---
title: "Blue Cross Blue Shield of Michigan ABA coverage: the intake guide."
url: "https://carelu.com/payers/blue-cross-blue-shield-michigan"
markdown_url: "https://carelu.com/payers/blue-cross-blue-shield-michigan.md"
state: MI (Michigan)
payer: Blue Cross Blue Shield of Michigan
kind: Commercial insurance
description: "How Blue Cross Blue Shield of Michigan and Blue Care Network cover ABA: no age limit since 2022, AAEC or independent diagnostic evaluations, Blue Cross Behavioral Health prior authorization, billing and documentation rules, Michigan’s mandate caps and exemptions, and what intake should verify."
last_reviewed: September 2026
---

# Blue Cross Blue Shield of Michigan ABA coverage: the intake guide.

_Payer Guide · Blue Cross Blue Shield of Michigan · Last updated September 2026 · 21 primary sources_

> Michigan’s Blue plan: ABA regardless of age since 2022, AAEC or independent evaluation, Blue Cross Behavioral Health PA.

Blue Cross Blue Shield of Michigan and its HMO, Blue Care Network (BCN), are Michigan’s Blue plan. Behavioral health prior authorizations for their commercial members, autism included, run through Blue Cross Behavioral Health. Blue Cross publishes an unusually complete set of autism documents, and three of its rules go beyond the state mandate: no age limit on ABA since 2022, no required re-evaluation, and no billable-unit limits beyond the authorization. This guide stacks Blue Cross’s own rules on top of Michigan’s mandate and the plan’s funding type.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required for BCN HMO plans and for Blue Cross PPO fully insured and select self-funded groups — 97151/97152 are on the Blue Cross Behavioral Health prior-authorization list; some PPO groups do not require it. The diagnostic evaluation’s behavioral-health components need no PA. [6][4][1]
- **Prior auth for treatment**: Required through Blue Cross Behavioral Health for all BCN HMO plans and for Blue Cross PPO fully insured and select self-funded groups (97153–97158 on the PA list); submit the comprehensive diagnostic evaluation with the request. [6][4][1]
- **Autism diagnosis required?**: Yes — current-DSM ASD confirmed by a comprehensive diagnostic evaluation from an AAEC or PCP/independent evaluators; re-evaluation not required. [1][3]

## At a glance

- **Covers ABA?:** Yes — ABA for ASD, regardless of age for dates of service since Jan. 1, 2022 (check group customizations)
- **State mandate:** MCL 500.3406s (insurers; 2012 PA 100, amended 2016) and MCL 550.1416e (health care corporation certificates)
- **Mandate age:** Treatment coverage may be limited to members through age 18
- **Mandate caps:** Annual maximums allowed: $50,000 through age 6, $40,000 ages 7–12, $30,000 ages 13–18; no visit limits
- **Exempt from mandate:** Self-funded ERISA plans; exchange QHPs beyond essential health benefits; short-term policies of 6 months or less
- **Licensure:** Behavior analysts licensed by LARA (Public Health Code Part 182A, law since 2016; BACB certification required); technicians unlicensed
- **Prior auth:** Blue Cross Behavioral Health: all BCN HMO plans; Blue Cross PPO fully insured and select self-funded groups
- **Diagnosis route:** Approved autism evaluation center (AAEC) or PCP/independent evaluators

## Getting the diagnosis Blue Cross accepts

Before an ABA provider can ask Blue Cross Behavioral Health for prior authorization, the member needs a comprehensive diagnostic evaluation showing the DSM criteria for autism, completed by a licensed physician, licensed psychologist or other licensed clinician qualified to diagnose autism. Michigan members have two routes: an approved autism evaluation center (AAEC), which arranges each discipline’s evaluation and hands the family the results, or a primary care provider and/or independent autism evaluation providers. Prior authorization is not required for the behavioral health components of the evaluation, but some BCN commercial members need a PCP referral for each medical specialist involved. AAECs and independent teams must field medical, behavioral and speech-language specialists and use standardized testing with interviews and observation (ADOS, ADI-R, CARS, SCQ, ASRS, SRS are named examples). [1][2][3][4]

Blue Cross does not require a comprehensive re-evaluation later: "It’s optional, based on clinical need." Blue Cross accepts only current-DSM autism codes; Asperger’s and PDD now fall under the ASD diagnosis. [1][2][3][4]

## Prior authorization and billing

Blue Cross Behavioral Health manages autism prior authorizations for Blue Cross commercial, Medicare Plus Blue, BCN commercial and BCN Advantage. The procedure-code list (v.2026.3) marks 97151 through 97158 as requiring prior authorization for BCN HMO, Medicare Plus Blue PPO, and Blue Cross commercial "fully insured groups and … select self-funded groups," and the member page confirms "All Blue Care Network HMO plans require prior authorization" while "Some Blue Cross Blue Shield of Michigan PPO plans require prior authorization, but not all." Out-of-network providers submit through online ABA assessment and treatment request forms. Blue Cross also notes that its autism benefits comply with the Michigan mandate but "The mandate doesn’t apply to some self-funded employer groups," Medicare Advantage or Medigap plans, or Blue Cross Complete (Medicaid). [5][6][4][7][8][9]

Billing: the supervising LBA bills all ABA, technician time included; behavior analysts must be Michigan-licensed to be paid (since Jan. 7, 2020); "There are no limits for billable ABA services" beyond the authorized units; each date of service goes on its own line with the authorization number. Blue Cross publishes no commercial ABA rates — they are contract terms. [5][6][4][7][8][9]

## Documentation Blue Cross audits

Blue Cross’s July 2026 documentation standards spell out each note: patient identification, place of service and any telemedicine, technician and supervising LBA with credentials, date with start and stop times (narratives in no more than four-hour blocks), interventions, data and progress, and the signatures and credentials of the RBT and supervising LBA (97153/97154) or the LBA (97155–97158). Where the LBA supervises live, the note must separate 97153 technician care from 97155 supervision. Caregivers are expected to participate in at least two hours a month of caregiver training and attend at least 80% of scheduled sessions. [10]

## The Michigan autism mandate: what it guarantees, and its age and dollar limits

Michigan’s autism mandate has two parallel statutes: MCL 500.3406s for insurers (added by 2012 PA 100, amended by 2016 PA 276, applying to policies delivered, issued or renewed beginning 180 days after its April 18, 2012 enactment) and MCL 550.1416e for health care corporation group and nongroup certificates. Both require coverage "for the diagnosis of autism spectrum disorders and treatment of autism spectrum disorders," including behavioral health treatment such as applied behavior analysis, and bar the carrier from limiting the number of visits, from denying coverage because treatment "is educational or habilitative in nature," and from applying dollar limits, copays, deductibles or coinsurance that do not apply to physical illness generally. [11][12]

Unlike newer mandates, Michigan’s still carries age and dollar ceilings the carrier may choose to apply: coverage for treatment may be limited "through 18 years of age" and to a maximum annual benefit of $50,000 through age 6, $40,000 from 7 through 12, and $30,000 from 13 through 18. Treatment must be "prescribed or ordered" by a licensed physician or licensed psychologist who finds it medically necessary, behavioral health treatment must be "provided or supervised by a board certified behavior analyst or a licensed psychologist," and the diagnosis means assessments "including the autism diagnostic observation schedule, performed by a licensed physician or a licensed psychologist." While a member is in treatment the carrier may require a treatment plan and treatment review, request the ADOS results, request that the ADOS be repeated no more than once every three years, and request an annual development evaluation. Utilization review, medical-necessity review, network requirements and coordination of benefits still apply. Exempt: self-funded ERISA employer plans (outside state insurance law), exchange qualified health plans to the extent the coverage exceeds essential health benefits, and, under 500.3406s, short-term policies of six months or less. [11][12]

## Licensure

Michigan licenses behavior analysts through LARA’s Board of Behavior Analysts under Part 182A of the Public Health Code (Michigan’s licensure law dates from 2016). A license requires current BACB certification in good standing sent directly from the BACB, a criminal background check, human-trafficking and implicit-bias training, and renews every four years; assistant behavior analysts have their own LARA license and supervision verification. Technicians are not licensed by the state. Blue Cross ties payment to it: behavior analysts "must be licensed by the state of Michigan to be reimbursed by Blue Cross or BCN," and psychologists who want to provide ABA file an attestation form. [13][14][15][7]

## Intake gates

The questions that decide whether a family can start with Blue Cross Blue Shield of Michigan, and what they have to bring.

- **Age limit**: No age cap on Blue Cross commercial or BCN commercial ABA since 2022: "For dates of service on or after Jan. 1, 2022, the above services are benefits for members with an ASD diagnosis regardless of age"; before that, ABA ran "only through the age of 18." This is more generous than the state mandate, which would allow an age-18 limit. Employer groups can customize autism benefits, so check the member’s coverage. [3][4][11]
- **Diagnosis recency**: No expiry: "A comprehensive diagnostic re-evaluation is not required by Blue Cross Behavioral Health. It’s optional, based on clinical need," separate from the reassessments the licensed behavior analyst completes during treatment (typically semi-annual). Under the mandate a fully insured plan may still request that the ADOS be repeated no more than once every three years. [1][7][11]
- **Who may diagnose**: The comprehensive diagnostic evaluation must be "completed by a licensed physician, a licensed psychologist or another licensed clinician who is qualified to diagnose autism by state licensure and related training," either at an approved autism evaluation center (AAEC) in Michigan or through a primary care provider and/or independent evaluation providers (pediatrician, developmental pediatrician, pediatric neurologist, neurologist, child psychologist, child or adult psychiatrist, neuropsychologist, psychologist, speech-language therapist). AAECs and independent evaluation teams must have medical, behavioral and speech-language disciplines on the core team. [1][4][2]
- **Diagnostic tools required**: The evaluation must contain DSM diagnostic criteria (current edition). For AAECs and independent evaluation teams Blue Cross requires standardized, age-appropriate testing that includes both interviews and observation — examples: ADOS, ADI-R, CARS, SCQ, ASRS, SRS — plus cognitive, adaptive, language and sensory assessments, an in-depth medical history and developmental and behavioral observations. [1][2]
- **Referral required?**: Blue Cross needs a comprehensive diagnostic evaluation before an ABA provider may request prior authorization, and the evaluation’s treatment plan should recommend ABA. For some BCN (HMO) commercial members "a referral from the primary care provider is required for each medical specialist who will see the member during the evaluation process." For a fully insured Michigan policy the mandate adds an order requirement: covered treatment is care "prescribed or ordered for an individual diagnosed with 1 of the autism spectrum disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary," and the treatment plan is developed "when the treatment of an autism spectrum disorder is first prescribed or ordered." Self-funded ERISA plans sit outside the statute. [1][11]
- **Prior-auth decision time** _(plan-dependent)_: Turns on how the plan is funded. Fully insured Michigan insurance and HMO plans follow MCL 500.2212e: after May 31, 2024 a non-urgent prior authorization request "is considered granted" if the insurer does not grant it, deny it, or ask for more information "within 7 calendar days after the date and time of submission," and again within 7 calendar days after additional information is submitted; a request the provider certifies as urgent is considered granted if not acted on within 72 hours. An approved authorization "is valid for not less than 60 calendar days or for a duration that is clinically appropriate, whichever is later." The statute’s "health benefit plan" covers individual and group insurance, HMO contracts, and self-funded plans of the state or local governments, not private self-funded employer plans, which follow ERISA: pre-service decisions "not later than 15 days after receipt of the claim," one 15-day extension, urgent claims within 72 hours. [16][17]
  - Ask the plan: At benefits verification ask whether the plan is fully insured (Michigan-regulated) or self-funded (ERISA), then confirm the Blue Cross Behavioral Health turnaround and reauthorization lead time (the Blue Cross Behavioral Health number on the member ID card (Blue Cross 1-800-762-2382; BCN 1-800-482-5982)).
- **Other insurance (who pays first)** _(plan-dependent)_: Which plan pays first is set by Michigan’s Coordination of Benefits Act for state-regulated plans: for a dependent child whose parents are married or living together, "The plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (same birthday: the plan covering the parent longer); for divorced or separated parents a court order assigning health coverage controls, then the order in MCL 550.253. The autism mandate adds that a member with two policies covering autism gets benefits "subject to the limits of this section when coordinating benefits." If the child also has Michigan Medicaid, Blue Cross pays first: Medicaid is payer of last resort and "is not liable for payment of services denied because coverage rules of the primary health insurance were not followed," so get Blue Cross’s authorization even when Medicaid (the PIHP) will pay secondary. TRICARE pays after other coverage except Medicaid (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270). [18][11][19][20][21]
  - Ask the plan: Ask Blue Cross at benefits verification for the member’s coordination-of-benefits order (the Blue Cross Behavioral Health number on the member ID card (Blue Cross 1-800-762-2382; BCN 1-800-482-5982)); self-funded plans set their own COB terms in the plan document. Record every other coverage the child has.

## Delivery and billing rules

Coverage decides whether Blue Cross Blue Shield of Michigan 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**: Blue Cross requires ABA to be delivered or supervised by a Michigan-licensed behavior analyst: "Effective Jan. 7, 2020, behavior analysts must be licensed by the state of Michigan to be reimbursed by Blue Cross or BCN." Technician line therapy is administered "under the direction of an LBA," and LBA supervision of line therapy and skills training is billed as protocol modification (97155). Blue Cross publishes no minimum supervision ratio. Its documentation standards add a caregiver requirement: parents or guardians should participate in at least two hours a month of direct caregiver training with the LBA/BCBA and bring the child to at least 80% of scheduled sessions. [7][10]
- **Concurrent billing (97153 + 97155)**: Allowed for 97153 and 97155. The billing guide describes 97155 as protocol modification that "may simultaneously direct a technician in administering the modified protocol while the member is present," and the documentation standards require that "If live supervision with technician and LBA, documentation must clearly show *97153 is for direct technician care and *97155 is for the LBA’s supervision." Direction of a technician without the client present "is not reported separately," and 97155 may not be used to bill training a technician to perform line therapy. [7][10]
- **Daily limits / MUEs**: "There are no limits for billable ABA services. The services billed must be based on the units authorized." Units billed may not exceed the number on the authorization letter for each code, each date of service goes on its own claim line within the authorized dates, and progress-note narratives must be documented in no more than four-hour (16-unit) increments. [7][10]
- **Session-note signature**: Each ABA progress note must carry the "Signature and credentials of the RBT and supervising LBA" for technician services (97153, 97154) and the "Signature and credentials of the LBA" for 97155, 97156, 97157 and 97158, along with the date, start and stop times, the place of service and whether telemedicine was used, and the names and credentials of the technician and supervising LBA. [10]
- **Bill as provider**: The supervising LBA bills. "Line therapy is billable only by an LBA. A technician’s services are billed by the supervising LBA," and skills-training groups likewise. Behavior analysts must be licensed by the State of Michigan (since Jan. 7, 2020) to be reimbursed; H-codes and S-codes are payable only to non-Michigan providers who cannot use the AMA category I codes. Bill each date of service on its own line with the autism diagnosis from the authorization and the 10-digit authorization number. [7]

## What intake should collect for Blue Cross Blue Shield of Michigan

- **BCN (HMO) or Blue Cross PPO, and funding type:** All BCN HMO plans require ABA prior authorization; PPO depends on the group. Self-funded groups may sit outside the mandate.
- **Comprehensive diagnostic evaluation:** From an AAEC or PCP/independent evaluators, showing DSM criteria and recommending ABA; attach it to the PA request.
- **PCP referral (BCN):** Some BCN members need a PCP referral for each medical specialist in the evaluation.
- **Caregiver availability:** Blue Cross expects at least two hours a month of caregiver training and 80% session attendance.
- **Other coverage:** Record Medicaid, a second parent’s plan, TRICARE or CHAMPVA for coordination of benefits.

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

## Common questions

### Does Blue Cross Blue Shield of Michigan cover ABA for adults?

For Blue Cross commercial and BCN commercial members, ABA and the other autism services are benefits regardless of age for dates of service on or after Jan. 1, 2022 — subject to the member’s own group benefits.

### Does the diagnosis have to come from an approved autism evaluation center?

No. Michigan members can use an AAEC or a primary care provider and/or independent evaluators, as long as the comprehensive evaluation meets Blue Cross’s requirements and shows the DSM criteria.

### Is prior authorization always required?

For all BCN HMO plans, yes. For Blue Cross PPO it depends on the group: fully insured groups and select self-funded groups require it. Check the member’s autism coverage.

### Is there an hour or unit limit?

Blue Cross says there are no limits for billable ABA services beyond the units authorized. A fully insured plan may still apply the mandate’s annual dollar maximums for members through age 18 if its certificate does.

## Primary sources

1. [BCBSM / BCN — Obtaining a comprehensive diagnostic evaluation for autism and finding treatment (rev. November 2025)](https://www.bcbsm.com/amslibs/content/dam/public/common/documents/approved-autism-evaluation-centers.pdf)
2. [BCBSM / BCN — Requirements for comprehensive diagnostic evaluations by AAECs and independent evaluation teams (rev. November 2025)](https://authorizations.bcbsm.com/static-assets/documents/autism-diagnostic-evaluation-requirements.pdf)
3. [BCBSM / BCN — Overview of autism coverage (rev. November 2025)](https://authorizations.bcbsm.com/static-assets/documents/autism-coverage-overview.pdf)
4. [Blue Cross Blue Shield of Michigan — What do I need to know about autism coverage?](https://www.bcbsm.com/individuals/help/using-your-insurance/autism-coverage/)
5. [BCBSM / BCN — Autism Services (provider prior authorization page)](https://authorizations.bcbsm.com/prov-ref-autism)
6. [BCBSM / BCN — Procedure codes for which providers must request prior authorization (v.2026.3)](https://authorizations.bcbsm.com/static-assets/documents/procedure-codes-that-require-prior-auth.pdf)
7. [BCBSM / BCN — Autism services: Billing guidelines and procedure codes (rev. November 2025)](https://authorizations.bcbsm.com/static-assets/documents/autism-billing-guidelines-procedure-codes.pdf)
8. [BCBSM / BCN — Behavioral health: care management and utilization management programs (December 2025)](https://authorizations.bcbsm.com/static-assets/documents/cm-um-behavioral-health.pdf)
9. [Blue Cross Behavioral Health — Frequently asked questions for providers (November 2025)](https://authorizations.bcbsm.com/static-assets/documents/blue-cross-behavioral-health-faq.pdf)
10. [BCBSM / BCN — Behavioral health medical record documentation requirements for autism treatment services (rev. July 2026)](https://authorizations.bcbsm.com/static-assets/documents/bh-documentation-rqumts-autism-services.pdf)
11. [MCL 500.3406s — autism coverage (Insurance Code), Michigan Legislature](https://www.legislature.mi.gov/Laws/MCL?objectName=mcl-500-3406s)
12. [MCL 550.1416e — autism coverage (Nonprofit Health Care Corporation Reform Act), Michigan Legislature](https://www.legislature.mi.gov/Laws/MCL?objectName=mcl-550-1416e)
13. [LARA — Michigan Board of Behavior Analysts (Public Health Code Part 182A; R 338.1801–338.1835)](https://www.michigan.gov/lara/bureau-list/bpl/health/hp-lic-health-prof/behavior-analysts)
14. [LARA — Michigan Behavior Analyst Licensing Guide (rev. 1/26/2026)](https://www.michigan.gov/lara/-/media/Project/Websites/lara/bpl/Behavior-Analysts/Licensing-Info-and-Forms/Behavior-Analyst-Licensing-Guide-FAQ-12626.pdf)
15. [BACB — U.S. Licensure of Behavior Analysts](https://www.bacb.com/u-s-licensure-of-behavior-analysts/)
16. [MCL 500.2212e — prior authorization process and timelines, Michigan Legislature](https://www.legislature.mi.gov/Laws/MCL?objectName=mcl-500-2212e)
17. [29 CFR 2560.503-1 — ERISA claims procedure](https://www.ecfr.gov/current/title-29/section-2560.503-1)
18. [MCL 550.253 — Coordination of Benefits Act, order of benefit determination](https://www.legislature.mi.gov/Laws/MCL?objectName=mcl-550-253)
19. [Michigan Medicaid Provider Manual (July 1, 2026) — Coordination of Benefits chapter](https://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf)
20. [10 U.S.C. 1079(i)(1) — TRICARE pays after other coverage except Medicaid](https://www.govinfo.gov/content/pkg/USCODE-2023-title10/html/USCODE-2023-title10-subtitleA-partII-chap55-sec1079.htm)
21. [38 CFR 17.270 — CHAMPVA is the last payer](https://www.ecfr.gov/current/title-38/section-17.270)

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.