Horizon NJ Health — the Horizon BCBSNJ Medicaid plan — is the largest NJ FamilyCare MCO and the one with the most built-out ABA machinery: its own medical policy, MCG-based utilization review, and a documented assessment fast-track. It manages ABA across Core Medicaid, DDD, MLTSS, and FIDE-SNP populations. Horizon uses the state's code set and daily unit table, but layers a meaningfully stricter process on top than the state baseline — and has announced further policy revisions taking effect through 2026.
The front door is the ABA Authorization Request Form submitted through NaviNet's UM Request Tool, with an ASD diagnosis script from a QHP attached. The assessment step is fast-tracked: once Horizon confirms eligibility, diagnosis, and the script, it issues an assessment authorization of 32 units of 97151 valid for 30 days — no full clinical review at that stage. Treatment is where the review lives: the post-assessment ABA Request Form goes back through NaviNet, a UM clinician reviews against MCG criteria, requests are reviewed within 14 days of receipt, and approved cases get 6-month authorizations. Two hard edges: Horizon enforces the state's daily MUE unit limits ("shall not consider for reimbursement units exceeding the daily maximum as clinically authorized"), and claims above authorized units are not reimbursed — so the authorization, not the treatment plan, is the billing ceiling.[1][6]
Horizon has announced two 2026-era changes we could not fully verify against primary policy text — treat both as "confirm in the portal" items. First, a medical-policy revision effective January 1, 2026 revising criteria for prior authorization and pre-service and post-service medical-necessity reviews (search excerpts reference standardized-instrument testing no more often than every 6 months). Second, H0032 is retired for ABA on authorizations and claims effective July 15, 2026 — use the 97151–97158 / 0362T / 0373T set only — with Horizon stating that authorization requirements for ABA treatment hours are not changing as part of that move. Neither announcement could be confirmed against the live policy documents at research time, so verify the current text with Horizon before building process around the details.[2][3]
Horizon publishes real ABA escalation contacts: ABA UM escalations go to Erin McNeill (732-256-6336, erin_mcneill@horizonblue.com), the behavioral Medicaid inbox is BHMedicaid_@horizonblue.com, and member services runs at 1-800-682-9091; claims use payor ID 22326. On rates: Horizon publishes no ABA fee schedule — it aligned behavioral-health fees to the DMAHS rate increase for claims on or after March 1, 2024, but the specific ABA amounts are unverified, so treat your participating-provider agreement as the source of truth.[5]
The questions that decide whether a family can start with Horizon NJ Health, and what they have to bring. Each maps onto something intake should ask on the first call.
Two published numbers, and they differ in precision rather than in substance. The founding DMAHS newsletter sets the benefit for "any Medicaid eligible child, under the age of 21, who has been diagnosed with ASD as defined by ICD 10 diagnoses F84.0 through F84.9 by a qualified healthcare provider," delivered under EPSDT, which reaches "individuals under the age of twenty-one." Optum's New Jersey Medicaid entry adds the floor as well as the ceiling: "ABA services shall be made available to children 18 months to 21 years of age based on medical necessity," and its NJ FamilyCare provider orientation repeats it — "Must be 18 months – 21 years old," including in the specialized FamilyCare carve-out. No hour caps are attached to the age band. Horizon manages ABA across Core Medicaid, DDD, MLTSS and FIDE-SNP populations, so note which segment the member sits in alongside age.[6][7]
New Jersey names them twice, and the second list is narrower than the first. The newsletter's general test: "The need for ABA services must be determined by a qualified healthcare professional (QHP) capable of making a diagnosis of autism. QHPs include licensed health care professionals, who are qualified by education, training, or licensure/regulation (when applicable) to perform a professional service within his/her scope of practice." The enumerated list of acceptable QHPs "for the diagnosis and treatment planning for adaptive behavior services" is then: Physicians; Psychologists, which "Requires an active board certified behavior analyst (BCBA) certification in good standing and a qualifying doctoral-level degree (BCBA-D)"; and BCBAs, who appear for treatment planning rather than diagnosis. Optum's NJ entry restates the split: the diagnosis comes from "a physician or psychologist," and "It is not uncommon for one QHP to make the diagnosis (such as a physician) and a separate QHP (such as a BCBA) to develop and supervise the treatment plan."[6][1]
None required — and New Jersey is one of the few states that says so in terms. Optum's NJ Medicaid entry: "A comprehensive diagnostic evaluation is not required to access ABA services," with "ABA services … available to any child diagnosed with autism spectrum disorder as defined by ICD-10 diagnoses F84.0 through F84.9." The DMAHS newsletter names no instrument either. That makes this the friendliest diagnostic bar of the three states on this page — intake should not queue a New Jersey family for an ADOS-2 before starting the authorization. Horizon NJ Health publishes no deviation from this, and its own material was checked for one.[7][6]
The state sets no referral requirement, and Horizon turns the diagnosis itself into the trigger document: the ABA Authorization Request Form goes through NaviNet's UM Request Tool "with an ASD diagnosis script from a QHP attached," and once Horizon confirms eligibility, diagnosis and the script it issues the 32-unit/30-day assessment authorization without full clinical review. Treatment is the second step — the post-assessment ABA Request Form back through NaviNet, reviewed against MCG criteria within 14 days, approved in 6-month spans. So collect the script at first contact: it is not a referral, but it functions as one here.[1][6]
Horizon NJ Health's UM timeframes policy (last reviewed December 10, 2025): for Medicaid behavioral health, non-urgent prior authorization decisions within seven (7) calendar days of receipt of the request, with an extension of up to 14 calendar days at the member's or provider's request or when in the member's best interest; urgent outpatient requests decided within 24 hours of receipt of the necessary information — if the request is incomplete Horizon asks for more information within 24 hours and decides within 24 hours of receiving it, "but no later than seventy-two (72) hours, from receipt of the original request." Continued or extended services for a member in a course of treatment: decided within 24 hours of the request. For Medicaid only, "If Horizon fails to respond to an authorization request within the specific timeframes, the hospital or physician request shall be deemed approved." Federal floor for every NJ FamilyCare MCO: standard decisions within 7 calendar days of the request for contract rating periods starting on or after January 1, 2026 (14 days before that), extendable by up to 14 calendar days at the member's or provider's request or when the plan justifies needing more information; expedited within 72 hours.[9][10]
Horizon NJ Health's manual: "Horizon NJ Health is the payor of last resort on all claims" — verify other coverage and document that the claim was first processed by the other insurer. Do not file with Horizon "until they receive the EOB from the member's other insurance carrier(s)"; then submit the claim, PCP referral and the primary's EOB (all pages) within 60 days of the other carrier's correspondence or 180 days from the date of service, whichever is later. Authorization still applies when Horizon is secondary: "With the exception of Medicare, Horizon NJ Health's same notification policies that are routinely applied and required must be followed for any claims to be considered for payment" — get Horizon's ABA authorization even when the commercial plan pays first. State rule underneath: NJ FamilyCare pays last: "All TPL, for example, health insurance, Medicare, CHAMPUS, prepaid health plans… shall, if available, be used first and to the fullest extent." Bill the commercial plan first; supplementation claims "shall not be filed with the program unless accompanied by a statement of payment, Explanation of Benefits (EOB), or denial from the other carrier." Two traps: "No program payments shall be made when the third-party payer requires a contracting or participating provider to accept that third-party payer's payment as payment in full," and when NJ FamilyCare is secondary it pays the lesser of its allowed amount minus other payments, or the patient liability. TRICARE and CHAMPVA both pay ahead of Medicaid: TRICARE rules state "Medicaid is not a double coverage plan. In any double coverage situation involving Medicaid, CHAMPUS is always the primary payer," and CHAMPVA "assumes primary payer status" over Medicaid.[11][12][13][14]
Not published. Neither the DMAHS newsletter nor Optum's New Jersey entry sets a maximum age for the diagnostic evaluation, and the state's written position runs the other way: Optum's NJ Medicaid entry says flatly that "A comprehensive diagnostic evaluation is not required to access ABA services," so there is no comprehensive evaluation whose recency could be gated. What is dated in New Jersey is the authorization rather than the diagnosis — Horizon issues 32 units of 97151 valid for 30 days, and treatment authorizations run in 6-month spans. Horizon is the plan those clocks come from: its assessment authorization is 32 units of 97151 valid for 30 days, so book the assessment before requesting it. Search excerpts of Horizon's 1/1/2026 medical-policy revision reference standardized-instrument testing no more often than every 6 months, but that text could not be confirmed against the live policy.[1][6]
Ask the plan: Horizon NJ Health provider services, or the ABA UM escalation contact on the DMAHS BH integration contact sheet.
The state is silent and the carrier layer is not. Neither the founding DMAHS newsletter nor the daily unit guide addresses telehealth, remote delivery, modifiers or place-of-service codes for ABA. The one published New Jersey position is Optum's, for its own line of business: BCBAs and licensed BH clinicians in contracted ABA practices may deliver ABA supervision and caregiver training by telehealth if the practice is an approved Optum virtual-visits provider (attestation on Provider Express) and flags virtual delivery to the Care Advocate at authorization — then bills "the same procedure code you would use for an in-person service, 97155 or 97156, on your claim with the “02” place of service code." Direct technician treatment is not in that carve-out. Horizon republishes no telehealth position of its own for ABA.[6][8]
Ask the plan: Horizon NJ Health provider services, or the ABA UM escalation contact on the DMAHS BH integration contact sheet.
Coverage decides whether Horizon NJ Health pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
New Jersey says yes, in writing, and draws the line precisely. “If the QHP is overseeing the activities of the technician, the time of direct supervision by the QHP shall be concurrently billable using code 97155.” But “billing for 97155 is limited to time where the QHP is either engaged directly with the patient or is directing a technician in implementing a modified protocol with the patient. Billing for supervision where the technician is not present is not allowed.” Two other concurrency rules ride along: 97156 may be billed while the RBT delivers direct treatment to the child “in a separate location”; and for 0373T “providers may not bill for the QHP time concurrently” and billing is limited to a single technician’s face-to-face time, never the combined time of multiple technicians (three technicians for two hours bills eight units, not twenty-four). This is NJ FamilyCare state policy and the operative floor for Horizon NJ Health; no plan-specific deviation was found in Horizon NJ Health’s published material.[6]
Ask the plan: Horizon NJ Health provider services, to confirm the plan has not layered its own concurrency edit on top.
New Jersey publishes its own table rather than adopting a CMS MUE regime, and labels it guidance: the limits “are for guidance purposes only and may be overridden when medically necessary based on individual need” under EPSDT. Per day, in 15-minute units: 97151 32, 97152 8, 97153 32, 97154 12, 97155 24, 97156 16, 97157 16, 97158 16, 0362T 8, 0373T 32. Treat them as soft ceilings the plans enforce as edits — a request above them needs explicit EPSDT medical-necessity framing rather than a quiet resubmission. Horizon NJ Health publishes no daily table of its own, so the state guide is what to plan against.[6]
Ask the plan: Horizon NJ Health’s provider manual / claim-edit list.
This one has moved and the two live sources disagree. The founding DMAHS newsletter is flat: “ABA services may be provided in the therapist’s office, a community setting or the child’s home. Services may not be provided within a school facility.” Optum’s ABA State Mandates document (annual review 7/2026), whose NJ Medicaid entry tracks the same state policy, now reads: “Services may be provided in the school setting as long as services are not provided during normal school hours.” Office, home and community are settled; school is plan-dependent and moving; group home is addressed by neither. Neither position is republished by Horizon NJ Health, so resolve it with the plan before scheduling school-based sessions.[6][7]
Ask the plan: Horizon NJ Health provider services.
Neither the state nor Horizon NJ Health publishes a session-note signature rule for ABA — no named signer and no timeframe.
Blocked on: Horizon NJ Health’s provider manual documentation chapter, or DMAHS’s Autism Line (609-588-8522).
Yes — it administers the NJ FamilyCare ABA benefit under EPSDT, with its own medical policy and MCG-based review layered on the state code set. Both assessment and treatment require prior authorization via NaviNet.
Fast — once eligibility, an ASD diagnosis, and a QHP script are confirmed, Horizon issues a 32-unit 97151 authorization valid for 30 days without a full clinical review. Treatment requests then get MCG review within 14 days, in 6-month spans.
Two announced changes: revised PA and medical-necessity review criteria effective January 1, 2026, and retirement of H0032 for ABA effective July 15, 2026 (use 97151–97158/0362T/0373T). We could not verify the full policy text — confirm current details with Horizon directly.
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.
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