---
title: Carelon Health of Pennsylvania ABA coverage (HealthChoices IBHS).
url: "https://carelu.com/payers/carelon-behavioral-health-pennsylvania"
markdown_url: "https://carelu.com/payers/carelon-behavioral-health-pennsylvania.md"
state: PA (Pennsylvania)
payer: "Carelon Health of Pennsylvania (HealthChoices BH-MCO; formerly Beacon / Value Behavioral Health)"
kind: Medicaid managed care plan (MCO)
parent_program: Pennsylvania Medicaid (Medical Assistance)
description: "How Carelon Health of Pennsylvania authorizes ABA under HealthChoices IBHS in Armstrong, Beaver, Butler, Crawford, Fayette, Indiana, Lawrence, Mercer, Venango, Washington and Westmoreland counties: no auth for the assessment, CN.48 packets with the Act 62 cover sheet, 180-day authorizations, telehealth POS 10/02, and Act 62 COB."
last_reviewed: September 2026
---

# Carelon Health of Pennsylvania ABA coverage (HealthChoices IBHS).

_Payer Guide · Carelon Health of Pennsylvania · Last updated September 2026 · 14 primary sources_

> HealthChoices BH-MCO, 11 western counties; IBHS ABA — no PA on the assessment, 180-day treatment auths, Act 62 cover sheet.

Carelon Health of Pennsylvania (formerly Beacon Health Options / Value Behavioral Health of PA) is the HealthChoices behavioral health managed care organization for Medicaid members in Armstrong, Beaver, Butler, Crawford, Fayette, Indiana, Lawrence, Mercer, Venango, Washington and Westmoreland counties. As everywhere in Pennsylvania Medicaid, ABA is the ABA category of Intensive Behavioral Health Services (IBHS): for anyone under 21 with a behavioral health diagnosis, started by a written order.

Carelon’s IBHS policy CN.48 (DHS-approved 9/26/2024) is explicit on the funnel question: "The assessment does not require a prior authorization process however treatment does require a prior authorization process." Treatment is requested through ProviderConnect with a full IBHS packet — including Carelon’s Act 62 cover sheet whenever the child has an autism diagnosis — and approved for up to 180 days.

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

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: No — CN.48: "The assessment does not require a prior authorization process however treatment does require a prior authorization process." Providers may use up to 92 units (23 hours) for the assessment. Carelon’s authorization-requirements list says the IBHS extended assessment for ABA "does not require an authorization", and the covered-services grid bills that assessment as 97151 AO/AP with "Auth Req? N" (other 97151 lines are "Y"). [1][4][5]
- **Prior auth for treatment**: Yes — BC-ABA, behavior analytic, assistant BC-ABA and BHT-ABA each "requires a Written Order recommending services and a complete IBHS packet". The packet goes through ProviderConnect within 45 days of the first assessment day for ABA (written order, assessment, tool results, signed Service Delivery Schedule, ITP, Act 62 cover sheet if ASD, Family Choice form); care managers review within 5 business days and approve up to 180 days. [1][4][3]
- **Autism diagnosis required?**: No autism diagnosis required — CN.48 requires a written order naming a behavioral health diagnosis "listed in the most recent DSM or ICD". An ASD diagnosis changes the paperwork (Act 62 cover sheet), not eligibility. [1][6]

## At a glance

- **Plan type:** HealthChoices BH-MCO (behavioral health carve-out) — ABA is delivered as IBHS ABA services
- **Counties:** Armstrong, Beaver, Butler, Crawford, Fayette, Indiana, Lawrence, Mercer, Venango, Washington, Westmoreland
- **Assessment (97151):** No prior authorization — up to 92 units (23 hours); the grid bills it as 97151 AO/AP with "Auth Req? N"
- **Treatment PA:** Yes — IBHS packet via ProviderConnect within 45 days of starting the ABA assessment; Act 62 cover sheet for any ASD diagnosis
- **Authorization length:** Up to 180 days; continued-stay request at least 10 business days before expiry
- **Decision clock:** State Appendix AA: 2 business days prospective, 1 business day concurrent, 21-day deemed approval
- **Telehealth:** POS 10 (home) / 02 (elsewhere); GT discontinued (Jan. 2026); FQ variants listed for audio-only
- **Other coverage:** Carelon pays last; with Act 62 coverage it acknowledges the case and reviews medical necessity once the primary benefit is met

## The Carelon IBHS ABA pathway (Policy CN.48)

- **1. Written order:** From a licensed practitioner with an active PROMISe ID, face-to-face, within 12 months of initiation, naming a DSM/ICD behavioral health diagnosis, clinical support, maximum hours of each service per month, settings and measurable discharge markers. In-network order writers submit the order to Carelon and the county through ProviderConnect within 7 business days. [1][3][2]
- **2. Assessment (no PA):** Up to 92 units (23 hours); ABA assessments completed within 30 calendar days of initiation, face-to-face and across settings, with a signed Service Delivery Schedule. [1][3][2]
- **3. ITP:** Within 45 calendar days of initiation for ABA; exact hours per setting; signed by the youth or parent and a clinical-director-qualified reviewer; updated every 180 days. [1][3][2]
- **4. Authorization packet:** Through ProviderConnect within 45 days of the first assessment day for ABA: written order, assessment, tool results (e.g., CANS), signed Service Delivery Schedule, ITP, Act 62 cover sheet if ASD, and the Family Choice/Confirmation Form. An abbreviated packet (order, initial treatment plan, Act 62 sheet, family choice form) is allowed when treatment must start during the assessment. [1][3][2]
- **5. Review:** Care managers review within 5 business days; approval is for up to 180 days. Incomplete packets are returned; if not corrected within 5 business days the authorization starts on the date a complete packet arrives. [1][3][2]
- **6. Continued stay:** At least 10 business days before the authorization expires: written order, updated assessment, tool results, signed schedule, ITP with progress summary, Act 62 cover sheet if ASD. [1][3][2]

## Codes and the covered-services grid

Carelon’s HealthChoices Covered Services Grid (PV 07/22/2026) is the claims source of truth: IBHS ABA codes are billed by PROMISe provider type 11, specialty 592 with "Auth Req? Y" for 97151 (BC-ABA; U7 for behavior analytic), 97152/97153 (BHT-ABA; U8 for assistant BC-ABA), 97155 and 97156 — while the assessment service class billed as 97151 AO or AP carries "Auth Req? N". Permitted places of service for 97151/97153/97155 are 02, 03, 10, 11, 12 and 99 (97156 omits 03), with FQ audio-only variants on POS 02/10. [5][12]

Carelon’s March 2026 IBHS summit reminded providers that BHT-ABA is not a stand-alone service — it must be overseen by BC-ABA or BA — that services requested must be on the written order, and that the requested start date for an initial cannot precede the family’s ITP signature. [5][12]

## Act 62 and other insurance

Carelon’s Act 62 FAQ: a child is Act 62 eligible with an ASD diagnosis and primary insurance; the Act 62 cover sheet goes with every new authorization request (only the top portion if there is no primary). When the primary covers autism services, Carelon issues an acknowledgement letter that services are covered under Act 62 and "will be reviewed for Medical Necessity once the primary insurance benefit has been met"; no Carelon authorization is needed when only copays, coinsurance or deductibles are billed. If the primary has no Act 62 coverage, send proof (EOB, determination letter, or an employer letter that the group has fewer than 50 employees or excludes autism) to the Claims Liaison Team; Navinet printouts are not accepted. [6][7][8][5]

Carelon "is not permitted to pay for services if the provider is not participating with that member’s primary insurance". Timely filing for secondary claims runs 90 days from the primary EOB. One inconsistency to watch: the covered-services grid flags IBHS ABA codes "TPL Exempt: Y", yet the Act 62 FAQ says that for a child with ASD and primary insurance "Carelon will deny the claim and request the primary insurance EOB" — follow the Act 62 process. [6][7][8][5]

## Rates

Carelon pays under provider agreements; the covered-services grid lists codes, modifiers and places of service but not rates, and no public Carelon PA IBHS fee schedule was found. Confirm rates with your Carelon Provider Field Coordinator. [5]

## Intake gates

The questions that decide whether a family can start with Carelon Health of Pennsylvania (HealthChoices BH-MCO; formerly Beacon / Value Behavioral Health), and what they have to bring.

- **Age limit**: Under 21 — CN.48 defines the IBHS population as children (under 14), youth (14–17) and young adults (18 to under 21). No minimum age. [1][20]
- **Diagnosis recency**: What must be current is the written order: written within 12 months of initiation (the first day of assessment at the provider) and valid for twelve months "from the date that it was written and signed by the order writer" (CN.48). [1]
- **Who may diagnose**: The written order must come from a licensed practitioner with an active PROMISe ID in Pennsylvania (CN.48); Carelon’s packet checklist lists MD, CRNP, PA, licensed psychologist, LPC, LCSW and LMFT as order writers. [1][3]
- **Diagnostic tools required**: No named instrument is required behind the diagnosis. CN.48 asks for "Any contractually required or appropriate assessment tool results" in the packet, giving CANS, Child Behavior Checklist, BASC and CAFAS as examples. [1]
- **Referral required?**: A written order is required. In-network order writers submit it to Carelon and the county through ProviderConnect within 7 business days of the face-to-face; Carelon and the county contact the family within 7 business days to link them with a provider, and the order goes to the family’s chosen provider within 2 business days. A provider that cannot fulfil the order must tell the family within 2 business days. [1]
- **Telehealth**: Allowed under OMHSAS-22-02. Carelon discontinued the GT modifier; telehealth is identified "only by Place of Service": POS 10 in the patient’s home, POS 02 elsewhere (Alert 03.26.01, Jan. 2026). The covered-services grid lists 97151, 97153, 97155 and 97156 on POS 02/10, including FQ-modified lines for audio-only. [11][5]
- **Prior-auth decision time**: Carelon’s own documents vary: CN.48 says care managers review IBHS requests "within five (5) business days of receipt", and its provider manual says Carelon has "seven (7) calendar days to enter a provider’s authorization". The DHS HealthChoices Appendix AA that binds every BH-MCO is tighter — verbal decision within 2 business days (prospective) or 1 business day (concurrent) of complete information, additional information requested within 48 hours with 14 days to respond, and automatic approval if the member has no written decision within 21 days. Federal floor: 7 calendar days standard / 72 hours expedited (42 CFR 438.210(d)). Continued-stay requests are due at least 10 business days before expiry; retro requests within 45 calendar days of service. [1][10][13][21]
- **Other insurance (who pays first)**: Carelon is the payer of last resort: exhaust other coverage, attach the primary’s EOB with denial reason, file within 90 days of the EOB, and obtain the primary’s own authorization when required. Carelon "is not permitted to pay" if the provider does not participate with the primary. The authorization request (with the Act 62 cover sheet) still goes to Carelon when commercial is primary: for Act 62 cases Carelon issues an acknowledgement that services are covered under Act 62 and reviews medical necessity once the primary benefit is met, and no Carelon authorization is needed when billing only copays, coinsurance or deductibles. Proof of no autism coverage goes to the Claims Liaison Team (EOB, determination letter, or employer letter). TRICARE pays ahead of Medicaid (10 U.S.C. 1079(i)(1)). [6][8][9][7][22]

## Delivery and billing rules

Coverage decides whether Carelon Health of Pennsylvania (HealthChoices BH-MCO; formerly Beacon / Value Behavioral Health) 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 state IBHS rule (CN.48 defers to the IBHS regulations and publishes no separate ratio): 55 Pa. Code § 5240.82 requires 1 hour a month of individual face-to-face supervision for BA/BC-ABA staff (plus a second hour if they supervise assistant BC-ABA or BHT-ABA) and 30 minutes of observation every 6 months; BHT-ABA staff get 1 hour weekly at 37.5+ hours a week, otherwise twice a month, with 1 hour individual face-to-face monthly. Carelon’s March 2026 summit adds that BHT-ABA must be overseen by BC-ABA or BA and "MT shouldn’t be overseeing ABA cases". [15][1][12]
- **Session-note signature**: State rule plus Carelon’s standards: 55 Pa. Code § 5240.41 requires each service note to carry the signature of the staff person providing it. Carelon’s treatment-record standards require every entry to include the responsible clinician’s name, professional degree and identification number, dated; CN.48 requires the ITP and every update to be signed and dated by the youth or a parent/guardian and by the staff person who wrote it, and reviewed and signed by a clinical-director-qualified individual. Carelon’s September 2026 alert stresses that documentation must show who participated, when, where and for how long. [15][17][1][18]
- **Place of service**: Home, school and community. Carelon’s grid permits 97151, 97153 and 97155 at POS 02, 03 (school), 10, 11, 12 and 99, and 97156 at POS 02, 10, 11, 12 and 99 (no 03). The ITP must state exact hours per setting (home, community, school, center), and BHT school hours "should not switch to home setting over breaks from school". [5][12]
- **Bill as provider**: The IBHS agency bills — the grid ties every ABA code to PROMISe provider type 11, specialty 592 — with the rendering credential shown by modifier: 97151/97155 U7 for behavior analytic, unmodified for BC-ABA; 97152/97153 U8 for assistant BC-ABA, unmodified for BHT-ABA. All providers must register their NPI with DHS. [5][19]
- **Daily limits / MUEs** _(plan-dependent)_: No per-day unit ceiling is published. Carelon authorizes hours per month per service for up to 180 days; the grid gives each ABA code a 15-minute unit without a daily maximum, and its Billing Guide only bars date-span billing for services valued at more than one unit per day. The state FFS per-day ranges (OMHSAS-21-03) are fee-for-service only. [5][16]
  - Ask the plan: Your Carelon Health of PA provider agreement or Provider Field Coordinator — confirm whether any per-day unit edit applies to 97153/97155 beyond the authorized monthly hours.
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: Carelon Health of PA IBHS team (PAIBHS@carelon.com) or your Provider Field Coordinator — ask whether 97155 may be billed for the same minutes as 97153 when the analyst directs the technician, and keep the written answer. [5][1]

## What intake should collect for Carelon Health of Pennsylvania (HealthChoices BH-MCO; formerly Beacon / Value Behavioral Health)

- **Medicaid ID and county:** Carelon covers 11 western PA counties; a county change needs an authorization under the new eligibility line.
- **Written order (within 12 months):** Face-to-face order from a licensed practitioner with an active PROMISe ID — MD, CRNP, PA, licensed psychologist, LPC, LCSW or LMFT per Carelon’s checklist — naming diagnosis, services, maximum hours per month and settings.
- **Act 62 cover sheet inputs:** Primary insurance name, effective date, renewal date, calendar vs benefit year, and whether the plan pays for autism services — needed for every new request when the child has ASD.
- **Primary insurance proof:** EOB or determination letter (or employer letter for groups under 50 / autism exclusions); Navinet printouts are not accepted.
- **Signed Service Delivery Schedule:** Parent/legal guardian (or member 14+) signature is part of every packet.
- **Family Choice/Confirmation Form:** Reviewed with the family before services start.

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

## Common questions

### Does Carelon Health of Pennsylvania require prior authorization for the ABA assessment?

No. Policy CN.48: "The assessment does not require a prior authorization process however treatment does require a prior authorization process." Providers can use up to 92 units (23 hours) for the assessment; the covered-services grid lists the assessment as 97151 with modifier AO or AP and "Auth Req? N".

### How long does a Carelon IBHS authorization last?

Up to 180 days. Submit continued-stay requests through ProviderConnect at least 10 business days before the current authorization expires.

### Does my child need an autism diagnosis for ABA through Carelon?

No — IBHS ABA is available with any DSM/ICD behavioral health diagnosis on the written order. An autism diagnosis triggers Carelon’s Act 62 cover sheet and primary-insurance process.

### What if my child has private insurance with autism coverage?

Use a provider in the private plan’s network and bill it first. Carelon generates an acknowledgement letter that services are covered under Act 62 and reviews medical necessity once the primary benefit is met; if the provider bills Carelon only for copays, coinsurance or deductibles, no Carelon authorization is required.

### How do we bill ABA telehealth to Carelon?

Identify telehealth by place of service only — POS 10 in the member’s home, POS 02 elsewhere; Carelon discontinued the GT modifier (Alert 03.26.01, Jan. 2026). The grid lists FQ variants of the ABA codes on POS 02/10 for audio-only.

## Primary sources

1. [Carelon Health of PA Policy CN.48 — Intensive Behavioral Health Services (DHS approved 9/26/2024)](https://s18637.pcdn.co/wp-content/uploads/sites/79/CN-48-IBHS-Beacon-Policy-and-Procedure.pdf)
2. [Carelon Health of PA — Intensive Behavioral Health Services (IBHS) provider page](https://providers.pa.carelon.com/providers/intensive-behavioral-health-services-ibhs/)
3. [Carelon Health of PA — IBHS Packet Documentation Checklist](https://s18637.pcdn.co/wp-content/uploads/sites/79/IBHS-Packet-Documentation-Checklist.docx)
4. [Carelon Health of PA — Authorization Requirements by service class](https://s18637.pcdn.co/wp-content/uploads/sites/79/Authorization-Requirements.docx)
5. [Carelon Pennsylvania HealthChoices Covered Services Grid (PV 07/22/2026)](https://s18637.pcdn.co/wp-content/uploads/sites/79/Carelon-Pennsylvania-HealthChoices-Covered-Services-Grid-PV-07222026.xlsx)
6. [Carelon Health of PA — Act 62 Frequently Asked Questions](https://s18637.pcdn.co/wp-content/uploads/sites/79/ACT-62-Frequently-Asked-Questions.pdf)
7. [Carelon Health of PA — Autism Coverage: Acceptable Benefit Verification Information](https://s18637.pcdn.co/wp-content/uploads/sites/79/ACT-62-Autism-Coverage-Acceptable-Benefit-Verification-Information.pdf)
8. [Carelon Health of PA Provider Manual — 6: Third Party Liability (TPL)](https://providers.pa.carelon.com/providers/provider-manual/6-third-party-liability-tpl/)
9. [Carelon Health of PA — A Guide to Third Party Liability](https://s18637.pcdn.co/wp-content/uploads/sites/79/Third-Party-Liability-Guide.pdf)
10. [Carelon Health of PA Provider Manual — 3: Requests for Authorizations/Retro-authorizations](https://providers.pa.carelon.com/providers/provider-manual/3-requests-for-authorizationsretro-authorizations/)
11. [Carelon Health of PA Provider Alert 03.26.01 — Telehealth Billing Update: Discontinuation of GT Modifier (Jan. 22, 2026)](https://s18637.pcdn.co/wp-content/uploads/sites/79/PA-03.26.01-Telehealth-Billing-Update-Dis-of-GT-Modifier.pdf)
12. [Carelon Health of PA — IBHS Summit, March 6, 2026](https://s18637.pcdn.co/wp-content/uploads/sites/79/IBHS-Summit-March-2026.pdf)
13. [DHS HealthChoices BH Program Standards and Requirements, Appendix AA — Prior Authorization Requirements (Jan. 1, 2026)](https://s18637.pcdn.co/wp-content/uploads/sites/79/Appendix-AA-Prior-Authorization-Requirements.pdf)
14. [PA DHS — Behavioral Health Managed Care Organizations (BH-MCOs) by county](https://www.pa.gov/agencies/dhs/resources/medicaid/bhc/bhc-mcos)
15. [55 Pa. Code Chapter 5240 — Intensive Behavioral Health Services (licensing)](https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/055/chapter5240/chap5240toc.html)
16. [Carelon Health of PA — Billing Guide](https://s18637.pcdn.co/wp-content/uploads/sites/79/Carelon-Billing-Guide.pdf)
17. [Carelon Health of PA Provider Manual — 4: Treatment Record Standards](https://providers.pa.carelon.com/providers/provider-manual/4-treatment-record-standards/)
18. [Carelon Health of PA Provider Alert 22.26.09 — Documentation and Program Integrity Reminder (Sept. 3, 2026)](https://s18637.pcdn.co/wp-content/uploads/sites/79/PA-22.26.09-Documentation-and-Program-Integrity-Reminder.pdf)
19. [Carelon Health of PA Provider Manual — 4: National Provider Identifier (NPI)](https://providers.pa.carelon.com/providers/provider-manual/4-national-provider-identifier-npi/)
20. [55 Pa. Code Chapter 1155 — Intensive Behavioral Health Services (payment)](https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/055/chapter1155/chap1155toc.html)
21. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes](https://www.ecfr.gov/current/title-42/section-438.210)
22. [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)

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.