---
title: EmblemHealth ABA coverage (NY Medicaid Managed Care).
url: "https://carelu.com/payers/emblemhealth-new-york"
markdown_url: "https://carelu.com/payers/emblemhealth-new-york.md"
state: NY (New York)
payer: EmblemHealth (NY Medicaid)
kind: Medicaid managed care plan (MCO)
parent_program: New York Medicaid
description: "How EmblemHealth (HIP) handles NY Medicaid ABA — a published benefit that restates the state criteria verbatim, no distinct clinical policy located, and the PA questions to verify in the provider portal."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# EmblemHealth ABA coverage (NY Medicaid Managed Care).

_Payer Guide · EmblemHealth (NY) · Last updated September 2026 · 2 primary sources_

> Published ABA content restates the state criteria verbatim; PA specifics unpublished — verify.

EmblemHealth — operating NY Medicaid through its HIP entities (HIP of Greater New York, Westchester, and Nassau) — is the closest thing to a pure pass-through among the downstate plans: its published Medicaid ABA benefit content is a verbatim restatement of the state criteria effective with the January 1, 2023 carve-in, and we located no distinct EmblemHealth ABA clinical policy. That makes the state guide your clinical rulebook here — but it does not mean no PA exists. The plan's authorization specifics simply aren't published, so verify the process in the portal 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** _(ask the plan)_: Not published — no distinct EmblemHealth ABA clinical policy was located; verify the assessment workflow in the emblemhealth.com provider portal and get the answer in writing [1][2]
  - Ask the plan: EmblemHealth provider services through the emblemhealth.com provider portal. Ask whether 97151 requires authorization on the Medicaid line, and whether Carelon Behavioral Health runs ABA utilization management — get the answer in writing per case.
- **Prior auth for treatment** _(ask the plan)_: Not published — the plan’s ABA content restates the state criteria verbatim without authorization specifics; silence is not proof there is no PA, so confirm per case in the portal [1][2]
  - Ask the plan: EmblemHealth provider services through the emblemhealth.com provider portal. Ask whether the treatment codes require authorization and which entity adjudicates; the plan’s silence in public materials is not proof there is no PA.
- **Autism diagnosis required?**: Yes — state baseline: under 21, ASD/Rett per DSM-5, referral from the state's practitioner list [1][2]

## At a glance

- **Plan type:** Mainstream MMC (HIP of Greater NY / Westchester / Nassau)
- **Clinical rules:** State criteria restated verbatim — no distinct ABA policy located
- **Prior auth:** Not published — verify assessment and treatment PA in the provider portal
- **BH management:** Carelon Behavioral Health historically manages Emblem BH (unconfirmed for ABA specifically)
- **Portal:** emblemhealth.com provider portal
- **Carve-in date:** January 1, 2023, with the statewide MMC carve-in

## A state-baseline plan — with unpublished plumbing

EmblemHealth's published ABA benefit page restates the state program: members under 21 with ASD and/or Rett syndrome per DSM-5, referred by the state's practitioner list, effective with the 2023 carve-in. No named assessment instruments, no plan-specific recency rules, no published intensity framework — the clinical criteria are the state's. What the public materials don't answer: whether the assessment or treatment requires prior authorization on the Medicaid line, what the authorization periods are, and whether Carelon Behavioral Health (which has historically managed Emblem's behavioral benefit) runs ABA UM. Treat those as portal questions — confirm the ABA authorization workflow through emblemhealth.com provider services per case, and get answers in writing. [1][2]

## Intake gates

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

- **Age limit**: Follows the New York Medicaid rule, restated verbatim on EmblemHealth’s own Medicaid ABA benefit page: members under 21 with ASD per DSM-5 and/or Rett syndrome, effective with the January 1, 2023 carve-in. No minimum age; no adult pathway. [1][2]
- **Diagnosis recency**: Follows the New York Medicaid rule: the referral is valid no more than two years and no maximum age is set on the diagnostic evaluation. EmblemHealth publishes no recency rule of its own — we located no distinct EmblemHealth ABA clinical policy, and its published benefit content is a verbatim restatement of the state criteria. [1][2]
- **Who may diagnose**: Follows the New York Medicaid rule, restated on EmblemHealth’s benefit page: referral from the state’s practitioner list — a NYS-licensed, NYS Medicaid-enrolled physician, psychologist, psychiatric NP, pediatric NP or PA. LBAs and CBAAs may not diagnose or self-refer. No Emblem-specific credential was located. [1][2]
- **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.” EmblemHealth names no assessment instruments and publishes no plan-specific recency or intensity framework — its ABA content is the state criteria restated. [1][2]
- **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. What EmblemHealth does not publish is whether it layers prior authorization on top: no distinct ABA clinical policy was located and the authorization specifics are absent from the public materials. That is not evidence there is no PA — verify the workflow in the emblemhealth.com provider portal before booking, and get the answer in writing. [1][2]
  - Ask the plan: The emblemhealth.com provider portal or provider services — confirm whether assessment and treatment require prior authorization, and whether Carelon Behavioral Health runs ABA utilization management for the Medicaid line.
- **Prior-auth decision time**: “Preauthorization or notification is always required” for autism treatment, and EmblemHealth’s behavioral health UM is run by Carelon Behavioral Health. Emblem’s manual says determinations “for most non-urgent requests, must be made within three (3) business days of receipt of the necessary information, but depending on the line of business, and if additional information is required, the plan may have additional time,” and concurrent determinations within one business day of the necessary information; for Medicaid it points to “authorization request timeframes as described in the Medicaid Managed Care Model Contract.” That contract fills the gaps: expedited within 72 hours, standard no more than 14 days after receipt (extendable up to 14 days), and federal rules cap the standard decision at 7 calendar days for plan rating periods starting on or after January 1, 2026. Neither Emblem nor Carelon’s NY Medicaid addendum publishes an ABA reauth lead time. [3][4][5][6]
- **Other insurance (who pays first)**: Medicaid pays last: providers “must bill all applicable insurance sources before submitting claims to Medicaid,” and under the state contract the plan must “alert the provider and ask them to bill the TPHI that should be primary to the Plan.” Emblem’s own rule is about when it may hold a claim: it “does not deny a claim, in whole or in part, based on coordinating benefits unless we have a reasonable basis to believe the member has other health insurance coverage that is primary,” and if it asks the member about other coverage and hears nothing in 45 days it adjudicates the claim. Behavioral health claims go through Carelon Behavioral Health; COB billing mechanics are in Emblem’s claim submission guides. Whether Emblem/Carelon still requires its own ABA authorization when it is secondary is not published — ask Carelon (800-397-1630). [7][8][5]
- **Telehealth** _(ask the plan)_: Not published. EmblemHealth’s Medicaid ABA benefit page restates the state criteria and says nothing about telehealth delivery of ABA codes; the state manual answers telehealth only for supervision. [1][2]
  - Ask the plan: The emblemhealth.com provider portal or provider services — confirm telehealth code eligibility and place of service in writing per case.

## Delivery and billing rules

Coverage decides whether EmblemHealth (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**: Follows the New York Medicaid rule, which the state applies to FFS and managed care alike: “an LBA can supervise no more than six CBAAs/unlicensed individuals at a time,” “LBAs are required to supervise unlicensed individuals for a minimum of five percent of the hours the unlicensed individual spends providing behavior analysis services each calendar month,” and “supervision must include at least two face-to-face, real-time contacts per month” with the LBA observing service delivery in at least one. Supervision may run over synchronous audio-and-video where on-site is impractical. 97155 counts toward the 5% “only when the LBA joins the patient and the unlicensed individual during a treatment session to direct the unlicensed individual/technician in implementing a new or modified treatment protocol.” CBAAs need direct supervision, and the supervisor “should assess each patient’s/client’s progress at least every 6 months… and review and sign treatment notes and reports prepared by the CBAA supervisee.” EmblemHealth publishes no supervision rule of its own — we located no distinct EmblemHealth ABA clinical policy, so the state rule is the whole answer here. [2][1]
- **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.” No EmblemHealth-specific documentation or signature rule was located. [2][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. EmblemHealth publishes no setting rule of its own; the state’s school bar is the operative constraint. [2][1]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not published. No distinct EmblemHealth ABA clinical policy was located, and the state manual is silent on 97153 with 97155. [1][2]
  - Ask the plan: The emblemhealth.com provider portal or provider services; Carelon Behavioral Health has historically managed Emblem’s behavioral benefit, but its role in ABA utilization management is unconfirmed.
- **Daily limits / MUEs** _(ask the plan)_: Not published — authorization periods, unit ceilings and hour-cap logic are all absent from EmblemHealth’s public ABA materials, and no distinct clinical policy was located. The state sets no per-day ceiling either. [1][2]
  - Ask the plan: The emblemhealth.com provider portal or provider services — confirm authorization periods and any unit limits per case in writing.
- **Bill as provider** _(ask the plan)_: Not published. 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. EmblemHealth states no managed-care claim convention of its own, and the state manual directs MMC providers to their plan for billing guidance — so confirm the claim format with Emblem before billing CBAA- or technician-delivered units. [2][1]
  - Ask the plan: The emblemhealth.com provider portal or provider services — confirm the rendering/supervising NPI convention and the correct HIP entity for the member.

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

- **Complete state referral packet:** Emblem's published criteria are the state's — the under-21 ASD/Rett referral with DSM-5 checklist is the clinical core.
- **PA confirmation in writing:** Authorization specifics are unpublished — confirm assessment and treatment PA per case via the portal.
- **HIP entity on the card:** Greater NY, Westchester, or Nassau — capture the exact entity for eligibility checks.

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

## Verification of benefits (VOB) data

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

### EDI routing

- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** Carelon Behavioral Health

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | inferred — the Medicaid ABA benefit page states generic coverage ("EmblemHealth will cover Applied Behavior Analysis (ABA) services for eligible EmblemHealth Medicaid members") but names NO individual CPT codes at all; coverage of this specific code is inferred from that general statement, not directly confirmed. | — | — | — | — | — |
| 97152 | inferred — the Medicaid ABA benefit page states generic coverage ("EmblemHealth will cover Applied Behavior Analysis (ABA) services for eligible EmblemHealth Medicaid members") but names NO individual CPT codes at all; coverage of this specific code is inferred from that general statement, not directly confirmed. | — | — | — | — | — |
| 97153 | inferred — the Medicaid ABA benefit page states generic coverage ("EmblemHealth will cover Applied Behavior Analysis (ABA) services for eligible EmblemHealth Medicaid members") but names NO individual CPT codes at all; coverage of this specific code is inferred from that general statement, not directly confirmed. | — | — | — | — | — |
| 97154 | inferred — the Medicaid ABA benefit page states generic coverage ("EmblemHealth will cover Applied Behavior Analysis (ABA) services for eligible EmblemHealth Medicaid members") but names NO individual CPT codes at all; coverage of this specific code is inferred from that general statement, not directly confirmed. | — | — | — | — | — |
| 97155 | inferred — the Medicaid ABA benefit page states generic coverage ("EmblemHealth will cover Applied Behavior Analysis (ABA) services for eligible EmblemHealth Medicaid members") but names NO individual CPT codes at all; coverage of this specific code is inferred from that general statement, not directly confirmed. | — | — | — | — | — |
| 97156 | inferred — the Medicaid ABA benefit page states generic coverage ("EmblemHealth will cover Applied Behavior Analysis (ABA) services for eligible EmblemHealth Medicaid members") but names NO individual CPT codes at all; coverage of this specific code is inferred from that general statement, not directly confirmed. | — | — | — | — | — |
| 97157 | inferred — the Medicaid ABA benefit page states generic coverage ("EmblemHealth will cover Applied Behavior Analysis (ABA) services for eligible EmblemHealth Medicaid members") but names NO individual CPT codes at all; coverage of this specific code is inferred from that general statement, not directly confirmed. | — | — | — | — | — |
| 97158 | inferred — the Medicaid ABA benefit page states generic coverage ("EmblemHealth will cover Applied Behavior Analysis (ABA) services for eligible EmblemHealth Medicaid members") but names NO individual CPT codes at all; coverage of this specific code is inferred from that general statement, not directly confirmed. | — | — | — | — | — |
| 0362T | — | — | — | — | — | — |
| 0373T | — | — | — | — | — | — |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158:** No distinct EmblemHealth ABA clinical policy was located — the state's eligibility criteria (under 21, ASD/Rett, referral) is restated verbatim on the benefit page as the entire clinical rulebook. Verify PA and code-level mechanics through the emblemhealth.com provider portal per case.

### Contacts

- **Provider services phone:** 800-397-1630
- **Phone menu path:** General EmblemHealth line. For behavioral health specifically (incl. ABA), call Carelon Behavioral Health directly at 888-447-2526.
- **Portal:** [Carelon Behavioral Health Provider Portal](https://plan.carelonbehavioralhealth.com)

Questions to ask on a verification call:

- Which EmblemHealth entity (GHI, HIP, or EmblemHealth Insurance Co.) underwrites this Medicaid line, and what is the correct payer ID for eligibility/claims?
- Does ABA specifically route through Carelon Behavioral Health, or does EmblemHealth adjudicate it directly — what is Carelon's payer ID if applicable?
- Is prior authorization required for ABA, since no ABA-specific PA statement was found on either of EmblemHealth's published pre-authorization lists?
- What are the per-code daily/annual unit caps for 97151-97158, 0362T, and 0373T?
- What POS settings are allowed for ABA services, and is telehealth reimbursable?
- What billing modifiers does EmblemHealth require for ABA claims?
- Is the ABA cost share a copay or coinsurance, charged per-visit or per-day, and does the deductible apply?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/06/pVeify-Payer-List-June-26.pdf (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23)
- https://business.optum.com/content/dam/o4-dam/resources/pdfs/white-papers/institutional-claims-payer-list.pdf (accessed 2026-07-23)
- https://www.emblemhealth.com/content/dam/emblemhealth/pdfs/provider-manual/behavioral-health-services.pdf (accessed 2026-07-23)
- https://www.emblemhealth.com/providers/news/beacon-health-carleon-health-202304 (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.emblemhealth.com/providers/resources/State-Sponsored-Programs/medicaid-applied-behavior-analysis-benefit- (accessed 2026-07-23)
- https://www.emblemhealth.com/content/dam/emblemhealth/pdfs/provider/sortable-policies/preauthorization-list-emblemhealth.pdf (accessed 2026-07-23)

## Common questions

### Does EmblemHealth cover ABA therapy?

Yes — its Medicaid plans carry the NY ABA carve-in on the state criteria, restated verbatim in its published benefit content: under 21, ASD/Rett per DSM-5, with the state practitioner referral.

### Does EmblemHealth require prior authorization for ABA?

The plan publishes no ABA-specific PA details — no distinct clinical policy was located. Verify the authorization workflow through the emblemhealth.com provider portal before booking, and get the answer in writing.

## Primary sources

1. [EmblemHealth — Medicaid ABA benefit page](https://www.emblemhealth.com/providers/resources/State-Sponsored-Programs/medicaid-applied-behavior-analysis-benefit-)
2. [eMedNY ABA Provider Policy Manual (state baseline)](https://www.emedny.org/ProviderManuals/ABA/PDFS/ABA_Policy.pdf)
3. [EmblemHealth Provider Manual — Utilization and Care Management (generated 06-26-2026)](https://www.emblemhealth.com/content/dam/emblemhealth/pdfs/provider-manual/care-management.pdf)
4. [EmblemHealth Provider Manual — Behavioral Health Services (generated 05-04-2026)](https://www.emblemhealth.com/content/dam/emblemhealth/pdfs/provider-manual/behavioral-health-services.pdf)
5. [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)
6. [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)
7. [EmblemHealth Provider Manual — Claims (generated 07-28-2026)](https://www.emblemhealth.com/content/dam/emblemhealth/pdfs/provider-manual/claims.pdf)
8. [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.