---
title: Buckeye Health Plan ABA coverage (Next Gen MCO).
url: "https://carelu.com/payers/buckeye-health-plan"
markdown_url: "https://carelu.com/payers/buckeye-health-plan.md"
state: OH (Ohio)
payer: Buckeye Health Plan (OH)
kind: Medicaid managed care plan (MCO)
parent_program: Ohio Medicaid
description: "How Buckeye Health Plan administers Ohio Medicaid ABA — no PA on in-network assessments, Centene policy CP.BH.104 hour parameters, the Autism Services PA form package, and school-attendance expectations."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Buckeye Health Plan ABA coverage (Next Gen MCO).

_Payer Guide · Buckeye Health Plan · Last updated September 2026 · 5 primary sources_

> In-network assessments PA-free; CP.BH.104 hour parameters (6/day, 30/wk) and school rules.

Buckeye Health Plan (Centene) runs Ohio Medicaid ABA under Centene's corporate clinical policy CP.BH.104 — and offers the most intake-friendly front door of Ohio's stricter plans: in-network assessment codes 97151 and 97152 require no prior authorization (PA applies out-of-network only). The treatment side is where Centene's structure bites, with explicit hour parameters and a documentation package that rewards preparation.

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**: Not required in-network — 97151/97152 need PA for out-of-network only (plan form) [2]
- **Prior auth for treatment**: Required — 97153–97158 via the Autism Services PA form with IDI/FBA, schedule, parent-training plan, IEP [2]
- **Autism diagnosis required?**: Yes — autism diagnosis; CDE accepted within the past 5 years [1]

## At a glance

- **Plan type:** Ohio Next Generation MCO (Centene)
- **Policy:** CP.BH.104 (rev. 2/2026) + CP.BH.105 documentation requirements
- **Assessment PA:** None in-network; out-of-network only (97151, 97152)
- **Hour parameters:** ≤6 hrs/day, ≤30 hrs/wk unless justified; <20 hrs/wk for full-time students
- **Supervision:** 97155 ≥2 hrs/wk or 10% of direct hours; max 20% unless justified
- **Diagnosis window:** CDE accepted within the past 5 years
- **Diagnosis recency:** CDE accepted within the past 5 years

## The treatment-request package

Treatment PA (97153–97158) runs through Buckeye's Autism Services Prior Authorization Request Form, which wants the individual diagnostic interview or FBA, objective testing results, a description of coordination with other services, the proposed schedule with rendering provider type per session, a parent-training plan, and a copy of the IEP or IFSP. The form also requires an HSPP-or-physician attestation of active participation in the treatment plan. Requests fax to (866) 694-3649 (UM phone (800) 224-1991); retrospective dates aren't processed on the standard form and route to a separate fax. The pre-auth check tool on buckeyehealthplan.com answers code-level questions. [2]

## Hour parameters and school expectations

CP.BH.104 sets the numbers: treatment should not exceed 6 hours/day and 30 hours/week without detailed clinical justification (severity or escalation criteria, with BCBA and guardian signatures), and the policy expects under 20 hours/week for children attending school full-time — comprehensive ABA is framed as 30–40 hours/week for the cases that warrant it. Protocol modification (97155) should run at least 2 hours/week or 10% of direct hours (whichever is greater), capped at 20% unless justified. The comprehensive diagnostic evaluation is accepted if conducted within the past five years. [1]

## Intake gates

The questions that decide whether a family can start with Buckeye Health Plan (OH), and what they have to bring.

- **Diagnosis recency**: Buckeye accepts the comprehensive diagnostic evaluation if it was conducted within the past five years — the most generous window of the Ohio plans, and worth knowing against CareSource’s 24-month letter trigger. [4][1][2][1]
- **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. [4][1][2]
- **Referral required?**: No referral or service order is required, but the treatment package is prescriptive: treatment PA (97153–97158) runs through Buckeye’s Autism Services Prior Authorization Request Form, which wants the individual diagnostic interview or FBA, objective testing results, a description of coordination with other services, the proposed schedule with the rendering provider type per session, a parent-training plan, and a copy of the IEP or IFSP — plus an HSPP-or-physician attestation of active participation in the treatment plan. In-network assessment codes 97151 and 97152 need no prior authorization at all; PA applies out-of-network only. [4][1][2][2][1]
- **Prior-auth decision time**: Buckeye’s 2026 Medicaid manual: standard (non-urgent pre-service) determinations are made “no later than 7 calendar days after Buckeye receives the request for service.” Expedited determinations: “no later than 48 hours after Buckeye receives the request,” with provider attestation of urgency. Lead time: “Standard prior authorization requests should be submitted for medical necessity review at least five (5) business days before the scheduled service delivery date or as soon as the need for service is identified.” No separate 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. [6][7]
- **Other insurance (who pays first)**: Buckeye’s 2026 manual publishes no COB procedure of its own beyond asking providers to “obtain and report to Buckeye information regarding other insurance coverage,” so the state MCO rule governs. 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). [8][6]
  - Ask the plan: Buckeye Provider Services: whether a Buckeye ABA authorization is required when a commercial plan pays first.
- **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. [4][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 Buckeye Health Plan (OH) 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**: Buckeye publishes a numeric floor the state rule does not: protocol modification (97155) should run at least 2 hours a week or 10% of direct hours, whichever is greater, capped at 20% unless justified. The OAC 4783-6-02 COBA supervision-plan requirements still apply underneath. [4][1][2][1][5]
- **Daily limits / MUEs**: CP.BH.104 sets the numbers: treatment should not exceed 6 hours a day and 30 hours a week without detailed clinical justification — severity or escalation criteria, with BCBA and guardian signatures — and the policy expects under 20 hours a week for children attending school full time, with comprehensive ABA framed as 30–40 hours a week for the cases that warrant it. [4][1][2][1]
- **Place of service**: CP.BH.104 ties intensity to school attendance rather than naming payable settings: under 20 hours a week is expected for children attending school full time, and the treatment package requires a copy of the IEP or IFSP. The Ohio Medicaid School Program boundary still applies — the MCO is not responsible for services provided through MSP. [4][1][2][1][2]
- **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. [4][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. [4][1][2]

## What intake should collect for Buckeye Health Plan (OH)

- **Network status:** In-network assessments skip PA entirely — confirm contracting before promising the fast path.
- **School schedule:** Full-time students face the <20 hrs/week expectation — capture attendance honestly.
- **IEP / IFSP copy:** Required in the treatment package — request it at intake, not at submission.
- **Physician/HSPP engagement:** The attestation of active participation needs a named, willing clinician.

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

## Verification of benefits (VOB) data

How Buckeye Health Plan (OH) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00354
- **Payer ID (Change Healthcare / Optum):** 0004202 — ODM FI trading partner / MCE payer ID 0004202 (companion guide); a distinct Change Healthcare CPID was not separately confirmed.
- **Supports 270/271 eligibility:** Yes
- **Real-time eligibility:** Yes
- **Behavioral health administrator:** none
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes — Centene CP.BH.104; comprehensive diagnostic evaluation accepted within the past 5 years | In-network: no PA on assessment codes 97151/97152 (out-of-network only) per ohio.ts prose — NOTE: this waiver is not stated in CP.BH.104 itself; it sits on Buckeye's separate PA list / pre-auth check tool, so it ships inferred pending that source. | 32 units/day (CMS MUE ceiling — not restated in CP.BH.104, which caps by aggregate hours: <=6 hrs/day, <=30 hrs/wk without justification, <20 hrs/wk for full-time students) per day | home, clinic, school, community, telehealth (modality named in CP.BH.104 Background; no POS numbers given) | Allowed as a modality per CP.BH.104 (in-person or telehealth); no code-specific modifier/POS number published. | — |
| 97152 | Yes — Centene CP.BH.104; comprehensive diagnostic evaluation accepted within the past 5 years | In-network: no PA on assessment codes 97151/97152 (out-of-network only) per ohio.ts prose — NOTE: this waiver is not stated in CP.BH.104 itself; it sits on Buckeye's separate PA list / pre-auth check tool, so it ships inferred pending that source. | 16 units/day (CMS MUE ceiling — not restated in CP.BH.104, which caps by aggregate hours: <=6 hrs/day, <=30 hrs/wk without justification, <20 hrs/wk for full-time students) per day | home, clinic, school, community, telehealth (modality named in CP.BH.104 Background; no POS numbers given) | Allowed as a modality per CP.BH.104 (in-person or telehealth); no code-specific modifier/POS number published. | — |
| 97153 | Yes — Centene CP.BH.104; comprehensive diagnostic evaluation accepted within the past 5 years | Required — 97153-97158 via the Autism Services PA Request Form (IDI/FBA, schedule, parent-training plan, IEP/IFSP, HSPP/physician attestation); fax (866) 694-3649, UM (800) 224-1991. | 32 units/day (CMS MUE ceiling — not restated in CP.BH.104, which caps by aggregate hours: <=6 hrs/day, <=30 hrs/wk without justification, <20 hrs/wk for full-time students) per day | home, clinic, school, community, telehealth (modality named in CP.BH.104 Background; no POS numbers given) | Allowed as a modality per CP.BH.104 (in-person or telehealth); no code-specific modifier/POS number published. | — |
| 97154 | Yes — Centene CP.BH.104; comprehensive diagnostic evaluation accepted within the past 5 years | Required — 97153-97158 via the Autism Services PA Request Form (IDI/FBA, schedule, parent-training plan, IEP/IFSP, HSPP/physician attestation); fax (866) 694-3649, UM (800) 224-1991. | 18 units/day (CMS MUE ceiling — not restated in CP.BH.104, which caps by aggregate hours: <=6 hrs/day, <=30 hrs/wk without justification, <20 hrs/wk for full-time students) per day | home, clinic, school, community, telehealth (modality named in CP.BH.104 Background; no POS numbers given) | Allowed as a modality per CP.BH.104 (in-person or telehealth); no code-specific modifier/POS number published. | — |
| 97155 | Yes — Centene CP.BH.104; comprehensive diagnostic evaluation accepted within the past 5 years | Required — 97153-97158 via the Autism Services PA Request Form (IDI/FBA, schedule, parent-training plan, IEP/IFSP, HSPP/physician attestation); fax (866) 694-3649, UM (800) 224-1991. | 24 units/day (CMS MUE ceiling — not restated in CP.BH.104, which caps by aggregate hours: <=6 hrs/day, <=30 hrs/wk without justification, <20 hrs/wk for full-time students) per day | home, clinic, school, community, telehealth (modality named in CP.BH.104 Background; no POS numbers given) | Allowed as a modality per CP.BH.104 (in-person or telehealth); no code-specific modifier/POS number published. | — |
| 97156 | Yes — Centene CP.BH.104; comprehensive diagnostic evaluation accepted within the past 5 years | Required — 97153-97158 via the Autism Services PA Request Form (IDI/FBA, schedule, parent-training plan, IEP/IFSP, HSPP/physician attestation); fax (866) 694-3649, UM (800) 224-1991. | 16 units/day (CMS MUE ceiling — not restated in CP.BH.104, which caps by aggregate hours: <=6 hrs/day, <=30 hrs/wk without justification, <20 hrs/wk for full-time students) per day | home, clinic, school, community, telehealth (modality named in CP.BH.104 Background; no POS numbers given) | Allowed as a modality per CP.BH.104 (in-person or telehealth); no code-specific modifier/POS number published. | — |
| 97157 | Yes — Centene CP.BH.104; comprehensive diagnostic evaluation accepted within the past 5 years | Required — 97153-97158 via the Autism Services PA Request Form (IDI/FBA, schedule, parent-training plan, IEP/IFSP, HSPP/physician attestation); fax (866) 694-3649, UM (800) 224-1991. | 16 units/day (CMS MUE ceiling — not restated in CP.BH.104, which caps by aggregate hours: <=6 hrs/day, <=30 hrs/wk without justification, <20 hrs/wk for full-time students) per day | home, clinic, school, community, telehealth (modality named in CP.BH.104 Background; no POS numbers given) | Allowed as a modality per CP.BH.104 (in-person or telehealth); no code-specific modifier/POS number published. | — |
| 97158 | Yes — Centene CP.BH.104; comprehensive diagnostic evaluation accepted within the past 5 years | Required — 97153-97158 via the Autism Services PA Request Form (IDI/FBA, schedule, parent-training plan, IEP/IFSP, HSPP/physician attestation); fax (866) 694-3649, UM (800) 224-1991. | 16 units/day (CMS MUE ceiling — not restated in CP.BH.104, which caps by aggregate hours: <=6 hrs/day, <=30 hrs/wk without justification, <20 hrs/wk for full-time students) per day | home, clinic, school, community, telehealth (modality named in CP.BH.104 Background; no POS numbers given) | Allowed as a modality per CP.BH.104 (in-person or telehealth); no code-specific modifier/POS number published. | — |
| 0362T | Yes — Centene CP.BH.104; comprehensive diagnostic evaluation accepted within the past 5 years | Required — 97153-97158 via the Autism Services PA Request Form (IDI/FBA, schedule, parent-training plan, IEP/IFSP, HSPP/physician attestation); fax (866) 694-3649, UM (800) 224-1991. | 16 units/day (CMS MUE ceiling — not restated in CP.BH.104, which caps by aggregate hours: <=6 hrs/day, <=30 hrs/wk without justification, <20 hrs/wk for full-time students) per day | home, clinic, school, community, telehealth (modality named in CP.BH.104 Background; no POS numbers given) | Allowed as a modality per CP.BH.104 (in-person or telehealth); no code-specific modifier/POS number published. | — |
| 0373T | Yes — Centene CP.BH.104; comprehensive diagnostic evaluation accepted within the past 5 years | Required — 97153-97158 via the Autism Services PA Request Form (IDI/FBA, schedule, parent-training plan, IEP/IFSP, HSPP/physician attestation); fax (866) 694-3649, UM (800) 224-1991. | 32 units/day (CMS MUE ceiling — not restated in CP.BH.104, which caps by aggregate hours: <=6 hrs/day, <=30 hrs/wk without justification, <20 hrs/wk for full-time students) per day | home, clinic, school, community, telehealth (modality named in CP.BH.104 Background; no POS numbers given) | Allowed as a modality per CP.BH.104 (in-person or telehealth); no code-specific modifier/POS number published. | — |

Code notes:

- **97151, 97152, 97153, 97154, 97156, 97157, 97158, 0362T, 0373T:** Behavioral assessment completed <=2 months before initial treatment auth; reassessment every 6 months. Verify via: Buckeye pre-auth check tool for code-level PA status.
- **97155:** Protocol modification (97155) should run >=2 hrs/wk or 10% of direct hours (whichever is greater), capped at 20% unless justified (CP.BH.104). Behavioral assessment completed <=2 months before initial treatment auth; reassessment every 6 months. Verify via: Buckeye pre-auth check tool for code-level PA status.

### Contacts

- **Provider services phone:** (800) 224-1991
- **Portal:** [Buckeye Provider Portal](https://provider.buckeyehealthplan.com)
- **Fax:** (866) 694-3649

Questions to ask on a verification call:

- Can you confirm whether assessment codes 97151/97152 are currently PA-exempt for in-network providers per the current PA list/pre-auth tool — CP.BH.104 itself doesn't state this waiver?
- Do you enforce a per-code daily unit cap on top of CP.BH.104's aggregate hour limits (<=6 hrs/day, <=30 hrs/wk)?
- What POS code should be used when billing a telehealth ABA session?

### 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.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23)
- https://www.buckeyehealthplan.com/content/dam/centene/Buckeye/policies/clinical-policies/CP.BH.104.pdf (accessed 2026-07-23)
- https://www.buckeyehealthplan.com/content/dam/centene/Buckeye/WebsitePDFs/BehavioralHealthEducation/Medicaid-ABA-OTR-P-Form-508-6-28-23.pdf (accessed 2026-07-23)
- https://www.buckeyehealthplan.com/login.html (accessed 2026-07-23)

## Common questions

### Does Buckeye Health Plan cover ABA therapy?

Yes — under Centene's CP.BH.104 policy. In-network assessments (97151, 97152) need no prior authorization; treatment codes require PA via the Autism Services form.

### What are Buckeye's ABA hour limits?

No more than 6 hours/day and 30 hours/week without detailed clinical justification, and under 20 hours/week expected for full-time students. Protocol modification runs 2 hrs/week or 10% of direct hours, capped at 20% unless justified.

### How current must the autism diagnosis be for Buckeye?

The comprehensive diagnostic evaluation is accepted if conducted within the past 5 years.

## Primary sources

1. [Buckeye — CP.BH.104 Applied Behavior Analysis](https://www.buckeyehealthplan.com/content/dam/centene/Buckeye/policies/clinical-policies/CP.BH.104.pdf)
2. [Buckeye — Autism Services PA Request Form](https://www.buckeyehealthplan.com/content/dam/centene/Buckeye/WebsitePDFs/BehavioralHealthEducation/Medicaid-ABA-OTR-P-Form-508-6-28-23.pdf)
3. [Buckeye — clinical & payment policies index](https://www.buckeyehealthplan.com/providers/resources/clinical-payment-policies.html)
4. [Ohio Administrative Code — rule 5160-34-02](https://codes.ohio.gov/ohio-administrative-code/rule-5160-34-02)
5. [Ohio Administrative Code — rule 4783-6-02 (COBA supervision responsibilities)](https://www.law.cornell.edu/regulations/ohio/Ohio-Admin-Code-4783-6-02)
6. [Buckeye Health Plan — Medicaid Provider Manual 2026 (amended 1/6/2026)](https://www.buckeyehealthplan.com/content/dam/centene/Buckeye/WebsitePDFs/Manuals/Buckeye_Provider%20Manual_BHP%20MEDICAID%20Provider%20Manual%202026_FINAL_amd%201.6.26_R.pdf)
7. [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)
8. [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.