CDPHP ABA coverage (NY Medicaid Managed Care).

Follows the New York Medicaid rule: ABA is covered for members “under 21 years of age with a diagnosis of Autism Spectrum Disorder (ASD) as defined by… (DSM-5) and/or Rett Syndrome.” No minimum age and no adult pathway — the 21st birthday is a hard cliff. CDPHP’s Provider Office Administrative Manual names ABA as a covered Medicaid–Select Plan and Medicaid–HARP benefit without setting an age of its own, and adds that “coverage is not subject to a maximum benefit and the individual is covered until the services are no longer medically necessary.”^[6][1]

Follows the New York Medicaid rule — the two-year referral is the clock and no maximum age is set on the diagnostic evaluation. CDPHP publishes no recency rule of its own; its manual defers documentation specifics to a “Prior Authorization Guideline” document behind the secure provider-portal login.^[6][1]

Ask the plan: The secure Prior Authorization Guideline at provider.cdphp.com, or the CDPHP Behavioral Health Access Center (518-641-3600 / 1-888-320-9584).

Follows the New York Medicaid rule: the diagnosis and referral must come from a NYS-licensed, NYS Medicaid-enrolled physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner or physician assistant, following DSM-5 criteria and NYSDOH’s Clinical Practice Guideline on ASD. LBAs and CBAAs sit outside that list — they may not diagnose and may not self-refer. CDPHP names a delivery credential rather than a diagnostic one: “ABA services must be provided by or supervised by a NYS-licensed, board-certified behavior analyst (BCBA/BCBA-D),” with a credentialed ABA provider network maintained.^[6][1]

Follows the New York Medicaid rule: no instrument is mandated. What the state requires with the referral is the “DSM-5 Diagnostic Checklist for ASD diagnoses” plus the severity level when the referral comes from an ASD-diagnosing provider; the treatment plan need only record the assessment methodology used and, “as appropriate, identify standardized assessment used (e.g., adaptive behavior scales, symptom inventories, aggression ratings) and results.” No CDPHP-specific instrument requirement is published; documentation specifics sit behind the secure-portal Prior Authorization Guideline.^[6][1]

Ask the plan: The secure Prior Authorization Guideline at provider.cdphp.com, or the Behavioral Health Access Center.

Follows the New York Medicaid rule: the member “must be referred for ABA services by a NYS-licensed and NYS Medicaid-enrolled physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner, or physician assistant,” the referral is “valid for no more than two years,” and it must carry age, the ASD/Rett diagnosis, date of initial diagnosis, co-morbid diagnoses, symptom severity level, a statement the patient needs ABA, and the DSM-5 Diagnostic Checklist. CDPHP’s own authorization posture is genuinely ambiguous from public materials: outpatient mental health and substance-use treatment by participating psychiatrists, psychiatric NPs, psychologists, LMSWs and mental health counselors needs no authorization, but “certain behavioral health services in Medicaid–Select Plan and Medicaid–HARP require prior authorization by calling the Behavioral Health Access Center,” with the list held in the secure-portal Prior Authorization Guideline. Nothing published confirms whether the ABA codes are among them.^[6][1][2]

Ask the plan: The CDPHP Behavioral Health Access Center (518-641-3600 / 1-888-320-9584) — confirm per case in writing whether 97151 and the treatment codes require PA.

CDPHP’s provider manual publishes no Medicaid decision clock of its own: it says CDPHP “complies with all specific time frames for decision making and notification under the law” and points to “established timeframes in the Medicaid Managed Care Model Contract.” That contract governs: a standard prior authorization is decided “within three (3) business days of receipt of necessary information, but no more than fourteen (14) days after receipt”; expedited within 72 hours; a concurrent request (reauth or more units) within one business day of the necessary information; each extendable up to 14 days. Federal rules cap the standard decision at 7 calendar days for plan rating periods starting on or after January 1, 2026. No ABA reauth lead time is published in the public manual; CDPHP’s full ABA policy sits behind the provider login.^[2][7][8][9]

“If CDPHP is secondary, the provider must wait for the explanation of benefits (EOB) from the primary carrier first before billing CDPHP,” then “submit a duplicate claim with the total amount billed (just as if CDPHP were the only insurance company) with the primary carrier’s explanation of benefits (EOB) attached.” A claim with no EOB when CDPHP has another carrier on file denies automatically (“RPC” — check the secure provider site for the primary carrier). For a Medicaid member this sits on the state rule that Medicaid pays last and providers “must bill all applicable insurance sources before submitting claims to Medicaid.” The COB section (revised January 2020) does not say whether CDPHP’s ABA authorization is still required when it is secondary — ask the Behavioral Health Access Center (518-641-3600).^[10][11]

Not published. CDPHP has no ABA-specific telehealth billing policy — no place-of-service code, modifier or reimbursement-parity statement — in any document we could access; its behavioral-health resources instead link out to the American Telemedicine Association’s 2017 telemental-health practice guidelines, a third-party clinical standard rather than a coverage commitment.^[4][1]

Ask the plan: The CDPHP Behavioral Health Access Center (518-641-3600 / 1-888-320-9584) — confirm POS and modifier requirements before delivering remotely.

CDPHP states the credential — “ABA services must be provided by or supervised by a NYS-licensed, board-certified behavior analyst (BCBA/BCBA-D)” — but publishes no ratio. The numbers come from the state and apply to managed care alike: 5% of each unlicensed individual’s monthly service hours supervised, at least two face-to-face real-time contacts per month with one observation of service delivery, and no more than six CBAAs/unlicensed individuals per LBA.^[1][6]

No annual maximum — “coverage is not subject to a maximum benefit and the individual is covered until the services are no longer medically necessary” — but that does not rule out per-authorization unit limits, which sit behind the secure-portal Prior Authorization Guideline along with the code-level PA requirements. Confirm before assuming unlimited units.^[1]

Ask the plan: The secure Prior Authorization Guideline at provider.cdphp.com, or the Behavioral Health Access Center — confirm per-authorization unit limits.

Follows the New York Medicaid rule: the LBA supervisor must “review and sign treatment notes and reports prepared by the CBAA supervisee,” and documentation of supervision itself “should be recorded in the patient file.” Clinical documentation must carry the treatment plan with assessment and goals, the goal data, total hours of service per week by who delivered them, and the location(s) of services. Records are kept “for a minimum of six years and, for minors, until the patient turns 22 years of age.” CDPHP publishes no additional session-note signature rule; its documentation specifics are deferred to the secure provider portal.^[6][1]

Follows the New York Medicaid rule: “LBAs and CBAAs may work in any legally authorized setting. Examples of such settings include private practice, settings where patients/clients reside full-time or part-time, clinics, hospitals, residences, and community settings” — but “NYS Medicaid does not reimburse for ABA services in a school setting.” The treatment plan must record the location(s) of services. CDPHP publishes no setting rule of its own; the state’s school bar is the operative constraint.^[6][1]

Not published. CDPHP’s manual names the ABA codes in scope (97151–97158) but defers code-level rules to the secure-portal Prior Authorization Guideline, and the state manual is silent on 97153 with 97155.^[1][6]

Ask the plan: The CDPHP Behavioral Health Access Center (518-641-3600 / 1-888-320-9584) and the secure Prior Authorization Guideline at provider.cdphp.com.

Not published as a claim convention. CDPHP requires ABA to be provided or supervised by a NYS-licensed BCBA/BCBA-D within its credentialed network, but names no rendering-versus-supervising NPI rule, and its Claim Submission manual references a filing deadline “within established filing limits” without stating the day count in the sections we could access. At the fee-for-service layer New York is explicit: LBAs bill “using the LBA’s National Provider Identification (NPI) number for the ‘Billing’ provider and/or ‘Supervising’ provider,” with “the NPI number of the CBAA that provided the ABA service… reported as the ‘Rendering’ provider on each claim”; for unlicensed aides and LBA limited-permit holders the supervising LBA’s NPI fills all three roles. CBAAs cannot bill directly and enroll as OPRA providers.^[1][6]

Ask the plan: CDPHP Provider Services (518-641-3500 / 1-800-926-7526) — confirm the rendering/supervising NPI convention and the exact timely-filing window.