---
title: Molina Healthcare of Ohio ABA coverage (Next Gen MCO).
url: "https://carelu.com/payers/molina-healthcare-ohio"
markdown_url: "https://carelu.com/payers/molina-healthcare-ohio.md"
state: OH (Ohio)
payer: Molina Healthcare of Ohio
kind: Medicaid managed care plan (MCO)
parent_program: Ohio Medicaid
description: "How Molina Healthcare of Ohio administers Medicaid ABA — state-policy-aligned criteria, the January 2026 move to Availity-only prior authorization, and the contacts and checks worth confirming in the portal."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Molina Healthcare of Ohio ABA coverage (Next Gen MCO).

_Payer Guide · Molina (OH) · Last updated September 2026 · 2 primary sources_

> Tracks state ABA policy; Availity-only PA since 1/2026 — key documents best pulled via portal.

Molina Healthcare of Ohio administers the Medicaid ABA benefit in line with the state framework — no distinct Molina ABA clinical policy has surfaced publicly — with the plan-specific story being workflow: effective January 1, 2026, Molina discontinued fax PA submissions in Ohio, making Availity Essentials the sole authorization channel. A sourcing note: Molina's site blocks automated access, so verify plan-level specifics in Availity or by phone rather than relying on cached summaries.

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

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment:** Not published / unverified. Verify via: Molina Healthcare of Ohio's Medicaid prior-authorization code list — portal-gated, and molinahealthcare.com 403s to automated retrieval. Pull it from Availity Essentials (Molina's sole PA channel in Ohio since 1/1/2026) or via carelu.com/sources; the state floor behind it is OAC 5160-34-02, itself unreachable.
- **Prior auth for treatment:** Not published / unverified. Verify via: Molina Healthcare of Ohio's Medicaid prior-authorization code list and behavioral-health PA guidance, via Availity Essentials or carelu.com/sources — the plan's public site blocks automated retrieval.

## At a glance

- **Plan type:** Ohio Next Generation MCO
- **Clinical rules:** State OAC 5160-34 framework — no distinct Molina ABA policy found
- **Prior auth:** Required for ABA per the plan's PA list
- **Submission:** Availity Essentials ONLY since 1/1/2026 (fax discontinued)
- **BH auth line:** (855) 322-4081 (confirm current number in the portal)
- **Rates:** Contracted; ODM fee schedule is the benchmark

## How Molina runs ABA authorization

Clinically, expect the OAC 5160-34 baseline: PA on covered ABA codes, DSM-5-TR diagnosis via comprehensive evaluation, and 6-month medical-necessity reviews. Operationally, the January 2026 change matters most — all prior authorization requests go through Availity Essentials, with fax submissions no longer accepted in Ohio. Because Molina's public site is inaccessible to automated tools (and some cached numbers may be stale), confirm the current PA code list and behavioral-health contacts inside Availity or via the plan's provider line before building SOPs around them. The OhioRISE rule applies here as everywhere: ABA for an OhioRISE-enrolled Molina member still bills to Molina. [2][1]

## Intake gates

The questions that decide whether a family can start with Molina Healthcare of Ohio, and what they have to bring.

- **Who may diagnose**: Follows the Ohio Medicaid framework: the ASD diagnosis comes from a documented comprehensive diagnostic evaluation by a licensed physician, psychologist, or other clinician qualified to diagnose autism, demonstrating DSM-5-TR criteria. [2][1]
- **Referral required?**: No referral or service order requirement is published, and Molina has no distinct Ohio ABA clinical policy — expect the OAC 5160-34 baseline. The plan-specific fact that matters is the channel: effective January 1, 2026 Molina discontinued fax prior-authorization submissions in Ohio, making Availity Essentials the sole authorization channel. Because Molina’s public site blocks automated access, confirm the current PA code list inside Availity rather than relying on cached summaries. [2][1][1]
- **Prior-auth decision time**: Molina’s 2026 Ohio Medicaid manual: “Standard requests must be made as soon as medically indicated, within a maximum of 7 calendar days after receipt of the request.” Expedited requests are decided “within 48 hours (including weekends and holidays) following receipt of the validated request.” No ABA reauthorization lead time is published. Ohio’s MCO rule sets the clock. For a standard request the MCO “must provide notice to the provider and member as expeditiously as the member’s health condition requires but no later than seven calendar days following receipt of the request for service,” extendable by up to fourteen calendar days (an MCO-requested extension needs ODM’s prior approval). An expedited decision is due “no later than forty-eight hours after receipt of the request for service” (OAC 5160-26-03.1, effective 1/1/2026). The 48 hours is stricter than the federal 72-hour managed-care cap. [3][4]
- **Other insurance (who pays first)**: Molina’s manual: “Medicaid is the payer of last resort. Commercial, private and governmental carriers must be billed prior to billing Molina … with the exception of EPSDT/Healthchek Services. EPSDT services are processed as primary and then Molina follows the Third Party Liability process.” Primary carrier payment information is required on the claim. Two of Molina’s listed “extenuating circumstances” let a provider file a clinical claim dispute without prior authorization: a retroactive COB change that makes Molina primary, and a service that “is not an included benefit in the primary insurance coverage.” The manual does not say whether ABA for a child counts as an EPSDT/Healthchek service for the pay-first exception. Ohio’s MCO rule: “The MCE is the payer of last resort when a member has third party resources available.” Providers must “take reasonable measures to obtain all third party payments and file claims with all TPPs prior to billing the MCE.” That means a remittance from the other payer showing a valid non-payment reason (service not covered, applied to the deductible or copay, benefit maximum reached), a partial payment with its remittance, or no response within ninety days of submitting to the other payer. The MCO pays at most its allowed amount minus the other payments, and must allow at least ninety days from the other payer’s remittance to file. Exception: “The MCE, except SPBM, pays first for preventive pediatric services before seeking reimbursement from any liable third party.” Children in the custody of a county children’s services agency are exempt from TPL cooperation (OAC 5160-26-09.1). [3][5]
  - Ask the plan: Molina Provider Services (855-322-4079): whether ABA claims for a child with commercial coverage are paid first under the EPSDT/Healthchek exception, and whether a Molina authorization is needed when the commercial plan pays.
- **Telehealth** _(ask the plan)_: No plan-specific ABA telehealth rule found; ODM’s Telehealth Services guidance for managed care entities and the Telehealth Billing Guidelines set the underlying rules. [2][1]
  - Ask the plan: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.

## Delivery and billing rules

Coverage decides whether Molina Healthcare of Ohio 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.

- **Bill as provider**: Follows the Ohio Medicaid framework: independent practitioners are Certified Ohio Behavior Analysts (ORC Chapter 4783) or BACB BCBAs and BCBA-Ds enrolled with ODM as Provider Type 19, Specialty 190, with BCaBAs and RBTs delivering under supervision. The routing rule holds everywhere in Ohio: OhioRISE does not pay for ABA — ODM’s Mixed Services Protocol assigns ABA claims to the member’s MCO or fee-for-service even for OhioRISE-enrolled youth. [2][1]
- **Supervision** _(ask the plan)_: Follows the Ohio framework, which sets no fixed ratio: OAC 4783-6-02 requires the COBA to write a supervision plan into each client’s treatment plan, consult before plan initiation and modification, and observe directly on a periodic basis, with frequency left to documented clinical judgment and assessment, plan development and efficacy review non-delegable. No plan-specific numeric ratio was found for this MCO — note that other Ohio plans do publish one (Optum 1–2 hours per 10 direct hours weekly; Buckeye 97155 at 10–20% of direct hours). [2][1]
  - Ask the plan: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02. [2][1]
- **Place of service** _(ask the plan)_: No plan-specific place-of-service rule found. The confirmed Ohio boundary is the school one: the MCO is not responsible for payment of services provided through the Medicaid School Program under OAC Chapter 5160-35, 5160-35-04 and 5160-26-03. [2][1]
  - Ask the plan: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.

## What intake should collect for Molina Healthcare of Ohio

- **Availity access:** The only PA channel since January 2026 — make sure the team's registration and payer connection are live.
- **ASD diagnosis (DSM-5-TR):** Comprehensive evaluation per the state baseline.
- **Current PA code list:** Pull it from Availity each quarter — the public site can't be relied on for updates.

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

## Verification of benefits (VOB) data

How Molina Healthcare of Ohio ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00151 — pVerify lists 00151 (Molina Healthcare of Ohio) and a separate 00849 (Molina Ohio Medicaid MCE) — confirm which routes OH Medicaid ABA eligibility.
- **Payer ID (Change Healthcare / Optum):** 20149 — Molina OH claims payer ID 20149 is from the claim.md clearinghouse directory (Molina uses Change Healthcare/Optum as its clearinghouse) — a secondary source, shipped inferred; ODM FI eligibility routing uses trading partner 0007316.
- **Supports 270/271 eligibility:** Yes
- **Real-time eligibility:** Yes
- **Behavioral health administrator:** none
- **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 — administered on the OAC 5160-34 state framework; no distinct Molina ABA clinical policy published | Required per Molina's PA list — submitted via Availity Essentials ONLY since 1/1/2026 (fax discontinued in Ohio). BH auth line (855) 322-4081 (confirm current number in the portal). | 32 units/day (CMS MUE ceiling — Molina publishes no distinct per-code table; state/CMS default) per day | — | — | — |
| 97152 | Yes — administered on the OAC 5160-34 state framework; no distinct Molina ABA clinical policy published | Required per Molina's PA list — submitted via Availity Essentials ONLY since 1/1/2026 (fax discontinued in Ohio). BH auth line (855) 322-4081 (confirm current number in the portal). | 16 units/day (CMS MUE ceiling — Molina publishes no distinct per-code table; state/CMS default) per day | — | — | — |
| 97153 | Yes — administered on the OAC 5160-34 state framework; no distinct Molina ABA clinical policy published | Required per Molina's PA list — submitted via Availity Essentials ONLY since 1/1/2026 (fax discontinued in Ohio). BH auth line (855) 322-4081 (confirm current number in the portal). | 32 units/day (CMS MUE ceiling — Molina publishes no distinct per-code table; state/CMS default) per day | — | — | — |
| 97154 | Yes — administered on the OAC 5160-34 state framework; no distinct Molina ABA clinical policy published | Required per Molina's PA list — submitted via Availity Essentials ONLY since 1/1/2026 (fax discontinued in Ohio). BH auth line (855) 322-4081 (confirm current number in the portal). | 18 units/day (CMS MUE ceiling — Molina publishes no distinct per-code table; state/CMS default) per day | — | — | — |
| 97155 | Yes — administered on the OAC 5160-34 state framework; no distinct Molina ABA clinical policy published | Required per Molina's PA list — submitted via Availity Essentials ONLY since 1/1/2026 (fax discontinued in Ohio). BH auth line (855) 322-4081 (confirm current number in the portal). | 24 units/day (CMS MUE ceiling — Molina publishes no distinct per-code table; state/CMS default) per day | — | — | — |
| 97156 | Yes — administered on the OAC 5160-34 state framework; no distinct Molina ABA clinical policy published | Required per Molina's PA list — submitted via Availity Essentials ONLY since 1/1/2026 (fax discontinued in Ohio). BH auth line (855) 322-4081 (confirm current number in the portal). | 16 units/day (CMS MUE ceiling — Molina publishes no distinct per-code table; state/CMS default) per day | — | — | — |
| 97157 | Yes — administered on the OAC 5160-34 state framework; no distinct Molina ABA clinical policy published | Required per Molina's PA list — submitted via Availity Essentials ONLY since 1/1/2026 (fax discontinued in Ohio). BH auth line (855) 322-4081 (confirm current number in the portal). | 16 units/day (CMS MUE ceiling — Molina publishes no distinct per-code table; state/CMS default) per day | — | — | — |
| 97158 | Yes — administered on the OAC 5160-34 state framework; no distinct Molina ABA clinical policy published | Required per Molina's PA list — submitted via Availity Essentials ONLY since 1/1/2026 (fax discontinued in Ohio). BH auth line (855) 322-4081 (confirm current number in the portal). | 16 units/day (CMS MUE ceiling — Molina publishes no distinct per-code table; state/CMS default) per day | — | — | — |
| 0362T | Yes — administered on the OAC 5160-34 state framework; no distinct Molina ABA clinical policy published | Required per Molina's PA list — submitted via Availity Essentials ONLY since 1/1/2026 (fax discontinued in Ohio). BH auth line (855) 322-4081 (confirm current number in the portal). | 16 units/day (CMS MUE ceiling — Molina publishes no distinct per-code table; state/CMS default) per day | — | — | — |
| 0373T | Yes — administered on the OAC 5160-34 state framework; no distinct Molina ABA clinical policy published | Required per Molina's PA list — submitted via Availity Essentials ONLY since 1/1/2026 (fax discontinued in Ohio). BH auth line (855) 322-4081 (confirm current number in the portal). | 32 units/day (CMS MUE ceiling — Molina publishes no distinct per-code table; state/CMS default) per day | — | — | — |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** Molina Ohio tracks the state ABA framework (PA on covered codes, DSM-5-TR diagnosis, 6-month reviews). Pull the current PA code list from Availity each quarter — the public site can't be relied on for updates. OhioRISE rule applies: ABA for an OhioRISE-enrolled Molina member still bills to Molina.

### Contacts

- **Portal:** [Availity Essentials (PA submission mandatory since 1/1/2026)](https://www.availity.com)

Questions to ask on a verification call:

- Can you confirm the current behavioral-health prior-authorization phone line — the number on your public PA page carries its own "confirm in the portal" caveat?
- What POS codes are approved for ABA billing (home, school, clinic, telehealth)?
- Is telehealth allowed for any ABA code, and if so is a GT/95 modifier required?
- Do you require a licensure-tier billing modifier (RBT vs. BCBA/BCBA-D)?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://dam.assets.ohio.gov/image/upload/medicaid.ohio.gov/Providers/MITS/HIPAA%205010%20Implementation/CompanionGuide/OMES/FFS/Ohio270-271.pdf (accessed 2026-07-23)
- https://www.claim.md/payer/20149 (accessed 2026-07-23)
- https://www.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23)
- https://www.molinahealthcare.com/members/oh/en-US/mem/medicaid/overvw/care/prior-authorizations.aspx (accessed 2026-07-23)
- https://codes.ohio.gov/ohio-administrative-code/rule-5160-34-02 (accessed 2026-07-23)

## Common questions

### Does Molina Healthcare of Ohio cover ABA therapy?

Yes — under the Ohio Medicaid framework (OAC 5160-34), with prior authorization required on ABA services. No distinct Molina clinical policy layers on top.

### How do I submit an ABA authorization to Molina Ohio?

Through Availity Essentials — Molina discontinued fax PA submissions in Ohio effective January 1, 2026.

## Primary sources

1. [Molina OH — prior authorization page (verify via portal)](https://www.molinahealthcare.com/members/oh/en-US/mem/medicaid/overvw/care/prior-authorizations.aspx)
2. [Ohio Administrative Code — rule 5160-34-02](https://codes.ohio.gov/ohio-administrative-code/rule-5160-34-02)
3. [Molina Healthcare of Ohio — 2026 Medicaid Provider Manual (March 2026 addendum)](https://www.molinahealthcare.com/-/media/Molina/PublicWebsite/PDF/Providers/oh/medicaid/manual/MHO-Medicaid-2026-Manual-508.pdf)
4. [OAC 5160-26-03.1 — MCO utilization management and authorization timeframes (eff. 1/1/2026)](https://codes.ohio.gov/ohio-administrative-code/rule-5160-26-03.1)
5. [OAC 5160-26-09.1 — MCO third party recovery and coordination of benefits](https://codes.ohio.gov/ohio-administrative-code/rule-5160-26-09.1)

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.