---
title: Anthem Ohio Medicaid ABA coverage (Next Gen MCO).
url: "https://carelu.com/payers/anthem-ohio-medicaid"
markdown_url: "https://carelu.com/payers/anthem-ohio-medicaid.md"
state: OH (Ohio)
payer: Anthem BCBS Ohio (Medicaid)
kind: Medicaid managed care plan (MCO)
parent_program: Ohio Medicaid
description: "How Anthem administers Ohio Medicaid ABA — the adopted CG-BEH-02 adaptive behavioral treatment guideline on top of OAC 5160-34, Availity/ICR submission, and EPSDT framing for under-21 members."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Anthem Ohio Medicaid ABA coverage (Next Gen MCO).

_Payer Guide · Anthem (OH Medicaid) · Last updated September 2026 · 4 primary sources_

> CG-BEH-02 adopted on top of the state rule; Availity/ICR, EPSDT framing in the provider manual.

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.

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

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment** _(ask the plan)_: Not published — the assessment-versus-treatment PA split is not stated for Ohio Medicaid; run the codes through the PA lookup tool at providers.anthem.com/oh per case and submit via Availity Essentials / Interactive Care Reviewer
  - Ask the plan: Anthem's Ohio Medicaid PA lookup tool at providers.anthem.com/oh, per code and per member, with the answer taken in writing before submitting through Availity Essentials / Interactive Care Reviewer. Anthem publishes no assessment-versus-treatment PA split for Ohio Medicaid, so this is settled case by case, not by a document.
- **Prior auth for treatment:** Not published / unverified. Verify via: Anthem OH Medicaid provider manual + the plan's Clinical UM Guidelines list — neither states the ABA authorization span or code set; request the current behavioral-health UM guidance from Anthem provider services or via carelu.com/sources.

## At a glance

- **Plan type:** Ohio Next Generation MCO
- **Clinical rules:** CG-BEH-02 adopted (per the plan's Clinical UM Guidelines list)
- **Prior auth:** Via Availity Essentials / Interactive Care Reviewer
- **Hour parameters:** CG-BEH-02 family: ≤40 hrs/wk; ~2 hrs protocol modification per 10 direct
- **EPSDT:** Under-21 services may exceed adult limits when medically necessary
- **OhioRISE:** Inpatient psych routes to OhioRISE — ABA stays with Anthem

## How Anthem administers the benefit

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]

## Intake gates

The questions that decide whether a family can start with Anthem BCBS Ohio (Medicaid), and what they have to bring.

- **Age limit**: 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]
- **Who may diagnose**: 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]
- **Referral required?**: 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]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: 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]
- **Telehealth** _(ask the plan)_: 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.

## Delivery and billing rules

Coverage decides whether Anthem BCBS Ohio (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 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]
- **Daily limits / MUEs**: 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]
- **Bill as provider**: 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]
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: 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. [3][1][2]
- **Place of service** _(ask the plan)_: 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.

## What intake should collect for Anthem BCBS Ohio (Medicaid)

- **PA lookup check:** The assessment-vs-treatment PA split isn't published — run the codes through the lookup tool per case.
- **ASD diagnosis (DSM-5-TR):** Comprehensive evaluation per the state baseline.
- **Requested hours + justification:** CG-BEH-02's hour parameters reward requests framed against severity and history.
- **OhioRISE status:** Psychiatric services may route to OhioRISE, but ABA bills to Anthem — keep the paths straight.

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

## Verification of benefits (VOB) data

How Anthem BCBS Ohio (Medicaid) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00759
- **Payer ID (Change Healthcare / Optum):** 0002937 — ODM FI MCE payer ID 0002937 (companion guide) — ABA claims ride the ODM FI to Anthem's medical payer ID, NOT a Carelon payer ID.
- **Supports 270/271 eligibility:** Yes
- **Real-time eligibility:** Yes
- **Behavioral health administrator:** Carelon Behavioral Health (utilization management / prior authorization ONLY — not a claims administrator)
- **ABA rides on:** medical benefit
- **Two-hop verification required:** Yes — Carelon is a UM/prior-authorization hop only (Carelon "provides utilization management services on behalf of the health plan"); ABA CLAIMS have no second hop — they route through the ODM FI to Anthem MCE payer ID 0002937. twoHopRequired=true reflects the authorization hop; there is NO separate BH claims payer ID.

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes — CG-BEH-02 (Adaptive Behavioral Treatment) adopted on the OAC 5160-34 baseline; EPSDT framing for under-21 members | Required — UM via Availity Essentials / Interactive Care Reviewer (per the 10/2025 provider manual). The assessment-vs-treatment PA split is not published — run codes through the PA lookup tool per case. | 32 units/day (CMS MUE ceiling — CG-BEH-02 family generally caps total treatment at <=40 hrs/wk; per-code caps not re-extractable from the cited Anthem assets this pass) per day | — | — | — |
| 97152 | Yes — CG-BEH-02 (Adaptive Behavioral Treatment) adopted on the OAC 5160-34 baseline; EPSDT framing for under-21 members | Required — UM via Availity Essentials / Interactive Care Reviewer (per the 10/2025 provider manual). The assessment-vs-treatment PA split is not published — run codes through the PA lookup tool per case. | 16 units/day (CMS MUE ceiling — CG-BEH-02 family generally caps total treatment at <=40 hrs/wk; per-code caps not re-extractable from the cited Anthem assets this pass) per day | — | — | — |
| 97153 | Yes — CG-BEH-02 (Adaptive Behavioral Treatment) adopted on the OAC 5160-34 baseline; EPSDT framing for under-21 members | Required — UM via Availity Essentials / Interactive Care Reviewer (per the 10/2025 provider manual). The assessment-vs-treatment PA split is not published — run codes through the PA lookup tool per case. | 32 units/day (CMS MUE ceiling — CG-BEH-02 family generally caps total treatment at <=40 hrs/wk; per-code caps not re-extractable from the cited Anthem assets this pass) per day | — | — | — |
| 97154 | Yes — CG-BEH-02 (Adaptive Behavioral Treatment) adopted on the OAC 5160-34 baseline; EPSDT framing for under-21 members | Required — UM via Availity Essentials / Interactive Care Reviewer (per the 10/2025 provider manual). The assessment-vs-treatment PA split is not published — run codes through the PA lookup tool per case. | 18 units/day (CMS MUE ceiling — CG-BEH-02 family generally caps total treatment at <=40 hrs/wk; per-code caps not re-extractable from the cited Anthem assets this pass) per day | — | — | — |
| 97155 | Yes — CG-BEH-02 (Adaptive Behavioral Treatment) adopted on the OAC 5160-34 baseline; EPSDT framing for under-21 members | Required — UM via Availity Essentials / Interactive Care Reviewer (per the 10/2025 provider manual). The assessment-vs-treatment PA split is not published — run codes through the PA lookup tool per case. | 24 units/day (CMS MUE ceiling — CG-BEH-02 family generally caps total treatment at <=40 hrs/wk; per-code caps not re-extractable from the cited Anthem assets this pass) per day | — | — | — |
| 97156 | Yes — CG-BEH-02 (Adaptive Behavioral Treatment) adopted on the OAC 5160-34 baseline; EPSDT framing for under-21 members | Required — UM via Availity Essentials / Interactive Care Reviewer (per the 10/2025 provider manual). The assessment-vs-treatment PA split is not published — run codes through the PA lookup tool per case. | 16 units/day (CMS MUE ceiling — CG-BEH-02 family generally caps total treatment at <=40 hrs/wk; per-code caps not re-extractable from the cited Anthem assets this pass) per day | — | — | — |
| 97157 | Yes — CG-BEH-02 (Adaptive Behavioral Treatment) adopted on the OAC 5160-34 baseline; EPSDT framing for under-21 members | Required — UM via Availity Essentials / Interactive Care Reviewer (per the 10/2025 provider manual). The assessment-vs-treatment PA split is not published — run codes through the PA lookup tool per case. | 16 units/day (CMS MUE ceiling — CG-BEH-02 family generally caps total treatment at <=40 hrs/wk; per-code caps not re-extractable from the cited Anthem assets this pass) per day | — | — | — |
| 97158 | Yes — CG-BEH-02 (Adaptive Behavioral Treatment) adopted on the OAC 5160-34 baseline; EPSDT framing for under-21 members | Required — UM via Availity Essentials / Interactive Care Reviewer (per the 10/2025 provider manual). The assessment-vs-treatment PA split is not published — run codes through the PA lookup tool per case. | 16 units/day (CMS MUE ceiling — CG-BEH-02 family generally caps total treatment at <=40 hrs/wk; per-code caps not re-extractable from the cited Anthem assets this pass) per day | — | — | — |
| 0362T | Yes — CG-BEH-02 (Adaptive Behavioral Treatment) adopted on the OAC 5160-34 baseline; EPSDT framing for under-21 members | Required — UM via Availity Essentials / Interactive Care Reviewer (per the 10/2025 provider manual). The assessment-vs-treatment PA split is not published — run codes through the PA lookup tool per case. | 16 units/day (CMS MUE ceiling — CG-BEH-02 family generally caps total treatment at <=40 hrs/wk; per-code caps not re-extractable from the cited Anthem assets this pass) per day | — | — | — |
| 0373T | Yes — CG-BEH-02 (Adaptive Behavioral Treatment) adopted on the OAC 5160-34 baseline; EPSDT framing for under-21 members | Required — UM via Availity Essentials / Interactive Care Reviewer (per the 10/2025 provider manual). The assessment-vs-treatment PA split is not published — run codes through the PA lookup tool per case. | 32 units/day (CMS MUE ceiling — CG-BEH-02 family generally caps total treatment at <=40 hrs/wk; per-code caps not re-extractable from the cited Anthem assets this pass) per day | — | — | — |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** CG-BEH-02 carries the familiar Anthem parameters (<=40 hrs/wk total, ~2 hrs protocol modification per 10 direct hours), but the Ohio-specific published delta is thin and the cited GPP assets did not yield extractable per-code text this pass. Inpatient psychiatric care routes to OhioRISE; ABA stays with Anthem. Verify via: the current CG-BEH-02 guideline text (Carelon/Anthem clinical-guideline index) and the PA lookup at providers.anthem.com/oh.

### Contacts

- **Portal:** [Availity Essentials / Interactive Care Reviewer](https://www.availity.com)

Questions to ask on a verification call:

- Is prior authorization the same process for assessment codes (97151/97152/0362T) as for treatment codes, or is there a separate assessment pathway?
- What POS codes are approved for ABA (home, school, clinic, telehealth)?
- Is telehealth allowed for ABA services, and what modifier/POS number applies?
- Is there a per-code daily unit cap beyond CG-BEH-02's general <=40 hrs/wk treatment guideline?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://dam.assets.ohio.gov/image/upload/medicaid.ohio.gov/Providers/MITS/HIPAA%205010%20Implementation/CompanionGuide/OMES/FFS/Ohio270-271.pdf (accessed 2026-07-23)
- https://www.carelonbehavioralhealth.com/content/dam/digital/carelon/cbh-assets/documents/oh/ohbcbs-cd-025424-23-carelon-bh-intgrtn-qrg.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/OH_CAID_FEB23CUMG.pdf (accessed 2026-07-23)
- https://providers.anthem.com/docs/gpp/OH_CAID_ProviderManual.pdf (accessed 2026-07-23)

## Common questions

### Does Anthem Ohio Medicaid cover ABA therapy?

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.

### Does OhioRISE change anything for Anthem ABA 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.

## Primary sources

1. [Anthem OH Medicaid — Clinical UM Guidelines list](https://providers.anthem.com/docs/gpp/OH_CAID_FEB23CUMG.pdf)
2. [Anthem OH Medicaid — provider manual (10/2025)](https://providers.anthem.com/docs/gpp/OH_CAID_ProviderManual.pdf)
3. [Ohio Administrative Code — rule 5160-34-02](https://codes.ohio.gov/ohio-administrative-code/rule-5160-34-02)
4. [Ohio Administrative Code — rule 4783-6-02 (COBA supervision responsibilities)](https://www.law.cornell.edu/regulations/ohio/Ohio-Admin-Code-4783-6-02)
5. [OAC 5160-26-03.1 — MCO utilization management and authorization timeframes (eff. 1/1/2026)](https://codes.ohio.gov/ohio-administrative-code/rule-5160-26-03.1)
6. [OAC 5160-26-09.1 — MCO third party recovery and coordination of benefits](https://codes.ohio.gov/ohio-administrative-code/rule-5160-26-09.1)

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.