---
title: CDPHP ABA coverage (NY Medicaid Managed Care).
url: "https://carelu.com/payers/cdphp-new-york"
markdown_url: "https://carelu.com/payers/cdphp-new-york.md"
state: NY (New York)
payer: CDPHP (NY Medicaid)
kind: Medicaid managed care plan (MCO)
parent_program: New York Medicaid
description: "How CDPHP (Capital District Physicians' Health Plan) handles NY Medicaid ABA — its in-house Behavioral Health Access Center, the ABA codes named in the Provider Office Administrative Manual, and the prior-auth and telehealth specifics that sit behind the secure provider portal."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# CDPHP ABA coverage (NY Medicaid Managed Care).

_Payer Guide · CDPHP (NY) · Last updated September 2026 · 6 primary sources_

> Capital District plan; ABA codes named in-house at CDPHP's own Behavioral Health Access Center — but PA specifics and limits sit behind the secure portal.

CDPHP — Capital District Physicians' Health Plan, Inc., covering 80,854 Medicaid Managed Care members per the state's July 2026 enrollment report — runs its NY Medicaid ABA benefit through its own "Medicaid–Select Plan" and "Medicaid–HARP" products, with behavioral health managed entirely in-house through an internal Behavioral Health Access Center rather than an outside BH vendor. CDPHP's Provider Office Administrative Manual (POAM) names the ABA CPT codes directly and states the benefit carries no annual maximum, which is more than several plans in this directory publish — but the manual repeatedly defers the actual prior-authorization mechanics and code-level limits to a "Prior Authorization Guideline" document that sits behind the secure provider-portal login, so this guide covers what CDPHP states plainly and flags what to confirm before booking.

This plan administers the **New York Medicaid** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [New York Medicaid (NYS DOH / eMedNY) guide](https://carelu.com/payers/new-york-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment:** Not published / unverified. Verify via: CDPHP’s “Prior Authorization Guideline” — the complete list of Medicaid–Select and HARP behavioral services requiring prior authorization, held behind the secure login at provider.cdphp.com and not readable from public materials. Until it can be retrieved, the Behavioral Health Access Center (518-641-3600 / 1-888-320-9584) answers per case. [1][2]
- **Prior auth for treatment:** Not published / unverified. Verify via: CDPHP’s “Prior Authorization Guideline” — the complete list of Medicaid–Select and HARP behavioral services requiring prior authorization, held behind the secure login at provider.cdphp.com and not readable from public materials. Until it can be retrieved, the Behavioral Health Access Center (518-641-3600 / 1-888-320-9584) answers per case. [1][2]
- **Autism diagnosis required?**: Yes — state baseline: under 21, ASD/Rett per DSM-5, with the state practitioner referral; CDPHP names 97151–97158 in its POAM but defers PA/limit specifics to the secure provider portal [6][1]

## At a glance

- **Plan type:** Mainstream MMC — "Medicaid–Select Plan" and "Medicaid–HARP" (Capital District Physicians' Health Plan, Inc.)
- **Footprint:** Capital District (Albany-area)
- **BH/ABA UM:** In-house — CDPHP Behavioral Health Access Center (518-641-3600 / 1-888-320-9584); no named BH vendor carve-out
- **ABA benefit limit:** "Not subject to a maximum benefit" — covered until services are no longer medically necessary, per the POAM
- **ABA codes named:** 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158 — PA/limit specifics deferred to the secure portal
- **Credentialing:** ABA must be provided or supervised by a NYS-licensed, board-certified behavior analyst (BCBA/BCBA-D) per the POAM

## What CDPHP states plainly — and what it defers to the portal

CDPHP's Provider Office Administrative Manual, Section 18 (Behavioral Health), names the ABA benefit directly: "Applied behavior analysis — Coverage is not subject to a maximum benefit and the individual is covered until the services are no longer medically necessary." It lists the CPT codes in scope — 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158 — and requires that "ABA services must be provided by or supervised by a NYS-licensed, board-certified behavior analyst (BCBA/BCBA-D)," noting CDPHP maintains a credentialed ABA provider network. For the operational detail — code-level prior-authorization requirements, unit or session limits, and documentation specifics — the manual repeatedly points providers to "the complete policy by logging in securely at provider.cdphp.com," so those specifics aren't independently confirmable from public materials. [1]

## Prior authorization: a general BH gate, ABA specifics unconfirmed

CDPHP's general behavioral-health rule is that no authorization is required for outpatient mental health or substance-use-disorder treatment by participating psychiatrists, psychiatric NPs, psychologists, LMSWs, and mental health counselors — but "certain behavioral health services in Medicaid–Select Plan and Medicaid–HARP require prior authorization by calling the Behavioral Health Access Center," with the complete list held in the secure-portal "Prior Authorization Guideline" document. Nothing in CDPHP's public materials confirms whether the ABA assessment (97151) is treated under that general no-PA rule or is one of the "certain services" requiring authorization, nor whether the treatment codes carry unit caps. Route ABA authorization questions to the Behavioral Health Access Center directly, and get the answer in writing per case before scheduling. [1][2]

## Telehealth and billing basics

CDPHP has no published ABA-specific telehealth billing policy (place-of-service code, modifier, or reimbursement parity) in any document we could access; its behavioral-health provider resources instead link out to the American Telemedicine Association's 2017 "Practice Guidelines for Telemental Health with Children and Adolescents" — a third-party clinical-practice standard, not a CDPHP coverage commitment. On claims: CDPHP's Claim Submission manual repeatedly references a filing deadline "within established filing limits" without stating the specific day count in the sections we could access, so confirm the exact timely-filing window with Provider Services; claim disputes use a "Provider Review Form" filed within 6 months of the claim's adjudication date, mailed to CDPHP Provider Services, 6 Wellness Way, Latham, NY 12110. [4][3]

## Intake gates

The questions that decide whether a family can start with CDPHP (NY Medicaid), and what they have to bring.

- **Age limit**: 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]
- **Diagnosis recency**: 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).
- **Who may diagnose**: 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]
- **Diagnostic tools required**: 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.
- **Referral required?**: 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.
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: “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]
- **Telehealth** _(ask the plan)_: 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.

## Delivery and billing rules

Coverage decides whether CDPHP (NY Medicaid) 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**: 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]
- **Daily limits / MUEs**: 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.
- **Session-note signature**: 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]
- **Place of service**: 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]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: 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.
- **Bill as provider** _(ask the plan)_: 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.

## What intake should collect for CDPHP (NY Medicaid)

- **Complete state referral packet:** Under-21 ASD/Rett dx, referral with severity and DSM-5 checklist — the clinical baseline CDPHP's POAM sits on top of.
- **BCBA/BCBA-D credentials:** CDPHP requires ABA be provided or supervised by a NYS-licensed BCBA/BCBA-D — confirm network credentialing status before scheduling.
- **PA confirmation in writing:** Code-level PA requirements and any limits aren't published — call the Behavioral Health Access Center (518-641-3600 / 1-888-320-9584) and get the answer in writing per case.
- **Telehealth confirmation:** No CDPHP-specific ABA telehealth billing policy was found — verify POS/modifier requirements before delivering remotely.
- **Timely filing window:** The exact day-count for claims filing isn't stated in the public POAM sections — confirm with Provider Services (518-641-3500 / 1-800-926-7526).

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

## Verification of benefits (VOB) data

How CDPHP (NY Medicaid) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00328 — pVerify lists TWO unresolved candidates for CDPHP: "00328 Capital District Physicians Health Plan (CDPHP)" and "002466 CDPHP(Capital District Physicians Health Plan)" — both generic (Elig: Yes, Claim: No on both), neither labeled Medicaid vs. commercial. Confirm which code applies to Medicaid Managed Care specifically via pVerify onboarding before automating.
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** none — in-house CDPHP Behavioral Health Access Center (518-641-3600 / 1-888-320-9584); no named BH vendor carve-out
- **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 | — | Not subject to a maximum benefit (per POAM §18) — but code-level unit limits, if any, sit behind the secure Prior Authorization Guideline on provider.cdphp.com, unconfirmed | — | — | — |
| 97152 | Yes | — | Not subject to a maximum benefit (per POAM §18) — but code-level unit limits, if any, sit behind the secure Prior Authorization Guideline on provider.cdphp.com, unconfirmed | — | — | — |
| 97153 | Yes | — | Not subject to a maximum benefit (per POAM §18) — but code-level unit limits, if any, sit behind the secure Prior Authorization Guideline on provider.cdphp.com, unconfirmed | — | — | — |
| 97154 | Yes | — | Not subject to a maximum benefit (per POAM §18) — but code-level unit limits, if any, sit behind the secure Prior Authorization Guideline on provider.cdphp.com, unconfirmed | — | — | — |
| 97155 | Yes | — | Not subject to a maximum benefit (per POAM §18) — but code-level unit limits, if any, sit behind the secure Prior Authorization Guideline on provider.cdphp.com, unconfirmed | — | — | — |
| 97156 | Yes | — | Not subject to a maximum benefit (per POAM §18) — but code-level unit limits, if any, sit behind the secure Prior Authorization Guideline on provider.cdphp.com, unconfirmed | — | — | — |
| 97157 | Yes | — | Not subject to a maximum benefit (per POAM §18) — but code-level unit limits, if any, sit behind the secure Prior Authorization Guideline on provider.cdphp.com, unconfirmed | — | — | — |
| 97158 | Yes | — | Not subject to a maximum benefit (per POAM §18) — but code-level unit limits, if any, sit behind the secure Prior Authorization Guideline on provider.cdphp.com, unconfirmed | — | — | — |
| 0362T | Not confirmed (see code notes) | — | — | — | — | — |
| 0373T | Not confirmed (see code notes) | — | — | — | — | — |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** Call the Behavioral Health Access Center (518-641-3600 / 1-888-320-9584) and get PA/limit specifics in writing per case before booking.

### Contacts

- **Provider services phone:** 1-888-320-9584
- **Phone menu path:** Behavioral Health Access Center (also reachable locally at 518-641-3600).
- **Hours:** Mon-Fri 8:00 a.m.-6:00 p.m. ET
- **Portal:** [CDPHP Secure Provider Site](https://provider.cdphp.com)

Questions to ask on a verification call:

- Does ABA require prior authorization via the Behavioral Health Access Center, and if so what documentation is needed?
- What are the per-code unit/hour caps and cap periods for 97151-97158, given CDPHP states "not subject to a maximum benefit" but defers specifics to the secure portal?
- Are 0362T and 0373T covered — they don't appear in the POAM's named ABA code list (97151-97158 only)?
- Is ABA billable via telehealth, and if so what POS code/modifier?
- What billing modifiers, if any, does CDPHP require for BCBA vs. RBT-delivered ABA services?
- Is the ABA cost share a copay or coinsurance, charged per-visit or per-day?
- Does CDPHP's deductible apply to ABA services, and which STC bucket does CDPHP return ABA benefits under on a 270/271 check?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.cdphp.com/-/media/files/providers/poam/section-5-referral-authorization-process.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.cdphp.com/-/media/files/providers/poam/section-18-behavioral-health.pdf (accessed 2026-07-23)
- https://www.cdphp.com/-/media/files/providers/behavioral-health/hedis-toolkit-and-bh-guidelines/practice-guidelines-telemental-health.pdf (accessed 2026-07-23)
- https://www.cdphp.com/customer-support/call-cdphp/providers (accessed 2026-07-23)
- https://www.cdphp.com/providers (accessed 2026-07-23)

## Common questions

### Does CDPHP cover ABA therapy?

Yes — CDPHP's Provider Office Administrative Manual names ABA (CPT 97151–97158) as a covered Medicaid–Select Plan and Medicaid–HARP benefit with no maximum benefit limit, provided or supervised by a NYS-licensed BCBA/BCBA-D.

### Does CDPHP require prior authorization for ABA?

Not confirmed from public materials — CDPHP states that "certain" behavioral health services in its Medicaid lines require prior authorization via the Behavioral Health Access Center, but doesn't specify whether ABA codes are among them. Confirm per case at 518-641-3600 / 1-888-320-9584.

### Is there a session or dollar cap on CDPHP's ABA benefit?

CDPHP's manual states the benefit "is not subject to a maximum benefit," but doesn't rule out per-authorization unit limits, which sit behind the secure-portal Prior Authorization Guideline — confirm before assuming unlimited units.

## Primary sources

1. [CDPHP Provider Office Administrative Manual, Section 18 — Behavioral Health (rev. July 2025)](https://www.cdphp.com/-/media/files/providers/poam/section-18-behavioral-health.pdf)
2. [CDPHP Provider Office Administrative Manual, Section 5 — Referral/Authorization Process (rev. January 2025)](https://www.cdphp.com/-/media/files/providers/poam/section-5-referral-authorization-process.pdf)
3. [CDPHP Provider Office Administrative Manual, Section 9 — Claim Submission (rev. July 2024)](https://www.cdphp.com/-/media/files/providers/poam/section-9-claim-submission.pdf)
4. [CDPHP — American Telemedicine Association telemental health guidelines (hosted resource)](https://www.cdphp.com/-/media/files/providers/behavioral-health/hedis-toolkit-and-bh-guidelines/practice-guidelines-telemental-health.pdf)
5. [NYS DOH Medicaid Managed Care Enrollment Report, July 2026](https://www.health.ny.gov/health_care/managed_care/reports/enrollment/monthly/2026/docs/en07_26.pdf)
6. [eMedNY ABA Provider Policy Manual (state baseline)](https://www.emedny.org/ProviderManuals/ABA/PDFS/ABA_Policy.pdf)
7. [CDPHP Provider Office Administrative Manual — Section 3, Government Programs (rev. Feb 2026)](https://www.cdphp.com/-/media/files/providers/poam/section-3-government-programs.pdf)
8. [NYS Medicaid Managed Care Model Contract (March 1, 2019), Appendix F §3 and §3.7](https://www.health.ny.gov/health_care/managed_care/docs/medicaid_managed_care_fhp_hiv-snp_model_contract.pdf)
9. [eCFR — 42 CFR 438.210(d), timeframe for decisions](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-D/section-438.210)
10. [CDPHP Provider Office Administrative Manual — Section 8, Coordination of Benefits (rev. January 2020)](https://www.cdphp.com/-/media/files/providers/poam/section-8-coordination-of-benefits.pdf)
11. [eMedNY Information for All Providers — General Policy (Version 2022-2)](https://www.emedny.org/ProviderManuals/AllProviders/PDFS/Information_for_All_Providers-General_Policy.pdf)

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.