---
title: Horizon NJ Health ABA coverage (NJ FamilyCare MCO).
url: "https://carelu.com/payers/horizon-nj-health"
markdown_url: "https://carelu.com/payers/horizon-nj-health.md"
state: NJ (New Jersey)
payer: Horizon NJ Health
kind: Medicaid managed care plan (MCO)
parent_program: NJ FamilyCare
description: "How Horizon NJ Health administers NJ FamilyCare ABA — the NaviNet authorization workflow, the 32-unit/30-day assessment fast-track, MCG criteria and 6-month treatment spans, daily MUE unit limits, and the announced 2026 policy changes."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Horizon NJ Health ABA coverage (NJ FamilyCare MCO).

_Payer Guide · Horizon NJ Health · Last updated September 2026 · 8 primary sources_

> Largest NJ MCO; NaviNet requests, 32-unit assessment fast-track, MCG review, 6-month auths.

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.

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

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — ABA Authorization Request Form via NaviNet with an ASD script from a QHP; Horizon issues 32 units of 97151 for 30 days [1]
- **Prior auth for treatment**: Required — post-assessment ABA Request Form via NaviNet; MCG-based review within 14 days; 6-month authorizations [1]
- **Autism diagnosis required?**: Yes — ASD (F84.0–F84.9) with a diagnosis script from a qualified healthcare professional [1]

## At a glance

- **Plan type:** NJ FamilyCare MCO (Horizon BCBSNJ) — the state's largest
- **Clinical rules:** Own ABA medical policy + MCG criteria on the state code set
- **Assessment auth:** Fast-tracked — 32 units of 97151 for 30 days on confirmed eligibility + dx
- **Treatment auth:** 6-month spans; requests reviewed within 14 days of receipt
- **Daily unit limits:** State MUE table enforced (97153 32u, 97155 24u, 97156 16u...)
- **Submission:** NaviNet UM Request Tool / Availity; payor ID 22326

## How Horizon runs ABA authorization

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]

## The 2026 changes (verify before relying)

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]

## Contacts and rates

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]

## Intake gates

The questions that decide whether a family can start with Horizon NJ Health, and what they have to bring.

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

## Delivery and billing rules

Coverage decides whether Horizon NJ Health 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.

- **Concurrent billing (97153 + 97155)**: 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.
- **Daily limits / MUEs**: 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.
- **Place of service** _(plan-dependent)_: 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.

## What intake should collect for Horizon NJ Health

- **ASD script + diagnosis:** The QHP's ASD script triggers the 32-unit/30-day assessment fast-track — collect it at first contact.
- **Population segment:** Core Medicaid vs. DDD vs. MLTSS vs. FIDE-SNP — Horizon manages ABA across all four; note which the member is in.
- **Requested units per code per day:** Horizon enforces the daily MUE table; claims above authorized units are not paid.
- **Assessment scheduling within 30 days:** The 97151 authorization expires in 30 days — book the assessment before requesting it.

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

## Verification of benefits (VOB) data

How Horizon NJ Health ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00297 — pVerify 00297 = "Horizon New Jersey Health" (verified).
- **Payer ID (Availity):** 22326 — Payor ID 22326 per Horizon's ABA overview and claims materials; appears as "Horizon Mercy" in the stale 2012 Availity list — confirm against a current export.
- **Payer ID (Change Healthcare / Optum):** 22326 — Change Healthcare/Optum lists 22326 (Horizon's legacy "Mercy Health Plan of New Jersey" line; supports 270/271).
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** none (Horizon administers BH in-house post-2023 BH integration)
- **BH administrator payer ID:** 22326
- **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 | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 32 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97152 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 8 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97153 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 32 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97154 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 12 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97155 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 24 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97156 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 16 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97157 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 16 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97158 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 16 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 0362T | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 8 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 0373T | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 32 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |

Code notes:

- **97151:** Assessment fast-track: once Horizon confirms eligibility, an ASD diagnosis, and a QHP script, it issues 32 units of 97151 valid for 30 days without a full clinical review (submit via NaviNet before requesting). Book the assessment within the 30-day window.
- **97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** Horizon enforces the state daily MUE unit limits ("shall not consider for reimbursement units exceeding the daily maximum") — claims above authorized units are not reimbursed. Treatment: post-assessment ABA Request Form via NaviNet, MCG review within 14 days, 6-month authorizations. Two announced 2026 changes to confirm in the portal: revised PA / medical-necessity review criteria eff. 1/1/2026, and H0032 retired for ABA eff. 7/15/2026 (use the 97151–97158 / 0362T / 0373T set).

### Medicaid rates

Source: No Horizon NJ Health-specific ABA fee schedule is publicly posted (Horizon aligned BH fees to the DMAHS rate increase for DOS on/after 3/1/2024, but the specific ABA amounts are unverified); the NJ FamilyCare FFS schedule is the documented reference baseline (MCOs are not required to match it). Confirm the plan-paid rate in your participating-provider agreement. Effective 2022-02-01.

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | $25.00 | 15min | renderedBy: BCBA / BCBA-D (assessment); status: launch-era value; current status unverified — confirm in the CY2026 Procedure Master Listing |
| 97152 | $11.20 | 15min | renderedBy: RBT / BCaBA (supporting assessment); status: launch-era value; current status unverified |
| 97153 | $15.00 | 15min | renderedBy: RBT / BCaBA; status: verified current (CY2026 Q2); raised from $11.20 eff 2/1/2022 |
| 97154 | $4.80 | 15min | renderedBy: RBT / BCaBA (group); status: launch-era value; current status unverified |
| 97155 | $21.25 | 15min | renderedBy: BCBA / BCBA-D; status: verified current (CY2026 Q2) |
| 97156 | $25.00 | 15min | renderedBy: BCBA / BCBA-D (family guidance); status: verified current (CY2026 Q2) |
| 97157 | $12.40 | 15min | status: launch-era value; current status unverified |
| 97158 | $5.60 | 15min | status: launch-era value; current status unverified |
| 0362T | $25.00 | 15min | status: launch-era value; current status unverified |
| 0373T | $16.40 | 15min | status: launch-era value; current status unverified |

### Contacts

- **Provider services phone:** 1-800-682-9091
- **Phone menu path:** Prior-auth progress requests and continued-stay requests: 800-626-2212 (or via Availity). Claims Contact line above is 1-800-682-9091 (email BHMedicaid_@horizonblue.com).
- **Portal:** [Availity Essentials](https://apps.availity.com/web/onboarding/availity-fr-ui/#/login)
- **Fax:** 732-938-1444

Questions to ask on a verification call:

- Are the January 2026 medical-policy changes to PA / medical-necessity review criteria already in effect for this member's plan?
- What is today's paid rate for the ABA codes — Horizon aligned BH fees to the state's 3/1/2024 rate increase, but we don't have it broken out by code?
- Which places of service are approved under this member's authorization (home, office, school, community, telehealth)?
- Is eligibility checking real-time or batch through your clearinghouse?

### VOB data sources

- https://www.horizonnjhealth.com/sites/default/files/2020-12/Overview%20of%20ABA%20Services.pdf (accessed 2026-07-23; source document older than 18 months)
- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://www.optum.com/content/dam/o4-dam/resources/pdfs/guides/professional-claims-payer-list.pdf (accessed 2026-07-23)
- https://test.njmmis.com/downloadDocuments/5010_270-271_HIPAACompanionGuide.pdf (accessed 2026-07-23)
- https://www.nj.gov/humanservices/dmhas/documents/pdf/resources/providers/DMAHS-BH-Integration-Points-of-Contact.pdf (accessed 2026-07-23)
- https://web.archive.org/web/2023/https://www.nj.gov/humanservices/dmahs/news/Provider_Newsletter_for_Applied_Behavior_Analysis_Therapy.pdf (accessed 2026-07-23)
- https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/scc/ABA_SCC_SM.pdf (accessed 2026-07-23)
- https://www.horizonnjhealth.com/for-providers/news/updates-and-announcements/horizon-to-stop-using-h0032-for-aba-services (accessed 2026-07-23)
- https://www.horizonnjhealth.com/for-providers/news/updates-and-announcements/medical-policy-changes-applied-behavior-analysis (accessed 2026-07-23)
- https://www.providerspark.com/for-providers/medicaid-rates/new-jersey/ (accessed 2026-07-23)
- https://autismnj.org/news/autism-new-jerseys-advocacy-leads-to-medicaid-rate-increase-for-aba-services/ (accessed 2026-07-23)

## Common questions

### Does Horizon NJ Health cover ABA therapy?

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.

### How fast is Horizon's ABA assessment authorization?

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.

### Is Horizon changing its ABA policy in 2026?

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.

## Primary sources

1. [Horizon Behavioral Health — ABA Government Programs overview (Nov 2020)](https://www.horizonnjhealth.com/sites/default/files/2020-12/Overview%20of%20ABA%20Services.pdf)
2. [Horizon: Medical Policy Changes — ABA (eff. 1/1/2026)](https://www.horizonnjhealth.com/for-providers/news/updates-and-announcements/medical-policy-changes-applied-behavior-analysis)
3. [Horizon to Stop Using H0032 for ABA Services (eff. 7/15/2026)](https://www.horizonnjhealth.com/for-providers/news/updates-and-announcements/horizon-to-stop-using-h0032-for-aba-services)
4. [Horizon BCBSNJ reimbursement policy — ABA in Treatment of ASD](https://www.horizonblue.com/providers/policies-procedures/policies/reimbursement-policies-guidelines/applied-behavior-analysis-treatment-autism-spectrum-disorders)
5. [DMAHS BH Integration Points of Contact V3.1](https://www.nj.gov/humanservices/dmhas/documents/pdf/resources/providers/DMAHS-BH-Integration-Points-of-Contact.pdf)
6. [DMAHS Provider Newsletter Vol 30 No 06 — Provision of ABA services (4/1/2020)](https://web.archive.org/web/2023/https://www.nj.gov/humanservices/dmahs/news/Provider_Newsletter_for_Applied_Behavior_Analysis_Therapy.pdf)
7. [Optum ABA State Mandates BH803ABASTM12026 — NJ Medicaid entry](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/scc/ABA_SCC_SM.pdf)
8. [Optum/UHC Community Plan — NJ FamilyCare ABA Provider Orientation (2022)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/njaba/NJ.FamilyCare.Medicaid.ABA.pdf)
9. [Horizon NJ Health — UM policy: Timeframes for Authorization Determination and Notification (last reviewed 12/10/2025)](https://www.horizonnjhealth.com/for-providers/resources/policies/health-services-policies/utilization-management/timeframes-for)
10. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/section-438.210)
11. [Horizon NJ Health — Provider Administrative Manual](https://www.horizonnjhealth.com/provider-admin-manual)
12. [N.J.A.C. 10:49-7.3 — Third-party liability (TPL) benefits (LII)](https://www.law.cornell.edu/regulations/new-jersey/N-J-A-C-10-49-7-3)
13. [32 CFR 199.8 — TRICARE double coverage (eCFR)](https://www.ecfr.gov/current/title-32/section-199.8)
14. [38 CFR 17.272 — CHAMPVA benefit limitations; Medicaid exception (eCFR)](https://www.ecfr.gov/current/title-38/section-17.272)

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.