MHS Indiana ABA coverage (Hoosier Healthwise / HIP).

Follows the Indiana Medicaid rule: ABA is covered for members 20 years of age and younger. Effective April 1, 2026 coverage runs exclusively through EPSDT, and for dates of service on or after October 1, 2026 IHCP will not authorize or reimburse ABA for members 21 and older — a state policy that binds every MCE.^[4][3][5]

Follows the Indiana Medicaid rule: a CDE more than one year old requires an updated statement of need, which must include a referral from an appropriate referring practitioner and an up-to-date behavior assessment completed by the ABA provider. Members continuing current services need no new CDE but do need an updated behavior assessment and treatment plan. A behavior assessment completed within the previous six months should be obtained from the original provider rather than repeated. IHCP states these documentation requirements apply to managed care as well as fee-for-service.^[5][4]

Follows the Indiana Medicaid rule: the CDE must be performed by a doctoral-level licensed clinical psychologist endorsed as an HSPP, a licensed physician, a licensed APRN, or a licensed physician assistant, each with specialized training in the current DSM autism criteria. MHS adds a documentation requirement rather than a credential one — its ABA Outpatient Treatment Request form requires the diagnosing provider to be named alongside the instrument, date and score.^[5][1]

MHS is the strictest front door in Indiana on this field, because its form will not process without it. The formal ASD diagnosis must name the standardized tool used — the OTR lists ADI-R, ADOS, CARS-2, M-CHAT, ASSQ or GARS — with the administration date, the score and the diagnosing provider. Separately, the treatment episode must commit to at least one outcome instrument used throughout (VB-MAPP, ABLLS, AFLS, PEAK or Vineland). Underneath both sits the state's own behavior-assessment requirement: the Vineland Comprehensive Parent Interview Form with the Maladaptive Behavior domain, the BASC Parenting Relationship Questionnaire (BASC-4 only after October 1, 2026) and an age-appropriate direct skills assessment, with the full scoring report and graphs. Incomplete or illegible OTRs are returned, which restarts the clock.^[1][4][6]

Follows the Indiana Medicaid rule: a physician must make a treatment referral recommending ABA therapy, and the CDE’s own required components include a physician’s referral for autism-specific services. Prior authorization is required on top of the referral for every ABA service, through this plan rather than through Acentra Health.^[4][5]

Follows the Indiana Medicaid rule: effective April 1, 2026, codes 97151, 97152, 97153, 97154 and 0373T can no longer be billed with telehealth modifier 95 and require in-person delivery. The plan publishes no ABA telehealth policy of its own.^[3]

MHS publishes the Indiana statutory clock as its own: “Urgent (expedited) PA requests will be reviewed within 24 hours of receipt of a complete request,” and “Non-urgent PA requests will be reviewed, and a determination will be issued within 48 hours of receipt of a complete request,” with “These timeframes do not include weekends or federal/state-approved holidays.” Note the clock starts on a complete request — an OTR missing a named standardized tool or the fulfillment rate is not complete. That is IC 27-1-37.5-23 (eff. 7/1/2025), which applies to Medicaid risk-based managed care and deems a service authorized if the deadline is missed; the federal floor (42 CFR 438.210(d): 7 calendar days, 72 hours expedited) is looser. Submission timing: contracted providers must request routine PAs “at least 48 hours prior to the date of service” (manual) — MHS publishes no separate ABA reauthorization lead time, only that concurrent OTRs report the prescription fulfillment rate.^{[9][10][11][12][13]}

MHS pays last: “Federal and state law requires IHCP be the payer of last resort,” and MHS says its own TPL data “is more current than IHCP data and should be used when billing MHS” (check the MHS portal, not only the state EVS). Bill the other insurance first; claims with primary insurance “must be received within 365 days of the date of service with primary EOB information” (or within 60 days of a primary EOB received after that), and COB claims sent electronically or through the portal need no paper EOP. If the other carrier does not answer within 90 days of billing, the claim can go to MHS showing the billing attempt, subject to repayment once the primary pays. Get this plan's ABA PA even when it is secondary: the IHCP Prior Authorization module says that when the member has primary coverage, the provider “must follow the primary insurer's requirements for obtaining PA and must also obtain PA from the appropriate IHCP PA contractor (based on the program assignment of the member) to receive payment from the IHCP for the balance of charges not paid by the primary insurance.” The MHS manual publishes nothing different on PA-when-secondary. TRICARE is not a problem here: 32 CFR 199.8 excludes Medicaid from the “double coverage plans” TRICARE pays after, so for a child with both, TRICARE pays before Medicaid.^[10][14][15]

Follows the Indiana Medicaid rule: ABA performed by a BCaBA or credentialed RBT must be under the direct supervision of a BCBA, BCBA-D or HSPP, and since April 1, 2026 at least 1 hour of BCBA (or IHCP-approved qualifying clinician) supervision is required per 8 hours of technician-delivered therapy. Behavior assessments may only be performed by a psychologist, BCBA-D or master's-level BCBA. IHCP states that its ABA documentation requirements apply to both fee-for-service and managed care, and this plan publishes no supervision standard of its own.^[4][3][5]

Follows the Indiana Medicaid limits: up to 40 hours per week may be requested with anything beyond that needing an additional PA; each prior authorization is capped at six months; and since April 1, 2026 comprehensive ABA (16+ hours/week, modifier UA) draws from a 4,000-hour (16,000-unit) lifetime allocation per member, with 97155 and 97156 excluded and targeted ABA (≤15 hours/week) exempt. No per-day MUE ceiling is published at either level.^[4][3]

Follows the Indiana Medicaid rule: the treatment plan must be built around the member's school attendance (including homeschooling) and other daily activities, while services focusing solely on recreational or educational outcomes are not covered, and neither are services duplicative of an IEP that address the same goals using the same techniques as the treatment plan.^[4]

Follows the Indiana Medicaid rule: ABA rendered by a BCaBA or RBT must be billed under the NPI of an IHCP-enrolled ABA therapist or school corporation, on a professional claim. Since July 1, 2025 the rendering practitioner must be enrolled under ABA specialty 615, 624 or 625, and since April 1, 2025 the rendering NPI must align with the credential-level modifier (U1 RBT / U2 BCaBA / U3 BCBA-HSPP). Plan-level claim formatting may still differ — MCEs publish their own billing requirements.^[4][3]

Not published by Indiana Medicaid or by this plan. IHCP is explicit that within managed care “individual managed care entities (MCEs) establish and publish their own billing and reimbursement requirements,” so unlike the clinical criteria, code-pair rules are not inherited from the state by default.^[5]

Ask the plan: The MCE directly — ask whether 97155 pays alongside 97153 for the same clock time, and request the plan's billing and reimbursement requirements in writing.

Neither Indiana Medicaid nor this plan publishes a session-note signature rule. The state's published signature requirements attach to the plan documents — the behavior assessment and the treatment plan must each be signed by the lead analyst and the parent or guardian — and BT202562, the bulletin titled for ABA documentation requirements, does not reach the individual session note. IHCP states its documentation requirements apply to managed care as well as fee-for-service, but also that MCEs establish and publish their own billing and reimbursement requirements, so the gap is not automatically filled at the state level.^[4][5]

Ask the plan: The MCE directly — ask for its ABA documentation and session-note standard in writing. BT202562 also promises a future bulletin clarifying documentation requirements under the updated ABA State Plan Amendment; check for it before relying on this.