CareSource Ohio ABA coverage (Next Gen MCO).

CareSource sets the clearest recency rule in Ohio: where the diagnostic evaluation is more than 24 months old, a provider letter documenting DSM symptoms within the past year is required. Continuation requests must document progress against baseline using the same measurement tools, and a request filed after a temporary break in services (summer, vacation) must be filed as a continuation, not a new initial request.^[4][1][2][1]

Narrower than the state framework: MM-0028 restricts the ASD diagnosis to a child or adolescent psychiatrist, psychologist, child neurologist, or developmental pediatrician — where the state rule accepts any licensed clinician qualified to diagnose autism. Screening referral packets against those four specialties at intake prevents the most common CareSource denial.^[4][1][2][1]

MM-0028 requires the diagnosis to rest on a standardized instrument, and names three: ADOS, ADI-R, or CARS-2.^[4][1][2][1]

Telehealth covers parent training and supervision. One-to-one ABA by telehealth is allowed only when medically necessary under a documented service-delivery plan.^[4][1][2][1]

CareSource’s Ohio Medicaid manual matches the rule: “Standard Pre-Service — 7 calendar days from receipt of the request,” with one extension of up to 14 calendar days for lack of information if the member asks. Urgent pre-service decisions come in “48 hours from receipt of request.” No ABA reauthorization lead time is published in the manual. 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.^[7][8]

CareSource coordinates by subtracting “the primary payment from the lessor of the primary carrier allowable or the Medicaid allowable. If the member’s primary insurer pays a provider equal to or more than CareSource’s fee schedule for a covered service, CareSource will not pay the additional amount.” When CareSource is secondary, submit within 365 calendar days of the date of service. If a claim is denied for missing COB information, send the primary payer’s EOB within the rest of the timely-filing period, or within 90 calendar days of the primary EOB date if that period has passed. The manual does not say whether CareSource’s ABA authorization is still needed when a commercial plan pays first. 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).^[7][9]

Ask the plan: CareSource Provider Services: whether a CareSource ABA authorization is required when a commercial plan pays first.

Follows the Ohio Medicaid framework, which publishes no verifiable age bound for ABA; under-21 members carry EPSDT protections through the MCO. 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.^[4][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 Medicaid-side referral or service-order requirement could be verified for this plan or for the state framework. Ohio’s ordering requirement — a psychologist trained in autism, a developmental pediatrician, or a pediatric clinical nurse specialist or certified nurse practitioner — lives in the commercial insurance mandate at R.C. 3923.84, not in Medicaid.^[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.

Follows the Ohio framework (OAC 4783-6-02: a written supervision plan in each client’s treatment plan, consultation before initiation and modification, periodic direct observation, no fixed ratio). CareSource’s own addition is on records: supervision records must be retained 5 years for COBAs or 7 years for BCBAs and RBTs after supervision ends, and claims tied to documentation discrepancies are subject to recoupment.^{[4][1][2][1][5]}

CareSource publishes real per-day maxima, moved from MM-0028 into companion reimbursement policy PY-1638 effective 9/1/2026 with the figures unchanged: daily units follow the CMS MUE maxima — 97151 at 32, 97153 at 32, 97155 at 24 and 97156 at 16 daily units, among others. Behavioral assessments should generally not exceed 6–10 hours per 6-month period without justification, and all ABA carries medical-necessity review at baseline and every 6 months, with discontinuation triggered by no meaningful progress across two successive 6-month authorization periods.^[4][1][2][2]

The operational standout in Ohio: treatment records must be submitted to CareSource prior to claim submission — "claims will not be accepted without accompanying treatment documentation." MM-0028 adds explicit anti-boilerplate requirements on progress notes: generic, copy-pasted symptom language is no longer sufficient documentation.^{[4][1][2][2][1]}

Follows the Ohio Medicaid framework (COBA or BACB BCBA/BCBA-D as the independent practitioner, ODM Provider Type 19 Specialty 190, BCaBAs and RBTs under supervision; OhioRISE never pays ABA). One rule narrowed in PY-1638: CareSource will no longer reimburse H0036 for ABA whenever a designated ABA CPT code is usable, so the older blanket acceptance of H0036 (CPST) billing from certified CBHCs in lieu of ABA CPT codes no longer holds.^{[4][1][2][2][6]}

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.^[4][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.^[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.