---
title: Mass General Brigham Health Plan ABA coverage (MassHealth ACPP).
url: "https://carelu.com/payers/mass-general-brigham-health-plan"
markdown_url: "https://carelu.com/payers/mass-general-brigham-health-plan.md"
state: MA (Massachusetts)
payer: Mass General Brigham Health Plan (MassHealth ACPP)
kind: Medicaid managed care plan (MCO)
parent_program: MassHealth
description: "How Mass General Brigham Health Plan (formerly AllWays) handles MassHealth ABA — the only plan whose behavioral health runs through Optum, with the BH803ABA state-mandate supplement's 30-hour-per-week Early Intervention cap and codified 1:10 supervision ratio."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Mass General Brigham Health Plan ABA coverage (MassHealth ACPP).

_Payer Guide · MGB Health Plan · Last updated September 2026 · 8 primary sources_

> The Optum-run MassHealth ACPP: BH803ABA state supplement, 30 hr/wk EI cap, codified 1:10 ratio.

Mass General Brigham Health Plan (formerly AllWays) fields one ACPP with the Mass General Brigham ACO — and it is the only MassHealth plan whose ABA runs through Optum Behavioral Health. That routes members into Optum's clinical machinery: the United Behavioral Health ABA criteria plus Optum's ABA State Mandates supplement (BH 803ABA STM12026, effective January 2026), which carries explicit Massachusetts Medicaid provisions. Notably, Optum's supplement hard-codes the very 1:10 supervision ratio MassHealth later enforced statewide — and adds a cap no other MA plan publishes: 30 hours per week for Early Intervention members.

This plan administers the **MassHealth** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [MassHealth (Massachusetts Medicaid) guide](https://carelu.com/payers/masshealth-massachusetts-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — via the Optum Behavioral Health process (plan-level submission specifics not published; verify via Provider Express) [1]
- **Prior auth for treatment**: Required — Optum process; 6-month authorization periods per statewide practice [1]
- **Autism diagnosis required?**: Yes — ASD via comprehensive DSM-aligned assessment; from 1/1/2026 also sole-diagnosis Down syndrome (state baseline) [8][1]

## At a glance

- **Plan type:** MassHealth ACPP (with the Mass General Brigham ACO)
- **BH administrator:** Optum Behavioral Health — unique among MassHealth plans
- **Clinical rules:** Optum ABA criteria + BH803ABA State Mandates supplement (MA entries)
- **EI cap:** MA Medicaid EI members (eff. 10/1/2021): ABA not to exceed 30 hrs/week
- **Supervision:** BCBA-to-paraprofessional at 1:10 per the Optum supplement — codified, not just audited
- **Prior auth:** Required — assessment and treatment via the Optum process; ~6-month periods

## The Optum layer on the MassHealth benefit

Optum's ABA State Mandates supplement carries a Massachusetts Medicaid entry effective October 1, 2021: for Early Intervention members, ABA services should not exceed 30 hours per week, and BCBA-to-paraprofessional supervision must run at 1:10 — with the supervisor and technician possibly both required to be present during home visits. No cap is stated for non-EI members, where the standard no-cap MassHealth benefit applies. The supplement makes MGB the one MA plan where the 1:10 ratio is written policy rather than audit posture — and in the 2026 statewide audit, Optum had not yet issued recoupment letters as of the March 2026 reporting, though the same analysis was run. Plan your under-3 referrals against the EI cap and the EI non-duplication rule together. [2][4]

## Working the Optum channel

Because behavioral health is carved to Optum, expect the Optum toolkit — Provider Express is Optum's standard portal, though its use for this plan specifically isn't published, so confirm the submission channel with the plan before the first request. Authorization cadence follows the statewide practice of roughly 6-month periods. Clinically, requests are reviewed against Optum's ABA criteria layered on the MassHealth baseline: EPSDT medical necessity, the DSM-aligned ASD diagnostic gate, and the Down syndrome pathway from January 1, 2026. [2][3]

## Intake gates

The questions that decide whether a family can start with Mass General Brigham Health Plan (MassHealth ACPP), and what they have to bring.

- **Age limit**: EPSDT sets the bound, and nothing else does. ABA is covered for MassHealth Standard and CommonHealth members under 21, and for Family Assistance members under 19 — with no lower age bound and no dollar, visit or unit-of-service cap underneath it. For the youngest referrals the binding rule is non-duplication rather than age: ABA cannot duplicate services the child already receives through Early Intervention. From 1/1/2026 the second diagnostic pathway (sole-diagnosis Down syndrome) rides the same age structure. One plan-specific overlay is not an age rule but reads like one at intake: Optum's Massachusetts Medicaid entry (effective 10/1/2021) says ABA "should not exceed 30 hours per week" for Early Intervention members, so establish EI enrollment alongside age. [7][2]
- **Prior-auth decision time**: Optum BH decides ABA, and the federal managed-care clock caps it. MGB delegates behavioral-health "Utilization management/care management" and "Service authorization" to Optum BH for all MGB ACO members. MGB's own ACO manual (dated 2026-04-01) still prints its general UM table: non-urgent pre-service "Within 14 calendar days after receipt of the request" plus up to 14 more on request, urgent "Up to 72 hours," and urgent concurrent within 24 hours. For rating periods starting on or after 1/1/2026, however, 42 CFR 438.210(d) caps standard decisions at "7 calendar days after receiving the request for service," with up to 14 more calendar days on request or justification. Expedited decisions are due within 72 hours. WellSense and Carelon moved their MassHealth decisions to 7 days on January 1, 2026. No ABA reauthorization lead time is published in the MGB manual. [9][10][11]
  - Ask the plan: Optum BH (Provider Express) for MGB ACO: the decision clock it applies to MassHealth ABA requests and its reauthorization lead time.
- **Other insurance (who pays first)**: MGB pays last. "When a patient enrolls with Mass General Brigham ACO Mass General Brigham Health Plan is always the payer of last resort." When MGB is secondary, "all claims must be submitted with a copy of the primary carrier's EOP, remittance advice, or denial letter." Behavioral-health claims "must be submitted to Optum BH directly." Report other coverage to MGB's COB team (617-772-5729) or on a TPL Indicator Form. MassHealth's rule adds that the provider must follow the primary plan's authorization and network rules. A primary denial for missing PA or for being out of network forfeits the secondary payment (130 CMR 450.316). TRICARE pays before MassHealth: "By law, TRICARE pays after all other health insurance, except for: Medicaid." [9][12][13]
  - Ask the plan: Optum BH for MGB ACO: whether it requires its own ABA PA when MGB is secondary, and its secondary-claim filing window.
- **Diagnosis recency** _(ask the plan)_: Not published. Neither the Massachusetts Standard ABA PA Form nor the Carelon/MBHP performance specification sets a maximum age for the diagnostic evaluation — the form asks for the current ICD-10 diagnosis and, on a "Request for initial evaluation," a copy of the comprehensive assessment, but names no recency window. What the form does date is utilization, not diagnosis: the continued-services page makes the BCBA attest whether at least 75% of the previously authorized direct-service hours were used. [8][2]
  - Ask the plan: Optum Care Advocate / Provider Express for the Mass General Brigham Health Plan line of business — Optum's published ABA criteria are commercial documents, and the plan does not republish the MassHealth standard-form requirements.
- **Who may diagnose** _(ask the plan)_: The standard form names them, and the list is broader than "send them to a developmental pediatrician." For autism it requires "A comprehensive assessment completed by a licensed physician (i.e. PCP, etc.), advanced practice registered nurse, physician's assistant, or psychologist experienced in the diagnosis and treatment of ASD with developmental or child/adolescent experience which aligns with DSM criteria across ASD core deficits." For the 1/1/2026 pathway it requires instead "A diagnosis of Down Syndrome (Trisomy 21) confirmed by genetic testing." Note the two signatures are different people: the diagnostician writes the assessment, while the form itself "should" be completed by the BCBA rendering and/or supervising the services — an analyst the performance specification requires to be a LABA licensed under 262 CMR 10.00. Optum's own criteria are broader in wording — a diagnosis "issued by a state licensed physician, psychologist, or other state licensed clinician qualified to make such diagnosis according to the diagnostic criteria based on the DSM-5-TR" — but that is its commercial Supplemental Clinical Criteria, and Optum's Massachusetts state-mandate entries are scoped to the EI hour cap and the 1/1/2026 Down syndrome expansion, neither of which is a diagnostician list for this MassHealth product. [8][2]
  - Ask the plan: Optum Care Advocate / Provider Express for the Mass General Brigham Health Plan line of business — Optum's published ABA criteria are commercial documents, and the plan does not republish the MassHealth standard-form requirements.
- **Diagnostic tools required** _(ask the plan)_: No instrument is mandated. The standard form requires a comprehensive assessment "which aligns with DSM criteria across ASD core deficits" without naming ADOS-2, ADI-R, CARS-2 or any other tool, and the performance specification names no diagnostic battery either; the Down syndrome pathway replaces the instrument question entirely with genetic testing. Massachusetts puts its measurement requirement downstream of intake instead — in progress documentation and medical-necessity review, not in the diagnostic gate. Optum's commercial criteria do name formal diagnostic tools (ADI-R, ADOS/ADOS-2, DISCO), but that list belongs to its commercial ABA criteria and should not be assumed onto this MassHealth product. [8][2]
  - Ask the plan: Optum Care Advocate / Provider Express for the Mass General Brigham Health Plan line of business — Optum's published ABA criteria are commercial documents, and the plan does not republish the MassHealth standard-form requirements.
- **Referral required?** _(ask the plan)_: No referral and no physician order is a condition of authorization. The Massachusetts Standard ABA PA Form has no referral field and is completed by the rendering or supervising BCBA/LABA, and the performance specification's referral language is about timeliness rather than permission: "Fourteen calendar days from referral is the Medicaid standard of timely provision for services established in accordance with 42 CFR 441.56(e)," with a waitlist duty (and an obligation to hand caregivers other regional providers' contact information) where the provider cannot start inside it. What the state does require is PCP evidence in the chart rather than at the door: the complete medical record must hold "Referral and assessment documentation" and "Documentation confirming physical examinations by a PCP," and the continued-services pages ask for a dated primary-care care-coordination entry. [5][8]
  - Ask the plan: Optum Care Advocate / Provider Express for the Mass General Brigham Health Plan line of business — Optum's published ABA criteria are commercial documents, and the plan does not republish the MassHealth standard-form requirements.
- **Telehealth** _(ask the plan)_: Permitted at the family's request, with no code list and no POS rule. The ABA provider "may deliver services and consultation via a Health Insurance Portability and Accessibility Act (HIPAA)-compliant telehealth platform at the parent/caregiver's request and if the service can be effectively delivered via telehealth as part of the intervention when appropriate," with the rationale documented and the documentation reflecting "clinical considerations for appropriateness across any service components being delivered via telehealth." Two guardrails ride along: telehealth "must not replace in-person availability," and the member or family "may rescind consent for telehealth at any time without risk of interruption of services." No per-code restriction, modifier or place-of-service code is published. Whether Optum applies the MBHP conditions on this line is not published. [5]
  - Ask the plan: Optum Care Advocate / Provider Express for the Mass General Brigham Health Plan line of business — Optum's published ABA criteria are commercial documents, and the plan does not republish the MassHealth standard-form requirements.

## Delivery and billing rules

Coverage decides whether Mass General Brigham Health Plan (MassHealth ACPP) 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** _(ask the plan)_: Mass General Brigham Health Plan routes ABA to Optum, but Optum’s published ABA reimbursement policy is a commercial document and its ABA State Mandates entry for Massachusetts is scoped to Medicaid Early Intervention members — for whom it requires “supervision by a Board-Certified Behavior Analyst (BCBA) to a paraprofessional … at the 1:10 ratio (one hour of supervision to ten hours of direct service),” with services not to exceed 30 hours per week. Neither document states the supervision standard Optum applies to the MassHealth ACPP line, where the MassHealth-wide 10–25% band is the state floor. [2][5]
  - Ask the plan: Optum Care Advocate / Provider Express for the Mass General Brigham Health Plan line of business.
- **Daily limits / MUEs** _(ask the plan)_: Massachusetts is a no-cap state that nonetheless has one published per-day number. There are no annual, lifetime or unit-of-service ceilings on the EPSDT benefit, and 101 CMR 358.03 is a rate regulation, not a limit regulation — it fixes per-15-minute rates and states they are “full compensation” including “necessary administration and professional supervision associated with patient care.” The only per-day cap in the performance specification is for group instruction, which “may occur up to 4.5 hours a day as clinically indicated, in groups of 2-8 Members.” No per-code MUE regime is published, so what bites in practice is medical-necessity review and the supervision-ratio audit, not a unit edit. Optum’s own per-day table (97153 32 units, 97155 24 units and so on) belongs to its commercial ABA reimbursement policy and should not be assumed onto this MassHealth product. [6]
  - Ask the plan: Optum provider services for the MGB Health Plan line.
- **Place of service** _(ask the plan)_: Home and community, with school carved out. ABA “is delivered by a contracted and credentialed provider in a variety of settings within a Member’s home and community,” and “services provided in a school setting are distinct and separate from those covered by the health plan and are typically covered by the educational system’s special education resources as part of the Individualized Education Program (IEP) pursuant to Public Law 94-142.” Providers “must not direct, limit, or discourage access to other medically necessary or school-based services.” Transition planning contemplates moving a member “from a center based setting to home/community settings,” so centers are in scope. Group homes are not addressed. No MGB-specific deviation is published. [5]
  - Ask the plan: Optum Care Advocate for the MGB Health Plan line.

## What intake should collect for Mass General Brigham Health Plan (MassHealth ACPP)

- **Early Intervention status:** EI members carry the 30 hr/week cap and possible dual-presence home-visit rule — establish EI enrollment at intake.
- **Diagnostic evaluation:** ASD assessment (or the 1/1/2026 Down syndrome pathway) — reviewed against Optum's criteria.
- **Supervision staffing plan:** 1:10 BCBA-to-paraprofessional is written into the Optum supplement — document it in the request.
- **Submission channel:** Confirm the Optum route (Provider Express vs. plan-specific) before the first authorization.

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

## Verification of benefits (VOB) data

How Mass General Brigham Health Plan (MassHealth ACPP) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 01589
- **Payer ID (Change Healthcare / Optum):** 87726
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** Optum Behavioral Health — the only MassHealth plan whose ABA runs through Optum
- **BH administrator payer ID:** 87726 — 87726 is the SAME number as UnitedHealthcare's national medical payer ID (confirmed via UHC's own 5/13/2026 payer list). How a clearinghouse distinguishes MGB's medical claims from its Optum BH claims when the ID is shared (taxonomy code? submitter ID?) was not confirmed this pass — verify directly with Optum/UHC EDI support before automating routing.
- **ABA rides on:** behavioral health benefit
- **Two-hop verification required:** Yes

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required — via Optum's two-step authorization (assessment, then treatment); plan-level submission specifics not published, verify via Provider Express | 32 units/day (≤8 hrs) per day | — | — | HN, HO, HP |
| 97152 | Yes | Required — via Optum's two-step authorization (assessment, then treatment); plan-level submission specifics not published, verify via Provider Express | 16 units/day (≤4 hrs) per day | — | — | HN, HM, HO, HP |
| 97153 | Yes | Required — via Optum's two-step authorization (assessment, then treatment); plan-level submission specifics not published, verify via Provider Express | 32 units/day (≤8 hrs) per day | — | — | HN, HM, HO, HP |
| 97154 | Yes | Required — via Optum's two-step authorization (assessment, then treatment); plan-level submission specifics not published, verify via Provider Express | 18 units/day (≤4.5 hrs) per day | — | — | HN, HM, HO, HP |
| 97155 | Yes | Required — via Optum's two-step authorization (assessment, then treatment); plan-level submission specifics not published, verify via Provider Express | 24 units/day (≤6 hrs) per day | — | — | HN, HO, HP |
| 97156 | Yes | Required — via Optum's two-step authorization (assessment, then treatment); plan-level submission specifics not published, verify via Provider Express | 16 units/day (≤4 hrs) per day | — | — | HN, HO, HP |
| 97157 | Yes | Required — via Optum's two-step authorization (assessment, then treatment); plan-level submission specifics not published, verify via Provider Express | 16 units/day (≤4 hrs) per day | — | — | HN, HO, HP |
| 97158 | Yes | Required — via Optum's two-step authorization (assessment, then treatment); plan-level submission specifics not published, verify via Provider Express | 16 units/day (≤4 hrs) per day | — | — | HN, HO, HP |
| 0362T | Yes | Required — via Optum's two-step authorization (assessment, then treatment); plan-level submission specifics not published, verify via Provider Express | 16 units/day (≤4 hrs) per day | — | — | — |
| 0373T | Yes | Required — via Optum's two-step authorization (assessment, then treatment); plan-level submission specifics not published, verify via Provider Express | 32 units/day (≤8 hrs) per day | — | — | — |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** Unit caps/modifiers sourced from Optum's NATIONAL ABA Reimbursement Policy (2022RP501A), applied here as 'inferred' absent a confirmed MGB-specific override. For Early Intervention (under-3) members specifically, Optum's Massachusetts state-mandate entry (eff. 10/1/2021) caps ABA at 30 hrs/week and codifies 1:10 BCBA-to-paraprofessional supervision — a distinct, MA-specific rule layered on top of the national reimbursement policy's per-code unit caps.

### Contacts

- **Provider services phone:** 1-855-444-4647
- **Phone menu path:** Behavioral health/ABA claims route to Optum specifically: 844-451-3518 (HMO/PPO members) or 866-262-8067 (Medicare members), per MGB's own claims page - no Medicaid/ACO-specific BH line was distinguished on that page, so confirm which applies for this MassHealth member before calling.
- **Portal:** [MGB Health Plan Provider Portal](https://provider.massgeneralbrighamhealthplan.org/)

Questions to ask on a verification call:

- Since MGB's medical claims and Optum BH claims share payer ID 87726, how does the clearinghouse route BH/ABA claims specifically - is a distinct submitter ID or taxonomy code required?
- Do MGB's ABA unit caps and modifiers match Optum's national reimbursement policy, or does MGB have a plan-specific override?
- For Early Intervention (under-3) MassHealth members, does the 30 hr/week ABA cap and 1:10 supervision ratio apply through MGB the same way it does through MBHP?

### VOB data sources

- https://pverify.com/payer-list/ (accessed 2026-07-23)
- https://massgeneralbrighamhealthplan.org/providers/claims (accessed 2026-07-23)
- https://www.uhcprovider.com/content/dam/provider/docs/public/resources/edi/Payer-List-UHC-Affiliates-Strategic-Alliances.pdf (accessed 2026-07-23)
- https://www.mass.gov/doc/masshealth-standard-companion-guide-health-care-eligibilitybenefit-inquiry-and-information-response-270271-0/download (accessed 2026-07-23; source document older than 18 months)
- https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/abaSCC.pdf (accessed 2026-07-23)
- https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/reimbPolicies/abaReimburs2020s.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)

## Common questions

### Does Mass General Brigham Health Plan cover ABA?

Yes — the MassHealth EPSDT benefit, administered through Optum Behavioral Health under Optum's ABA criteria plus its Massachusetts state-mandate supplement. PA is required for assessment and treatment.

### Does MGB Health Plan cap ABA hours?

Only for Early Intervention members: Optum's supplement limits EI-member ABA to 30 hours/week (effective 10/1/2021) with 1:10 BCBA-to-paraprofessional supervision. No cap is stated for non-EI members.

### How is MGB different from other MassHealth plans for ABA?

It's the only plan whose ABA runs through Optum — with the 1:10 supervision ratio codified in written policy and the EI hour cap no other MA plan publishes. Everything else follows the state baseline.

## Primary sources

1. [Optum ABA Supplemental Clinical Criteria (BH803ABASCC)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/abaSCC.pdf)
2. [Optum ABA State Mandates — BH 803ABA STM12026 (eff. Jan 2026)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/scc/ABA_SCC_SM.pdf)
3. [MassHealth Managed Care Options — plan/BH-vendor map (April 2023)](https://abh.memberclicks.net/assets/docs/KeepingCoverage/2023%20MassHealth%20Accountable%20and%20Managed%20Care%20Options%20031723.pdf)
4. [MassHealth ABA supervision audit & recoupment (Acuity News)](https://acuity.news/regulation/masshealth-aba-supervision-audit-recoupment-litigation-2026/)
5. [Carelon/MBHP Performance Specifications — Applied Behavior Analysis (upd. Feb 15, 2026)](https://providers.masspartnership.com/pdf/PerfSpec-ABA.pdf)
6. [101 CMR 358.03 Rate Provisions (Cornell LII mirror)](https://www.law.cornell.edu/regulations/massachusetts/101-CMR-358-03)
7. [AIRC — MassHealth ABA Coverage factsheet](https://massairc.org/factsheets/masshealth-aba-coverage/)
8. [MA Standard ABA PA Form (MassHealth version, upd. 3/12/2026)](https://www.wellsense.org/hubfs/Forms/Provider_Forms/Applied_Behavioral_Analysis_Prior_Authorization_Form_MassHealth.pdf)
9. [Mass General Brigham Health Plan — ACO Provider Manual (2026-04-01)](https://resources.massgeneralbrighamhealthplan.org/providers/MGB%20ACO%20Provider%20Manual.pdf)
10. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/section-438.210)
11. [WellSense — Reduction of prior authorization decision timeframes (provider communication, Oct 31 2025)](https://www.wellsense.org/hubfs/Provider/News/WellSense_Mass_Provider_Communications_PA_Updates_10_31_25.pdf)
12. [130 CMR 450.316 — MassHealth third-party liability: requirements (Cornell LII mirror)](https://www.law.cornell.edu/regulations/massachusetts/130-CMR-450-316)
13. [TRICARE — Using Other Health Insurance](https://tricare.mil/Plans/OHI)

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.