---
title: "Magellan Healthcare ABA: the carve-out administrator guide."
url: "https://carelu.com/payers/magellan-health"
markdown_url: "https://carelu.com/payers/magellan-health.md"
state: US (national)
payer: Magellan Health / Magellan Healthcare
kind: Commercial insurance
description: Magellan administers the ABA benefit for employer and commercial plans whose cards say something else. The public Magellan Care Guidelines ABA criteria, the fax-in authorization forms, focused vs. comprehensive hour bands, supervision ratios, the HO/HN modifiers and why 97152 is not a covered code.
last_reviewed: September 2026
---

# Magellan Healthcare ABA: the carve-out administrator guide.

_Payer Guide · Magellan Healthcare · Last updated September 2026 · 6 primary sources_

> Publishes dated, public ABA criteria — fax-in auth forms, 1–2 hrs supervision per 10 direct, 97152 not covered.

Magellan Healthcare is a behavioral health carve-out administrator: the employer or health plan owns the benefit, Magellan runs the network, the utilization management and often the claims. For an ABA practice that difference shows up the first time a family hands over a card with a familiar carrier name on it and the ABA authorization turns out to belong to Magellan — with its own forms, its own fax number, its own credentialing rules and its own code table.

Magellan is unusually good about publishing. Its ABA medical-necessity criteria are a public, dated, versioned document — the “Outpatient Applied Behavior Analysis” guideline inside the Magellan Care Guidelines, effective November 8, 2025, last reviewed June 17, 2025 — and it publishes a January 2026 provider orientation written specifically for commercial and employer plans, plus a public behavior-analyst network criteria document. If you know Magellan is administering the benefit, you can read the standard before you submit rather than after you are denied.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — the provider faxes an ABA Request for Initial Authorization with the diagnostic report; Magellan typically authorizes 8–12 hours of 97151 to complete the functional behavior assessment [3]
- **Prior auth for treatment**: Required — pre-authorization for direct treatment on the ABA Treatment Plan / Concurrent Review Template, in 15-minute increments [3]
- **Autism diagnosis required?**: Yes — an established DSM-5-TR autism spectrum diagnosis current within 24 months, made with a validated tool (ADOS, ADI-R, PEDS, Brigance and others) and confirmed by a doctoral-level clinician: an MD (family practice, pediatrics, developmental pediatrics, neurodevelopmental pediatrics, pediatric neurology or psychiatry) or a PhD/PsyD psychologist [1]

## At a glance

- **What it is:** Behavioral health carve-out administrator for employer, commercial and state books
- **ABA criteria:** Public — “Outpatient Applied Behavior Analysis,” Magellan Care Guidelines, eff. 11/8/2025 (2026–2027 edition eff. 10/10/2026)
- **Initial assessment:** Typically 8–12 hours of 97151 authorized for the FBA; more with clinical justification
- **Submission:** Fax the ABA Request for Initial Authorization with the diagnostic report; concurrent on the ABA Treatment Plan / Concurrent Review Template
- **Hour bands:** Focused 10–25 hrs/wk; comprehensive up to 40 hrs/wk — more where medically necessary
- **Supervision:** 1–2 hours of direct and indirect supervision authorized per 10 hours of direct care
- **Code gotcha:** 97152 is “not a covered code”; 97155 overlap with the technician IS accepted
- **Credentialing:** Master’s/doctoral analysts credentialed and recredentialed every 3 years; only credentialed providers may bill

## How to tell this plan is administered by Magellan

Magellan’s own orientation leads with the warning that matters: “Benefits are not the same for all Magellan members.” It instructs providers to obtain a copy of the member’s card at the first visit, check eligibility on Availity Essentials or by calling the appropriate toll-free number before treating, and re-verify routinely. That phrasing — “the appropriate toll-free number” — is the tell: there is no single Magellan member-services line, because Magellan is administering many different sponsors’ benefits, each with its own plan/program number. [3][2]

Practical signals an intake team can act on: [3][2]

- **A behavioral health number on the back of the card that is not the medical one:** Magellan’s own instruction is to call “the appropriate toll-free number” on the member’s card for eligibility. If the back of the card carries a separate mental health line, ask whose it is before you assume the medical carrier authorizes ABA. [3][2]
- **MagellanProvider.com and Availity both in play:** Magellan uses its own provider website for authorization forms and plan-specific information, and Availity Essentials for eligibility and claim status — two different logins. Being set up on the medical carrier’s portal tells you nothing about the ABA benefit. [3][2]
- **Plan- or state-specific criteria named on the MNC page:** Magellan publicly lists which books deviate from the national guidelines — California (SB 855 review-criteria grid, with a Jan. 1, 2025 change to outpatient ABA), Hawaiʻi (HMSA), Idaho, Louisiana CSoC, Nevada, New Mexico, North Carolina, Pennsylvania HealthChoices, Texas (Dell Children’s Health Plan and Superior Health Plan, following the Texas Medicaid Autism Services Policy), and Virginia DMAS. If the family’s plan appears there, the deviating criteria — not the national ones — govern. [3][2]
- **A 271 that returns behavioral health as a separate service-type set:** When eligibility comes back with mental health benefits carrying a different plan/program identifier than the medical benefits, that is the carve-out. Capture the program number, because Magellan’s plan-specific ABA fax numbers and email addresses are indexed by it. [3][2]
- **Magellan asks for the employer:** Its autism support contacts and forms are organized as “State & Plan Information → Autism-Specific Information” behind a provider login — which means the employer/plan name is a required input before you can even find the right fax number. [3][2]

## What Magellan requires: the public ABA criteria

Magellan splits the ABA decision in two: criteria to initiate care for the functional behavior assessment, then criteria to initiate care for direct treatment. The FBA gate is the diagnosis gate — an established and current (within 24 months) DSM-5 autism spectrum diagnosis using a validated assessment tool (ADOS, ADI-R, PEDS, Brigance Diagnostic Inventory of Early Development II among others), with confirmation of the diagnosis by a doctoral-level clinician within the past 24 months. [1]

Direct treatment then requires all of the following, and each one has an intake consequence: [1]

- **A developmental assessment within six months:** Completed with validated tools — Vineland, ABAS — unless a longer timeframe is mandated by state law or the customer contract. Magellan may ask for it more frequently where state law and contract permit. [1]
- **A one-standard-deviation threshold:** Validated developmental assessment must show the member cannot participate at an age-appropriate level in home, school or community activities, and the targeted behaviors or skill deficits must be at least one standard deviation below the mean or pose a significant threat of harm. [1]
- **A functional assessment by a BACB-certified analyst:** Completed with validated tools, including baseline information on adaptive functioning within the last six months (or longer if state law or the contract requires). [1]
- **Caregiver commitment:** The recipient’s caregivers must commit to participate in the goals of the treatment plan — a conversation intake should have, and document, before submission. [1]
- **Medical stability:** The member must be medically stable and not require 24-hour medical or nursing monitoring. [1]
- **A treatment plan with specific, quantifiable goals:** Objective, observable, quantifiable metrics, plus documentation that adjunctive treatments (psychotherapy, social skills training, medication services, educational services) have been considered for inclusion. [1]

## Hours, supervision and the code table

Magellan publishes its intensity bands rather than making you guess them. Focused interventions are generally authorized for 10–25 hours per week of direct treatment, with more than 25 hours approved where medically necessary. Comprehensive ABA of up to 40 hours per week is reserved for multiple targets across most or all developmental domains — typically younger children with substantial impairment across most areas of functioning — with more than 40 hours approved where medically necessary, and the guidelines note that literature generally supports 1–2 years of comprehensive intervention. On top of whichever band applies, Magellan says additional authorization will be provided for direct and indirect supervision at 1 to 2 hours per 10 hours of direct care, plus caregiver training. [1][3]

The code table in the January 2026 commercial and employer orientation is where a billing team should start, because two of its entries are surprises: [1][3]

- **97152 is not a covered code:** Stated flatly in the national code table. Build the assessment request around 97151 and, where applicable, 0362T — not 97152. [1][3]
- **97155 overlap with the technician is accepted:** “We do accept overlap with technician; all services are direct.” Concurrent 97153 and 97155 for the same clock time is permitted, which is not the case with every payer. [1][3]
- **Provider-level modifiers ride the code:** HO for the master’s-level analyst, HN for the bachelor’s/technician level — 97151 is BCBA only (HO); 97153 and 97154 are technician only (HN); 97158 is QHP only. California adds HM. [1][3]
- **A worked example of a typical week:** Magellan’s sample authorization shows 8–12 hours of 97151 for initial assessment and plan development, then a weekly pattern of 22.5 hours of 97153 (certified technician), 1.5 hours of 97155 (supervision rendered conjointly, in person) and 1 hour of 97156 (caregiver training). [1][3]
- **Reassessment and severe-behavior codes are market-dependent:** 90889 (reassessment/report writing, indirect) is capped at up to three hours per six months and is “not available in all markets”; 0362T and 0373T carry the same caveat. Confirm before you build them into a plan. [1][3]
- **Everything is in 15-minute increments:** Both the initial-authorization form and the concurrent-review template authorize services in 15-minute units; 16 units of 97155 means four hours of supervision, 240 units of 97153 means 60 hours of direct intervention. [1][3]

## The submission path, and who may bill

The sequence Magellan documents is: fax the ABA Request for Initial Authorization together with the diagnostic report; conduct the initial assessment once authorized; then request pre-authorization for additional services on the ABA Treatment Plan / Concurrent Review Template. You may use your own template for the concurrent review provided it contains Magellan’s required components. Requesting pre-authorization is explicitly the provider’s responsibility, review frequency varies with federal and state requirements and clinical need, and determinations are communicated by telephone with the option to discuss an adverse decision with a physician advisor. [3][4]

Credentialing is where an ABA group’s staffing model meets Magellan’s rules, and the rules are clear: master’s and doctoral-level practitioners must complete credentialing before joining the network and re-credential every three years, and only credentialed providers may bill for ABA services as in-network providers. Bachelor’s-level behavior analysts and support staff/technicians are not required to credential with Magellan if they work under the supervision of the licensed, credentialed practitioner — but that supervisory relationship must be documented in writing. [3][4]

Magellan’s published network criteria define three tiers. The master’s/doctoral analyst must hold a state behavior-analyst credential or BCBA certification, or meet Magellan’s licensed-practitioner criteria plus at least 40 coursework hours in behavior analysis and autism and one year (1,500 hours) of supervised clinical experience including direct care to children using ABA; liability limits of $1M/$1M; no sanctions; no federal exclusion (OIG-LEIE, SAM, state Medicaid lists); and a criminal background check at hire and at least every five years. The bachelor’s tier requires a state bachelor-level behavior-analyst credential, BCaBA, or QABA’s QASP. The support-staff tier requires a state behavior-technician credential, BACB RBT certification, or QABA’s ABAT — and both lower tiers must work under documented supervision. [3][4]

On claims: submit CPT/HCPCS on an 837P or CMS-1500 with the appropriate billing modifier and ICD-10 diagnosis codes, include the NPI for both rendering and billing provider, and attach the primary carrier’s EOB when Magellan is secondary. Magellan’s own list of top rejection reasons is a useful pre-submit checklist: missing or invalid CPT/HCPCS, missing or invalid diagnosis code, missing or inaccurate place-of-service code, missing provider name and/or degree level where required, and missing or invalid NPI. Claim status and EOB/EOP live on Availity Essentials, which is a separate registration from your MagellanProvider.com login (they can be linked by single sign-on). [3][4]

## Where Magellan differs from calling the insurer

First: you can read the standard in advance. Magellan combines MCG Behavioral Health Care Guidelines with its own proprietary Magellan Healthcare Guidelines; the Magellan Healthcare Guidelines half is publicly available, while the MCG half is proprietary and obtained by calling the number on the member’s card during a clinical review. The current edition is the 2025–2026 Magellan Care Guidelines; the 2026–2027 edition becomes effective October 10, 2026 for all plans unless the state/client-specific section says otherwise. Check the effective date before you quote a criterion. [2][6][1]

Second: national criteria are a default, not a guarantee. Where a state or client requires modified criteria, Magellan defers — sometimes entirely. In Louisiana, for Louisiana Healthcare Connections members, Magellan’s own guideline says it follows the guidelines published in the most current Louisiana Department of Health ABA Provider Manual, with the state’s comprehensive diagnostic evaluation and qualified-health-care-professional definitions governing, and the initial assessment authorization period capped at 180 days. That is a different rulebook from the national one, reached through the same fax number. [2][6][1]

Third: continued care is a data argument, not a narrative one. Magellan requires demonstrated improvement from baseline in the targeted skill deficits and behaviors using validated assessments of adaptive functioning, with the member still below the participation threshold. Discharge follows when goals are achieved or maximum benefit reached, when caregivers refuse treatment recommendations, when behavioral issues are exacerbated by treatment, when the member is unlikely to continue to benefit, when there is no progress toward goals for two or more successive authorization periods, or when continued care would be primarily for the convenience of the child or caregivers. “No progress for two authorization periods” is the one to watch: it makes the quality of your data collection a clinical-eligibility issue, not just a documentation issue. [2][6][1]

## How Magellan Health / Magellan Healthcare works state by state

The clinical policy above is national, but three state-level layers change what a family's card actually buys: the state autism mandate (what fully-insured plans must cover), the carrier's state Medicaid plans (which follow the state Medicaid rules, not this commercial policy), and plan funding type (self-funded ERISA plans can carve benefits differently).

- **Georgia** (mandate: Ava’s Law (O.C.G.A. § 33-24-59.10)): fully-insured Magellan Health / Magellan Healthcare plans issued in Georgia sit under the state mandate. State Medicaid baseline: [Georgia Medicaid guide](https://carelu.com/payers/georgia-medicaid).
- **North Carolina** (mandate: N.C.G.S. § 58-3-192 (autism coverage)): fully-insured Magellan Health / Magellan Healthcare plans issued in North Carolina sit under the state mandate. State Medicaid baseline: [North Carolina Medicaid guide](https://carelu.com/payers/north-carolina-medicaid).
- **Indiana** (mandate: Indiana autism insurance mandate (IC 27-8-14.2)): fully-insured Magellan Health / Magellan Healthcare plans issued in Indiana sit under the state mandate. State Medicaid baseline: [Indiana Medicaid (IHCP) guide](https://carelu.com/payers/indiana-medicaid).
- **Virginia** (mandate: Virginia autism insurance mandate (§ 38.2-3418.17)): fully-insured Magellan Health / Magellan Healthcare plans issued in Virginia sit under the state mandate. State Medicaid baseline: [Virginia Medicaid (DMAS) guide](https://carelu.com/payers/virginia-medicaid).
- **Tennessee** (mandate: Tenn. Code Ann. § 56-7-2367 (neurological parity)): fully-insured Magellan Health / Magellan Healthcare plans issued in Tennessee sit under the state mandate. State Medicaid baseline: [TennCare (Tennessee Medicaid) guide](https://carelu.com/payers/tenncare-tennessee-medicaid).
- **Ohio** (mandate: Ohio autism insurance mandate (R.C. 3923.84)): fully-insured Magellan Health / Magellan Healthcare plans issued in Ohio sit under the state mandate. State Medicaid baseline: [Ohio Medicaid guide](https://carelu.com/payers/ohio-medicaid).
- **New Jersey** (mandate: P.L. 2009, c.115 (N.J.S.A. 17:48-6ii et al.)): fully-insured Magellan Health / Magellan Healthcare plans issued in New Jersey sit under the state mandate. State Medicaid baseline: [NJ FamilyCare (New Jersey Medicaid) guide](https://carelu.com/payers/new-jersey-medicaid).
- **Maryland** (mandate: Habilitative services mandate (Md. Ins. § 15-835 + COMAR 31.10.39.03)): fully-insured Magellan Health / Magellan Healthcare plans issued in Maryland sit under the state mandate. State Medicaid baseline: [Maryland Medicaid (Medical Assistance) guide](https://carelu.com/payers/maryland-medicaid).
- **Colorado** (mandate: Colorado autism insurance mandate (C.R.S. § 10-16-104(1.4))): fully-insured Magellan Health / Magellan Healthcare plans issued in Colorado sit under the state mandate. State Medicaid baseline: [Health First Colorado (Colorado Medicaid) guide](https://carelu.com/payers/colorado-medicaid).
- **Utah** (mandate: Utah autism insurance mandate (Utah Code § 31A-22-642; caps removed 2020)): fully-insured Magellan Health / Magellan Healthcare plans issued in Utah sit under the state mandate. State Medicaid baseline: [Utah Medicaid guide](https://carelu.com/payers/utah-medicaid).
- **Arizona** (mandate: Steven’s Law (A.R.S. § 20-826.04; dollar caps repealed by SB 1590, 2025)): fully-insured Magellan Health / Magellan Healthcare plans issued in Arizona sit under the state mandate. State Medicaid baseline: [AHCCCS (Arizona Medicaid) guide](https://carelu.com/payers/arizona-ahcccs).
- **New York** (mandate: NY autism mandate (Ins. Law §§ 3216(i)(25), 3221(l)(17), 4303(ee))): fully-insured Magellan Health / Magellan Healthcare plans issued in New York sit under the state mandate. State Medicaid baseline: [New York Medicaid (NYS DOH / eMedNY) guide](https://carelu.com/payers/new-york-medicaid).
- **New Mexico** (mandate: New Mexico autism insurance mandate (NMSA 1978 § 59A-22-49)): fully-insured Magellan Health / Magellan Healthcare plans issued in New Mexico sit under the state mandate. State Medicaid baseline: [New Mexico Medicaid (Turquoise Care) guide](https://carelu.com/payers/new-mexico-medicaid).
- **Missouri** (mandate: Missouri autism insurance mandate (RSMo § 376.1224)): fully-insured Magellan Health / Magellan Healthcare plans issued in Missouri sit under the state mandate. State Medicaid baseline: [MO HealthNet (Missouri Medicaid) guide](https://carelu.com/payers/missouri-medicaid).
- **Texas** (mandate: Texas autism mandate (Tex. Ins. Code § 1355.015)): fully-insured Magellan Health / Magellan Healthcare plans issued in Texas sit under the state mandate. State Medicaid baseline: [Texas Medicaid (THSteps-CCP) guide](https://carelu.com/payers/texas-medicaid).
- **Massachusetts** (mandate: ARICA — Ch. 207, Acts of 2010 (M.G.L. c. 175 § 47AA et al.)): fully-insured Magellan Health / Magellan Healthcare plans issued in Massachusetts sit under the state mandate. State Medicaid baseline: [MassHealth (Massachusetts Medicaid) guide](https://carelu.com/payers/masshealth-massachusetts-medicaid).
- **Florida** (mandate: Steven A. Geller Autism Coverage Act (§ 627.6686, Fla. Stat.)): fully-insured Magellan Health / Magellan Healthcare plans issued in Florida sit under the state mandate. State Medicaid baseline: [Florida Medicaid — Behavior Analysis Services (AHCA) guide](https://carelu.com/payers/florida-medicaid).
- **Kansas** (mandate: Kansas autism insurance mandate (K.S.A. 40-2,194)): fully-insured Magellan Health / Magellan Healthcare plans issued in Kansas sit under the state mandate. State Medicaid baseline: [KanCare (Kansas Medicaid) guide](https://carelu.com/payers/kansas-medicaid).
- **Nebraska** (mandate: Neb. Rev. Stat. § 44-7,106 (autism coverage, 25 hr/wk cap)): fully-insured Magellan Health / Magellan Healthcare plans issued in Nebraska sit under the state mandate. State Medicaid baseline: [Nebraska Medicaid (Heritage Health) guide](https://carelu.com/payers/nebraska-medicaid).
- **Idaho** (mandate: No autism statute — DOI Bulletin 18-02 (habilitative-parity floor, plan years from 2019)): fully-insured Magellan Health / Magellan Healthcare plans issued in Idaho sit under the state mandate. State Medicaid baseline: [Idaho Medicaid guide](https://carelu.com/payers/idaho-medicaid).
- **Iowa** (mandate: Iowa autism mandates (Iowa Code §§ 514C.31, 514C.28; caps and age limits removed by H.F. 330 from 1/1/2026)): fully-insured Magellan Health / Magellan Healthcare plans issued in Iowa sit under the state mandate. State Medicaid baseline: [Iowa Medicaid (IA Health Link) guide](https://carelu.com/payers/iowa-medicaid).
- **Oklahoma** (mandate: Nick’s Law (36 O.S. § 6060.21; age and hour caps removed 2022)): fully-insured Magellan Health / Magellan Healthcare plans issued in Oklahoma sit under the state mandate. State Medicaid baseline: [Oklahoma Medicaid (SoonerCare / SoonerSelect) - Oklahoma Health Care Authority guide](https://carelu.com/payers/oklahoma-medicaid).
- **Michigan** (mandate: Michigan autism mandate (MCL 500.3406s, 550.1416e; through age 18, $50K/$40K/$30K caps allowed)): fully-insured Magellan Health / Magellan Healthcare plans issued in Michigan sit under the state mandate. State Medicaid baseline: [Michigan Medicaid guide](https://carelu.com/payers/michigan-medicaid).
- **Hawaii** (mandate: Luke’s Law (HRS § 431:10A-133; under 14, $25,000/yr ABA cap)): fully-insured Magellan Health / Magellan Healthcare plans issued in Hawaii sit under the state mandate. State Medicaid baseline: [Hawaii Medicaid (Med-QUEST / QUEST Integration) guide](https://carelu.com/payers/hawaii-medicaid).
- **California** (mandate: SB 946 autism mandate (H&S § 1374.73, Ins. Code § 10144.51; no age or dollar caps)): fully-insured Magellan Health / Magellan Healthcare plans issued in California sit under the state mandate. State Medicaid baseline: [Medi-Cal (California Medicaid) guide](https://carelu.com/payers/medi-cal-california-medicaid).
- **Pennsylvania** (mandate: Act 62 of 2008 (40 P.S. § 764h; under 21, CPI-adjusted cap $51,908 for 2026)): fully-insured Magellan Health / Magellan Healthcare plans issued in Pennsylvania sit under the state mandate. State Medicaid baseline: [Pennsylvania Medicaid (Medical Assistance) guide](https://carelu.com/payers/pennsylvania-medicaid).

## Intake gates

The questions that decide whether a family can start with Magellan Health / Magellan Healthcare, and what they have to bring.

- **Diagnosis recency**: Two clocks, and both are published. The autism diagnosis must be established and current within 24 months, with confirmation of the diagnosis by a doctoral-level clinician within the past 24 months. Separately, direct treatment requires a developmental assessment completed within six months using validated tools (Vineland, ABAS), and a functional assessment by a BACB-certified analyst including baseline information on adaptive functioning within the last six months — both “unless a longer timeframe is mandated by state law or the customer contract,” and Magellan may ask for them more frequently where state law and contract permit. A pediatrician’s letter with no confirming doctoral clinician will stall the initial request. [1]
- **Who may diagnose**: A closed and unusually specific list. The diagnosis must be confirmed by a doctoral-level clinician within the past 24 months: an MD in family practice, pediatrics, developmental pediatrics, neurodevelopmental pediatrics, pediatric neurology or psychiatry, or a PhD/PsyD psychologist. Note that this is confirmation of the diagnosis, not merely its origin — capture the confirming clinician’s name, specialty and the date on the intake form. [1]
- **Diagnostic tools required**: Three separate tool requirements stack. The diagnosis itself must have been made using a validated assessment tool — Magellan names the ADOS, the ADI-R, the PEDS and the Brigance Diagnostic Inventory of Early Development II “among others,” so the list is illustrative rather than closed. Direct treatment then requires a validated developmental assessment within six months (Vineland, ABAS) showing the member cannot participate at an age-appropriate level in home, school or community activities, with the targeted behaviors or skill deficits at least one standard deviation below the mean or posing a significant threat of harm. And a functional assessment by a BACB-certified analyst, completed with validated tools, must carry baseline adaptive-functioning information within the last six months. Continued care is then a data argument: demonstrated improvement from baseline using validated assessments of adaptive functioning. [1]
- **Referral required?**: No physician referral is required, but the assessment is prior-authorized and the sequence is fixed. Fax the ABA Request for Initial Authorization together with the diagnostic report; Magellan will typically authorize 8–12 hours of 97151 to complete the functional behavior assessment, with more on clinical justification. Then request pre-authorization for direct treatment on the ABA Treatment Plan / Concurrent Review Template — your own template is acceptable provided it contains Magellan’s required components. Requesting pre-authorization is explicitly the provider’s responsibility, review frequency varies with federal and state requirements and clinical need, and determinations come by telephone with the option to discuss an adverse decision with a physician advisor. Only credentialed providers may bill as in-network. [3][4]
- **Other insurance (who pays first)**: Magellan applies the NAIC order-of-benefit rules: the plan covering the person as the employee or subscriber pays before the plan covering them as a dependent; an active-employee plan pays before a retiree or laid-off plan; and for a child on both parents' plans, "The parent whose birthday (month and day only) falls first in a calendar year is the parent with the primary coverage for the dependent," with the longer-running plan primary on a shared birthday — "unless a contract specifically requires otherwise." Two boundaries matter at intake: "Unless specifically mandated by state law or a client contract, Magellan does not coordinate benefits with individual contracts (including private indemnity plans), Medicaid, TriCare, school sponsored plans," and "When Medicaid is a payer, it is always the payer of last resort" — a child with Magellan-administered employer coverage plus Medicaid bills Magellan first. When Magellan is secondary, "Attach primary carrier’s explanation of benefits when billing as the secondary insurer"; the 60-day participating commercial filing limit then runs from the date of the primary carrier's EOB. Magellan may hold a claim while it verifies other coverage; if no payment or denial notice arrives within 120 days of its EOB/EOP, the provider may pursue the primary carrier or the member. [10][3]
- **Age limit** _(plan-dependent)_: Magellan’s public ABA guideline sets no age limit. It frames intensity by developmental stage instead — comprehensive ABA of up to 40 hours a week is reserved for multiple targets across most or all developmental domains, “typically younger children with substantial impairment across most areas of functioning.” Because Magellan administers other sponsors’ benefits, any age bound comes from the employer plan or from a deviating state/client criteria set (California, Hawaiʻi, Idaho, Louisiana, Nevada, New Mexico, North Carolina, Pennsylvania, Texas and Virginia are on Magellan’s published deviation list). [1][2]
  - In licensed criteria: Eligibility on Availity Essentials or the appropriate toll-free number on the member’s card, plus Magellan’s Medical Necessity Criteria page to check whether this plan’s state/client criteria deviate. Magellan applies the proprietary MCG half of its Care Guidelines here; that half is licensed and is only supplied on request during a clinical review, so the plan’s UM line — not a document request — is the route to the answer.
- **Prior-auth decision time** _(plan-dependent)_: Magellan publishes no national ABA decision clock. Its 2026 national handbook commits to process benefit certifications "in accordance with the requirements, allowances and limitations of the member’s benefit plan," and the January 2026 commercial and employer ABA orientation says the "Frequency of authorization reviews may depend on federal and state requirements, clinical rationale of services being requested, and the member’s clinical need for ABA services." Decisions are communicated by telephone and carry a start and end date; no reauthorization submission lead time is published for ABA. The floor under an employer plan is federal: an ERISA group health plan must decide a pre-service claim "not later than 15 days after receipt of the claim by the plan" (one 15-day extension allowed) and an urgent claim within 72 hours, and an urgent request to extend an approved course of treatment within 24 hours if it is made at least 24 hours before the approval runs out. A fully insured plan is also bound by its state's utilization-review law, and a Magellan-administered Medicaid book by 42 CFR 438.210(d) — 7 calendar days standard / 72 hours expedited for rating periods starting on or after 1/1/2026. The shorter rule wins. [7][3][8][9]
  - Ask the plan: The plan-specific ABA team via MagellanProvider.com (State & Plan Information → Autism-Specific Information) or the toll-free number on the member's card — ask the decision timeframe for a non-urgent ABA request under this plan, whether it runs from receipt or from a complete request, and how many days before the authorization end date the concurrent review template must arrive.
- **Telehealth** _(licensed criteria)_: Not published for ABA. Magellan’s public ABA guideline and its January 2026 commercial and employer orientation set hour bands, supervision ratios and a national code table without stating which ABA codes may be delivered remotely or under which modifiers. Because Magellan administers many sponsors’ benefits and publishes a list of books whose criteria deviate — California, Hawaiʻi, Idaho, Louisiana, Nevada, New Mexico, North Carolina, Pennsylvania, Texas and Virginia — treat telehealth as a per-plan answer rather than a Magellan answer. [1][3][2]
  - In licensed criteria: The plan-specific ABA team via MagellanProvider.com (State & Plan Information → Autism-Specific Information) or the toll-free number on the card. For a deviating book such as Louisiana Healthcare Connections, read the state manual Magellan defers to — there, the Louisiana Department of Health ABA Provider Manual. Magellan applies the proprietary MCG half of its Care Guidelines here; that half is licensed and is only supplied on request during a clinical review, so the plan’s UM line — not a document request — is the route to the answer.

## Delivery and billing rules

Coverage decides whether Magellan Health / Magellan Healthcare 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**: Magellan authorizes direct and indirect supervision at 1 to 2 hours per 10 hours of direct care, on top of the authorized direct-treatment band, plus caregiver training. Bachelor’s-level analysts must work under a master’s/doctoral-level behavior analyst, and support staff/technicians under a master’s/doctoral- or bachelor’s-level analyst — in both cases the supervisory relationship must be documented in writing. [1][4]
- **Concurrent billing (97153 + 97155)**: Permitted. Magellan’s national ABA code table states for 97155 (direct by QHP / supervision): “We do accept overlap with technician; all services are direct.” Separately, 97152 is listed as not a covered code. [3]
- **Bill as provider**: Only credentialed providers may bill for ABA services as in-network providers; master’s/doctoral analysts credential before joining and re-credential every three years. Bachelor’s-level analysts and technicians need not credential when supervised by the licensed, credentialed practitioner. Claims go out on an 837P or CMS-1500 with the NPI of both the rendering and the billing provider and a provider-level modifier — HO for the master’s level, HN for bachelor’s/technician (HM added in California). [3]
- **Daily limits / MUEs** _(licensed criteria)_: Magellan publishes weekly bands rather than per-day unit ceilings. Focused interventions are generally authorized at 10–25 hours per week of direct treatment, with more than 25 approved where medically necessary; comprehensive ABA runs up to 40 hours per week, with more approved where medically necessary, and the guidelines note the literature generally supports 1–2 years of comprehensive intervention. Supervision is authorized on top at 1–2 hours per 10 hours of direct care, plus caregiver training. Two published caps are narrower: 90889 (reassessment/report writing, indirect) is limited to up to three hours per six months and is “not available in all markets,” as are 0362T and 0373T. Everything authorizes in 15-minute increments. No per-day MUE table is published. [1][3]
  - In licensed criteria: The plan- or employer-specific ABA team — Magellan organizes its autism contacts as State & Plan Information → Autism-Specific Information behind a provider login, so you need the plan/program number from the card. Ask whether any per-day unit ceiling applies on top of the weekly band. Magellan applies the proprietary MCG half of its Care Guidelines here; that half is licensed and is only supplied on request during a clinical review, so the plan’s UM line — not a document request — is the route to the answer.
- **Session-note signature** _(licensed criteria)_: Magellan does not publish a session-note signature standard in the public half of its Care Guidelines or in the January 2026 commercial and employer orientation. The closest published signal is its list of top claim rejection reasons, which includes “missing provider name and/or degree level where required” — a claims rule rather than a documentation one. [3][1]
  - In licensed criteria: The plan-specific Magellan ABA team via MagellanProvider.com (State & Plan Information → Autism-Specific Information), or the toll-free number on the member’s card. The proprietary MCG half of the Care Guidelines is supplied on request during a clinical review. Magellan applies the proprietary MCG half of its Care Guidelines here; that half is licensed and is only supplied on request during a clinical review, so the plan’s UM line — not a document request — is the route to the answer.
- **Place of service** _(licensed criteria)_: No place-of-service policy is published. Magellan’s criteria bear on setting only indirectly — the validated developmental assessment must show the member cannot participate at an age-appropriate level in home, school or community activities, and the treatment plan must document that adjunctive treatments including educational services were considered for inclusion. On the claim side, “missing or inaccurate place-of-service code” is one of Magellan’s named top rejection reasons, so the POS code matters operationally even though the payable-settings list is not published. [1][3]
  - In licensed criteria: The plan-specific ABA team via MagellanProvider.com or the number on the card — ask which settings this client pays for before scheduling school, daycare or community hours. Magellan applies the proprietary MCG half of its Care Guidelines here; that half is licensed and is only supplied on request during a clinical review, so the plan’s UM line — not a document request — is the route to the answer.

## What intake should collect for Magellan Health / Magellan Healthcare

- **Both sides of the card plus the employer name:** Magellan tells providers to obtain a card copy at the first visit and to call “the appropriate toll-free number” — the plan/program number on the card is what routes you to the right ABA team and fax number.
- **The diagnostic report, with the confirming doctoral clinician named:** Diagnosis must be current within 24 months, made with a validated tool, and confirmed by an MD or PhD/PsyD. A pediatrician’s letter without the confirming clinician will stall the initial request.
- **A developmental assessment dated within six months:** Vineland, ABAS or equivalent. If the family’s most recent one is older, plan to administer during your authorized FBA window rather than discovering the gap at review.
- **Caregiver availability and commitment:** Caregiver commitment to the treatment-plan goals is an explicit criterion, and caregiver training (97156/97157) is authorized alongside direct hours.
- **Concurrent services and school supports:** Magellan requires documentation that adjunctive treatments — psychotherapy, social skills training, medication services, educational services — were considered for inclusion.
- **Your staffing roster by tier:** Which analysts are credentialed (master’s/doctoral, recredentialed every three years) and which staff are bachelor’s-level or technicians under written supervision — only credentialed providers may bill in network.

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

## Common questions

### Are Magellan’s ABA criteria public?

Yes. The “Outpatient Applied Behavior Analysis” guideline sits inside the Magellan Care Guidelines, which carry an effective date and a last-review date — the current edition is effective November 8, 2025 (last reviewed June 17, 2025), and the 2026–2027 edition takes effect October 10, 2026. The Magellan Healthcare Guidelines half is publicly downloadable; the MCG half is proprietary and supplied on request during a clinical review.

### Does Magellan require prior authorization for the ABA assessment?

Yes. The provider faxes an ABA Request for Initial Authorization with the diagnostic report, and Magellan will typically authorize 8–12 hours for the functional behavior assessment, with additional hours available on clinical justification. Direct treatment is a second, separate pre-authorization.

### How many ABA hours per week will Magellan authorize?

Focused interventions are generally authorized at 10–25 hours per week of direct treatment and comprehensive ABA at up to 40 hours per week, with more approved where medically necessary. Supervision is authorized on top, at 1 to 2 hours per 10 hours of direct care, along with caregiver training.

### Can 97153 and 97155 be billed for the same time?

Yes. Magellan’s January 2026 commercial and employer code table says of 97155: “We do accept overlap with technician; all services are direct.” Note separately that 97152 is listed as not a covered code.

### Do RBTs have to be credentialed with Magellan?

No. Master’s and doctoral-level practitioners must credential before joining the network and re-credential every three years, and only credentialed providers may bill as in-network. Bachelor’s-level behavior analysts and support staff/technicians are not required to credential if they work under the supervision of the licensed, credentialed practitioner — with the supervisory relationship documented in writing.

### Do Magellan’s national criteria always apply?

No. Magellan publishes a state/client-specific list — California, Hawaiʻi, Idaho, Louisiana, Nevada, New Mexico, North Carolina, Pennsylvania, Texas and Virginia among them — where modified criteria govern. In Louisiana, for Louisiana Healthcare Connections members, Magellan follows the Louisiana Department of Health ABA Provider Manual outright.

## Primary sources

1. [2025–2026 Magellan Care Guidelines — Outpatient Applied Behavior Analysis (eff. 11/8/2025)](https://www.magellanprovider.com/media/553052/mcg_2025-2026.pdf)
2. [Magellan Healthcare — Medical Necessity Criteria](https://www.magellanprovider.com/providing-care/clinical-guidelines/medical-necessity-criteria.aspx)
3. [Magellan Provider Orientation — Autism Spectrum Disorders, commercial and employer plans (Jan. 2026)](https://www.magellanprovider.com/media/128995/aba_provider_orientation.pdf)
4. [Magellan Behavior Analyst Network Criteria (rev. 01/21)](https://www.magellanprovider.com/media/1819/autismcriteria.pdf)
5. [Magellan Healthcare — Autism Spectrum Disorders provider resources](https://www.magellanprovider.com/news-publications/state-plan-eap-specific-information/autism.aspx)
6. [Magellan Healthcare — Outpatient Applied Behavior Analysis: Louisiana Healthcare Connections (eff. 1/1/2024)](https://www.ldh.la.gov/assets/medicaid/MCPP/1.11.24/982_LHCC_20231006_Magellan_LAMedicaidABA_MNC_v3_redlined_bolded_underlined.pdf)
7. [Magellan 2026 Handbook for the National Provider Network (11/25v3)](https://www.magellanprovider.com/media/11893/provider_handbook.pdf)
8. [29 CFR 2560.503-1(f)(2) — ERISA group health plan claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
9. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/section-438.210)
10. [Magellan National Provider Handbook appendix — Coordination of Benefits (rev. 11/16)](https://www.magellanprovider.com/media/11916/f_cob.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.