MVP Health Plan ABA coverage (NY Medicaid Managed Care).

MVP states the age band explicitly rather than inheriting it silently: its Behavioral Health Services and Authorization Requirements grid lists Applied Behavior Analysis for NY Medicaid (including CHP) as “Auth Required,” effective with the benefit’s own 1/1/2023 start date, “for children ages 0–20.” That matches the state rule — under 21, no minimum age.^[2][7]

Follows the New York Medicaid rule: MVP’s 2026 ABA payment policy restates the state referral rule verbatim, including the two-year validity and the requirement to state the date of initial diagnosis. No maximum age is set on the diagnostic evaluation itself, and MVP publishes no separate recency rule.^[1][7]

Follows the New York Medicaid rule, restated verbatim in MVP’s ABA payment policy: the member must be referred by “an NYS-licensed and NYS Medicaid-enrolled physician (including psychiatrist and developmental/behavioral pediatrician), psychologist, psychiatric nurse practitioner, pediatric nurse practitioner, or physician assistant.” LBAs may not diagnose or self-refer.^[1][7]

Follows the New York Medicaid rule: no instrument is mandated. What the state requires with the referral is the “DSM-5 Diagnostic Checklist for ASD diagnoses” plus the severity level when the referral comes from an ASD-diagnosing provider; the treatment plan need only record the assessment methodology used and, “as appropriate, identify standardized assessment used (e.g., adaptive behavior scales, symptom inventories, aggression ratings) and results.” MVP’s payment policy restates the state’s referral payload — age, diagnosis, date of initial diagnosis, comorbidities, severity, the DSM-5 diagnostic checklist and a statement of medical necessity — and names no instrument of its own.^[1][7]

Follows the New York Medicaid rule, restated verbatim by MVP with the two-year validity and the full seven-element payload, but bolted onto a hard prior-authorization gate on both ends: the payment policy requires prior authorization “for ABA Assessments and Services” alike, and the BH authorization grid marks ABA “Auth Required” for Medicaid and CHP from 1/1/2023. Submit by phone (1-800-684-9286), fax (1-855-853-4850) with the clinical support, or email to BHservices@mvphealthcare.com. Treatment plans submitted with a PA request must now specify the place(s) of service.^[1][2][7]

MVP requires prior authorization for ABA assessments and services and, for Medicaid, says it “will render decisions in accordance with established timeframes outlined in the Medicaid Managed Care Model Contract.” That contract sets the clock: a standard request within three business days of the necessary information and no more than 14 days after receipt; expedited within 72 hours; a concurrent request (reauth or more units) within one business day of the necessary information; any of these extendable up to 14 days. Federal rules cap the standard decision at 7 calendar days for plan rating periods starting on or after January 1, 2026. MVP’s own operational rules: submit prior authorization requests “no less than five (5) calendar days prior” to the service, and when MVP asks for missing clinical information it must arrive within 2 business days (24 hours if urgent). No ABA reauth lead time is published.^{[8][1][9][10]}

Bill the other payer first; the claim to MVP must carry the other payer’s approved amount, paid amount and remaining patient liability. MVP’s own authorization rules still apply when it is secondary: “If MVP is the Secondary Payer, the rules and procedures of MVP as stated in the Member’s Subscriber Contract must be followed before MVP will make payment,” and “When billing MVP as the secondary Payer, all MVP primary billing requirements and codes must be followed… regardless of what was billed to the Other Payer.” In practice: get MVP’s ABA prior authorization even when the commercial plan is primary. Underneath is the state rule that Medicaid pays last (“Providers must bill all applicable insurance sources before submitting claims to Medicaid”). MVP’s COB department: 1-800-556-2477, option 2.^[8][11]

Published but tied to a lapsed federal deadline, so treat it as open. MVP’s ABA payment policy says it “shall reimburse ABA services delivered via video-enabled telehealth through March 31, 2025, or until the CMS waiver expires, whichever is later. Following the expiration or change of the waiver, MVP may deny ABA services delivered via telehealth in accordance with applicable state laws or regulations” — language unchanged in the April 2026 policy. What is unconditional: audio-only, fax-only and e-mail-only delivery are not reimbursable.^[1]

Ask the plan: MVP Provider Services — confirm the current telehealth reimbursement status for ABA codes before scheduling remote sessions; the policy’s waiver reference has not been updated since the cited date passed.

Follows the New York Medicaid rule, which the state applies to FFS and managed care alike: “an LBA can supervise no more than six CBAAs/unlicensed individuals at a time,” “LBAs are required to supervise unlicensed individuals for a minimum of five percent of the hours the unlicensed individual spends providing behavior analysis services each calendar month,” and “supervision must include at least two face-to-face, real-time contacts per month” with the LBA observing service delivery in at least one. Supervision may run over synchronous audio-and-video where on-site is impractical. 97155 counts toward the 5% “only when the LBA joins the patient and the unlicensed individual during a treatment session to direct the unlicensed individual/technician in implementing a new or modified treatment protocol.” CBAAs need direct supervision, and the supervisor “should assess each patient’s/client’s progress at least every 6 months… and review and sign treatment notes and reports prepared by the CBAA supervisee.” MVP publishes no supervision ratio of its own. What it does publish is a rendering restriction that shapes the staffing model: RBT- and unlicensed-professional-rendered services “are only reimbursable under 97152, 97153, and 97154 — not 97151 or 97155–97158,” so supervision, protocol modification and family guidance must be delivered by the analyst.^[7][1]

No per-day unit ceiling or hour cap is published — MVP authorizes rather than capping. The constraint that bites instead is code-level: “the following procedures are excluded from Medicaid Managed Care (MMC) plan coverage: Behavior identification supporting assessment (CPT 0362T); Adaptive behavior treatment with protocol modification (0373T),” an exclusion that has held across every policy version from 2024 through 2026 even though both codes appear on MVP’s general covered-code list. On claims: timely filing is 180 days from the date of service or per contract, with a matching 180-day adjustment window; EDI payee ID 14165.^[1]

Follows the New York Medicaid rule: the LBA supervisor must “review and sign treatment notes and reports prepared by the CBAA supervisee,” and documentation of supervision itself “should be recorded in the patient file.” Clinical documentation must carry the treatment plan with assessment and goals, the goal data, total hours of service per week by who delivered them, and the location(s) of services. Records are kept “for a minimum of six years and, for minors, until the patient turns 22 years of age.” MVP adds no session-note signature rule of its own; its documentation requirements run to the authorization request and the treatment plan, which must specify the place(s) of service.^[7][1]

The strictest published school rule among New York’s upstate plans. Effective July 1, 2025 MVP will not reimburse any ABA code — 97151–97158, 0362T, 0373T — billed with Place of Service = School; requests for school-setting delivery are “administratively denied,” and treatment plans submitted with a PA request must specify the place(s) of service. ABA is also not covered as a substitute for Early Intervention or when delivered under an IEP or a Preschool/School Supportive Health Services Program. That sits on top of the state rule, which already bars school-setting ABA; home, clinic and community remain available.^[3][1][7]

MVP does not publish an NPI convention, but it does publish the rendering restriction that governs who may bill what: RBT- and unlicensed-professional-rendered services “are only reimbursable under 97152, 97153, and 97154” — not 97151 or 97155–97158. At the fee-for-service layer New York is explicit: LBAs bill “using the LBA’s National Provider Identification (NPI) number for the ‘Billing’ provider and/or ‘Supervising’ provider,” with “the NPI number of the CBAA that provided the ABA service… reported as the ‘Rendering’ provider on each claim”; for unlicensed aides and LBA limited-permit holders the supervising LBA’s NPI fills all three roles. CBAAs cannot bill directly and enroll as OPRA providers. Claims route by EDI to payee ID 14165, or by paper to MVP Health Care, Attn: Claims Department, PO Box 2207, Schenectady, NY 12301.^[1][7]

Ask the plan: MVP Provider Services for the rendering/supervising NPI convention on managed-care ABA claims.

Not published. MVP’s ABA payment policy is explicit about who may render which code and which codes are excluded from Medicaid, but states no same-clock-time rule for 97153 with 97155, and the state manual is silent.^[1][7]

Ask the plan: MVP Provider Services (behavioral health 1-800-684-9286) — confirm in writing before billing the overlap.