre-service requests: 48 hours,” both counted from receipt of the request. If Anthem decides a request marked urgent is not urgent, it becomes an elective request and the provider is told. No ABA reauthorization lead time is published. Ohio’s MCO rule sets the clock. For a standard request the MCO “must provide notice to the provider and member as expeditiously as the member’s health condition requires but no later than seven calendar days following receipt of the request for service,” extendable by up to fourteen calendar days (an MCO-requested extension needs ODM’s prior approval). An expedited decision is due “no later than forty-eight hours after receipt of the request for service” (OAC 5160-26-03.1, effective 1/1/2026). The 48 hours is stricter than the federal 72-hour managed-care cap.[2][5]
Anthem is explicit that its own PA drops away on secondary claims: “No authorization is required for coordination of benefit (COB) claims.” Bill the primary carrier first, then send Anthem a claim for total billed charges with the primary carrier’s remittance advice, or a third-party letter explaining the denial. COB claims without one of these “will be mailed back.” Timely filing runs from the date of the other carrier’s explanation of payment (the manual’s table also says within 365 days of the date of service). Ohio’s MCO rule: “The MCE is the payer of last resort when a member has third party resources available.” Providers must “take reasonable measures to obtain all third party payments and file claims with all TPPs prior to billing the MCE.” That means a remittance from the other payer showing a valid non-payment reason (service not covered, applied to the deductible or copay, benefit maximum reached), a partial payment with its remittance, or no response within ninety days of submitting to the other payer. The MCO pays at most its allowed amount minus the other payments, and must allow at least ninety days from the other payer’s remittance to file. Exception: “The MCE, except SPBM, pays first for preventive pediatric services before seeking reimbursement from any liable third party.” Children in the custody of a county children’s services agency are exempt from TPL cooperation (OAC 5160-26-09.1).[2][6]
No plan-specific recency rule found — the Ohio Medicaid framework requires a documented comprehensive diagnostic evaluation demonstrating DSM-5-TR criteria but publishes no verifiable window. Note that two Ohio MCOs do set one (CareSource: a symptom letter where the evaluation is over 24 months old; Buckeye: a CDE within 5 years), so do not assume this plan is silent — confirm in its portal. codes.ohio.gov refused connection on every attempt this cycle and the 5160-34 chapter is still missing from the Title 5160 index, so the in-force rule text could not be read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Note also that ODM’s rewritten 5160-34 package is paused and pre-filing, not adopted, so draft content does not govern.[3][1][2]
Blocked on: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
No plan-specific instrument list found, and the state framework names none. Other Ohio MCOs do publish lists (CareSource: ADOS, ADI-R or CARS-2; Optum for UHC Community Plan: one validated screener plus one formal tool), so confirm in this plan’s portal rather than assuming. codes.ohio.gov refused connection on every attempt this cycle and the 5160-34 chapter is still missing from the Title 5160 index, so the in-force rule text could not be read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Note also that ODM’s rewritten 5160-34 package is paused and pre-filing, not adopted, so draft content does not govern.[3][1][2]
Blocked on: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
No plan-specific ABA telehealth rule found; ODM’s Telehealth Services guidance for managed care entities and the Telehealth Billing Guidelines set the underlying rules.[3][1][2]
Ask the plan: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
Coverage decides whether Anthem BCBS Ohio (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 Ohio framework (OAC 4783-6-02 COBA supervision plan, consultation before initiation and modification, periodic direct observation, no fixed ratio), with the CG-BEH-02 family’s parameter of roughly 2 hours of protocol modification per 10 direct hours layered on. Confirm the current guideline text before relying on the ratio.[3][1][2][1][4]
Anthem applies the CG-BEH-02 family parameters on top of the state framework: total requested treatment at or under 40 hours a week, with protocol modification around 2 hours per 10 direct hours. The Ohio-specific published delta is thinner than at CareSource or Buckeye, so verify the current hour rules in the guideline text or the PA lookup tool at providers.anthem.com/oh before finalising a request.[3][1][2][1]
Follows the Ohio Medicaid framework: independent practitioners are Certified Ohio Behavior Analysts (ORC Chapter 4783) or BACB BCBAs and BCBA-Ds enrolled with ODM as Provider Type 19, Specialty 190, with BCaBAs and RBTs delivering under supervision. The routing rule holds everywhere in Ohio: OhioRISE does not pay for ABA — ODM’s Mixed Services Protocol assigns ABA claims to the member’s MCO or fee-for-service even for OhioRISE-enrolled youth.[3][1][2]
Not resolved. No state-level rule on billing 97153 and 97155 for the same clock time could be verified, and this plan publishes none. codes.ohio.gov refused connection on every attempt this cycle and the 5160-34 chapter is still missing from the Title 5160 index, so the in-force rule text could not be read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Note also that ODM’s rewritten 5160-34 package is paused and pre-filing, not adopted, so draft content does not govern.[3][1][2]
Blocked on: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
No plan-specific session-note signature standard found, and none could be verified at state level. codes.ohio.gov refused connection on every attempt this cycle and the 5160-34 chapter is still missing from the Title 5160 index, so the in-force rule text could not be read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Note also that ODM’s rewritten 5160-34 package is paused and pre-filing, not adopted, so draft content does not govern.[3][1][2]
Blocked on: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
No plan-specific place-of-service rule found. The confirmed Ohio boundary is the school one: the MCO is not responsible for payment of services provided through the Medicaid School Program under OAC Chapter 5160-35, 5160-35-04 and 5160-26-03.[3][1][2]
Ask the plan: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
Yes — under its adopted CG-BEH-02 adaptive behavioral treatment guideline on top of OAC 5160-34, submitted via Availity's Interactive Care Reviewer, with EPSDT protections for under-21 members.
Inpatient psychiatric care for under-21s routes to OhioRISE, but ABA always stays with Anthem (per ODM's mixed-services protocol) — bill the MCO, not OhioRISE.
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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