---
title: "NJ FamilyCare (New Jersey Medicaid) ABA coverage: the intake guide."
url: "https://carelu.com/payers/new-jersey-medicaid"
markdown_url: "https://carelu.com/payers/new-jersey-medicaid.md"
state: NJ (New Jersey)
payer: NJ FamilyCare (New Jersey Medicaid)
kind: State Medicaid program
description: "How NJ FamilyCare covers ABA for autism under EPSDT — five-MCO administration since April 2020, the no-PA fee-for-service window pending MCO enrollment, published FFS rates and daily unit limits, QHP diagnosis rules, and NJ LBA licensure."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# NJ FamilyCare (New Jersey Medicaid) ABA coverage: the intake guide.

_Payer Guide · NJ FamilyCare · Last updated September 2026 · 17 primary sources_

> EPSDT via 5 MCOs since 4/2020; no-PA FFS window pending enrollment, published rates.

NJ FamilyCare, New Jersey's Medicaid program, covers ABA for children with autism under the EPSDT benefit — a benefit that moved from DCF's Children's System of Care (PerformCare) to the five NJ FamilyCare MCOs on April 1, 2020. Since then the model is fully managed-care: Horizon NJ Health, Aetna Better Health, Fidelis Care, UnitedHealthcare Community Plan, and Wellpoint each prior-authorize and pay ABA through their own networks. The one big exception is a genuine intake asset: members still pending MCO enrollment are covered fee-for-service through Gainwell Technologies — and no prior authorization is required at all while a member is in that pending-enrollment window. The state also publishes real FFS rates and a daily unit guide, which the MCOs have largely adopted as claim edits.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required via the MCO — the MCO authorizes a QHP assessment; NO PA while a member is FFS pending MCO enrollment [1]
- **Prior auth for treatment**: Required — MCO approval of the treatment plan is a precondition for ABA services [1]
- **Autism diagnosis required?**: Yes — ASD (F84.0–F84.9) by a qualified healthcare professional; a comprehensive diagnostic evaluation is not required [1][6]

## At a glance

- **Covers ABA?:** Yes — under EPSDT; benefit launched 4/1/2020 (ages ~18 months to 21)
- **Administered by:** 5 MCOs: Horizon NJ Health, Aetna Better Health, Fidelis Care, UHC Community Plan, Wellpoint
- **Assessment auth:** Required via the MCO — but NO PA while FFS pending MCO enrollment
- **Treatment auth:** Required — MCO treatment-plan approval is a precondition
- **Rates (per 15 min, FFS):** 97153 $15.00 · 97155 $21.25 · 97151/97156 $25.00
- **Daily unit guide:** 97151 32u · 97153 32u · 97155 24u · 97156 16u — overridable under EPSDT
- **Licensure:** NJ Licensed Applied Behavior Analyst (LBA) / assistant LaBA
- **Staff screening:** FBI/SBI fingerprint check at LBA/LaBA licensure; monthly exclusion screening (LEIE, NJ debarment, Treasurer lists); techs ride the BACB RBT background-check floor

## The structure: five MCOs, one FFS escape hatch

The founding DMAHS newsletter (Vol. 30 No. 06, April 2020) sets the design: ABA is delivered and prior-authorized through the member's NJ FamilyCare MCO, with the MCO required to "authorize a QHP to assess the child for the development of a proposed treatment plan," and treatment contingent on the MCO's approval of that plan. Fee-for-service — billed to Gainwell Technologies, the fiscal agent — applies only to members pending MCO enrollment, and critically, no prior authorization is required while a member sits in that FFS window. For intake, that makes enrollment status a first-order routing question: a newly eligible child who hasn't been assigned a plan yet can start without any authorization at all, then transitions to the MCO's process once assigned. FFS ABA providers enroll through a dedicated "Applied Behavior Analysis Treatment Provider" packet, including fingerprint background checks per N.J.A.C. 10:77-4.9(g). DMAHS runs a dedicated Autism Line for ABA and DIR services: 609-588-8522 / MAHS.ASDinquiries@dhs.nj.gov. The current five-MCO roster (Aetna Better Health of NJ, Fidelis Care, Horizon NJ Health, UnitedHealthcare Community Plan, and Wellpoint — formerly Amerigroup NJ) is confirmed unchanged as of this review directly from DMAHS's own NJ FamilyCare Health Plans roster page, each still carrying the identical statewide 21-county service area. [1][3][17]

## Diagnosis and authorization

The benefit requires an ASD diagnosis (ICD-10 F84.0–F84.9) made by a qualified healthcare professional — physicians and psychologists (including BCBA-D psychologists) for diagnosis, with BCBAs among the QHPs for treatment planning. Notably, per Optum's NJ Medicaid entry (updated November 2025), a comprehensive diagnostic evaluation is not required to access ABA — a plain ASD diagnosis from a physician or psychologist opens the benefit, for members roughly 18 months to 21 years. Authorization then runs in two steps at the MCO: an assessment authorization (Horizon, for example, issues 32 units of 97151 for 30 days once eligibility, diagnosis, and an ASD script from a QHP are confirmed), followed by treatment-plan review and treatment authorizations — Horizon's run in 6-month spans with requests reviewed within 14 days. Non-contracted providers can request a single case provider agreement from the MCO for continuity of care. [1][6]

## Rates and the daily unit guide

New Jersey publishes actual FFS rates per 15-minute unit: 97151 assessment at $25.00 (BCBA/BCBA-D), 97153 direct treatment at $15.00 (RBT/BCaBA) — raised from the launch rate of $11.20 effective February 1, 2022 using American Rescue Plan funds after Autism New Jersey's advocacy — 97155 protocol modification at $21.25, and 97156 family training at $25.00. The 97153/97155/97156 rates are confirmed current in the NJMMIS CY2026 Q2 listing; the 97151 rate hasn't been seen changed since launch but its current value is unverified. The full billable set also includes the Category III destructive-behavior/multi-tech codes 0362T ($25.00) and 0373T ($16.40). The founding newsletter attaches suggested daily unit limits — 97151 32u, 97152 8u, 97153 32u, 97154 12u, 97155 24u, 97156 16u, 97157 16u, 97158 16u, 0362T 8u, 0373T 32u — "for guidance purposes only," overridable when medically necessary under EPSDT; in practice the MCOs have adopted them as MUE claim edits. One caveat for revenue modeling: the FFS rates "are not required to be utilized" by the MCOs — though Aetna Better Health published an identical schedule. [1][2][4]

## Operational facts worth knowing

A few rules shape scheduling and billing. Concurrent billing: 97155 is billable while the technician bills 97153 when the QHP is directing the tech face-to-face — but supervision without the tech and patient present is not billable. School settings: the 2020 newsletter said services "may not be provided within a school facility," but Optum's November 2025 NJ entry now permits school-setting services as long as they don't occur during normal school hours — state guidance has evidently loosened, so confirm per MCO before building school-based programs. Licensure: New Jersey requires the Licensed Applied Behavior Analyst (LBA) credential — master's or doctorate plus current BCBA plus the NJ jurisprudence exam — with the assistant-level LaBA under an identified supervisor, per N.J.S.A. 45:8B-91 et seq. and N.J.A.C. 13:42B; the board's position is that supervision itself constitutes practicing behavior analysis and requires a license, while RBTs remain unlicensed under a licensee. Finally, PerformCare (DCF/CSOC) still authorizes ABA for non-Medicaid children served through DCF — ID numbers starting "3560" — so not every New Jersey ABA authorization runs through an MCO. [1][6][10]

## Staffing & credentialing: who you can hire, and what they must clear

At the technician level, New Jersey layers a Medicaid credential on an unlicensed role. The founding DMAHS newsletter names the RBT as the technician provider — high school diploma or GED, the 40-hour training, a passed competency exam, and "close, ongoing supervision" by a BCBA-D, BCBA, or BCaBA — and its provider-specialty table lists RBT (alongside BCaBA) as the permitted renderer of 97152/97153. The state itself doesn't license technicians: N.J.S.A. 45:8B-103.b(2) exempts "paraprofessional technicians" delivering ABA under a licensee's direction, and the board's rules (N.J.A.C. 13:42B-1.2, effective May 6, 2024) expressly fold BACB-certified RBTs into that exempt category. MCO manuals run looser — Optum's 2022 NJ orientation asks only that behavior technicians be high school graduates with appropriate BCBA training and supervision, and Horizon says RBT certification is "preferred," not required — but because state FFS policy makes RBT the operative credential, hire to the RBT standard to satisfy the strictest applicable rule. That standard carries its own screening: the BACB's RBT 2026 requirements demand age 18+, a criminal background check plus an abuse-registry check reviewed by an attestor, the updated 40-hour training (delivered by BCBAs/BCaBAs who've completed the 8-hour supervision training), and the RBT Initial Competency Assessment. [1][7][8][9][10][11][12][13][14][15][16]

Background-check obligations split by role. LBA and LaBA applicants clear a criminal history check as part of licensure — the board's FAQ notes application processing time depends partly on its completion — coordinated through the Division of Consumer Affairs' Criminal History Review Unit, which runs FBI and state (SBI) fingerprint checks via New Jersey's contracted live-scan vendor (the CHRU's published board list hadn't yet named the ABA board when checked in mid-2026). For unlicensed technicians, no NJ statute or FamilyCare ABA policy mandating fingerprint or child-abuse-registry checks was found — the BACB's RBT screening is the floor, supplemented by whatever your MCO contracts add (agency-level fingerprinting at FFS enrollment, per N.J.A.C. 10:77-4.9(g), is a separate provider-enrollment matter — see above). What binds every hire regardless of role is exclusion screening: NJ guidance (updated January 2023, an obligation the state has run since 2010) requires Medicaid providers and MCOs to verify monthly that current and prospective employees, contractors, and subcontractors aren't excluded, unlicensed, or uncertified — searching the NJ debarment list, the federal OIG LEIE, the NJ Treasurer's exclusions database, and where applicable the Consumer Affairs and Department of Health licensure databases. [1][7][8][9][10][11][12][13][14][15][16]

On the supervisory side, licensure is now operational, not just on paper: P.L.2019, c.337 created the Board of Applied Behavior Analyst Examiners and bars unlicensed practice, board rules took effect May 6, 2024, applications opened September 12, 2024, and by February 2026 there were 3,506 active licensees (3,476 LBAs, 30 LaBAs). LBAs need a graduate degree plus current BCBA certification; LaBAs a bachelor's plus BCaBA plus an identified LBA supervisor — with supervision floors of at least 5% of practice hours weekly (or one hour every two weeks, whichever is more) in the first year, dropping to 2% or one hour monthly thereafter, face-to-face, under a supervisor who has completed the BACB 8-hour supervisor training. An LBA may delegate intervention implementation to technicians but not assessment, treatment-plan development, or intervention design — and the board holds that supervision in all its forms is itself licensed practice. Two clocks worth tracking in hiring plans: providers working under DDD contracts must hold licenses by May 6, 2027 and Early Intervention contractors by May 6, 2029, while school-district employees delivering ABA solely for their district remain exempt. [1][7][8][9][10][11][12][13][14][15][16]

## Intake gates

The questions that decide whether a family can start with NJ FamilyCare (New Jersey Medicaid), and what they have to bring.

- **Age limit**: Two published numbers, and they differ in precision rather than in substance. The founding DMAHS newsletter sets the benefit for "any Medicaid eligible child, under the age of 21, who has been diagnosed with ASD as defined by ICD 10 diagnoses F84.0 through F84.9 by a qualified healthcare provider," delivered under EPSDT, which reaches "individuals under the age of twenty-one." Optum's New Jersey Medicaid entry adds the floor as well as the ceiling: "ABA services shall be made available to children 18 months to 21 years of age based on medical necessity," and its NJ FamilyCare provider orientation repeats it — "Must be 18 months – 21 years old," including in the specialized FamilyCare carve-out. No hour caps are attached to the age band. [1][6]
- **Who may diagnose**: New Jersey names them twice, and the second list is narrower than the first. The newsletter's general test: "The need for ABA services must be determined by a qualified healthcare professional (QHP) capable of making a diagnosis of autism. QHPs include licensed health care professionals, who are qualified by education, training, or licensure/regulation (when applicable) to perform a professional service within his/her scope of practice." The enumerated list of acceptable QHPs "for the diagnosis and treatment planning for adaptive behavior services" is then: Physicians; Psychologists, which "Requires an active board certified behavior analyst (BCBA) certification in good standing and a qualifying doctoral-level degree (BCBA-D)"; and BCBAs, who appear for treatment planning rather than diagnosis. Optum's NJ entry restates the split: the diagnosis comes from "a physician or psychologist," and "It is not uncommon for one QHP to make the diagnosis (such as a physician) and a separate QHP (such as a BCBA) to develop and supervise the treatment plan." [1][6]
- **Diagnostic tools required**: None required — and New Jersey is one of the few states that says so in terms. Optum's NJ Medicaid entry: "A comprehensive diagnostic evaluation is not required to access ABA services," with "ABA services … available to any child diagnosed with autism spectrum disorder as defined by ICD-10 diagnoses F84.0 through F84.9." The DMAHS newsletter names no instrument either. That makes this the friendliest diagnostic bar of the three states on this page — intake should not queue a New Jersey family for an ADOS-2 before starting the authorization. [6][1]
- **Referral required?**: No PCP referral and no physician order. The sequence the state sets is QHP determination, then MCO authorization: "Once an individual is properly diagnosed with ASD, the MCO shall authorize a QHP to assess the child for the development of a proposed treatment plan," and treatment follows "Contingent upon approval of the treatment plan." The genuine intake asset sits one step earlier — members still fee-for-service pending MCO enrollment are covered through Gainwell with no prior authorization required at all, so enrollment status, not a referral, is the routing question. Plan practice adds paperwork rather than a referral: Horizon wants an ASD diagnosis "script" from a QHP attached to the assessment request, which is the diagnosis document under another name. [1][16]
- **Prior-auth decision time**: NJ FamilyCare ABA is authorized by the child's MCO, not the state: "Effective 4/1/2020, ABA providers shall contact the child's NJ FamilyCare MCO to receive authorization to provide services. For children who are pending assignment to an MCO, services shall be covered under NJ FamilyCare Fee-for-Service (FFS) and no prior authorization shall be required until a managed care plan has been assigned." So there is no state decision clock for ABA — the MCO's clock applies. Federal floor for every NJ FamilyCare MCO: standard decisions within 7 calendar days of the request for contract rating periods starting on or after January 1, 2026 (14 days before that), extendable by up to 14 calendar days at the member's or provider's request or when the plan justifies needing more information; expedited within 72 hours. What the five MCOs publish: Horizon NJ Health, Aetna Better Health and Fidelis Care state 7 calendar days standard and 24 hours (no later than 72) urgent; UnitedHealthcare Community Plan's 2025 manual and Wellpoint's June 2025 manual still print 14 calendar days for non-urgent requests. [1][18][19][20][21][22][23]
- **Other insurance (who pays first)**: NJ FamilyCare pays last: "All TPL, for example, health insurance, Medicare, CHAMPUS, prepaid health plans… shall, if available, be used first and to the fullest extent." Bill the commercial plan first; supplementation claims "shall not be filed with the program unless accompanied by a statement of payment, Explanation of Benefits (EOB), or denial from the other carrier." Two traps: "No program payments shall be made when the third-party payer requires a contracting or participating provider to accept that third-party payer's payment as payment in full," and when NJ FamilyCare is secondary it pays the lesser of its allowed amount minus other payments, or the patient liability. Federal law allows the state to pay first and recover later only for preventive pediatric services (including EPSDT services) or where the coverage comes from an absent parent under child-support enforcement; New Jersey adopts those exceptions (plus prenatal care). Authorization when Medicaid is secondary is set by each MCO: Aetna Better Health waives its PA when the primary covers the service; Horizon NJ Health requires its normal notification/authorization policies; UnitedHealthcare will not pay a primary's medical-necessity denial unless it gave prior authorization; Wellpoint will not pay when the primary refused because its guidelines were not followed. TRICARE and CHAMPVA both pay ahead of Medicaid: TRICARE rules state "Medicaid is not a double coverage plan. In any double coverage situation involving Medicaid, CHAMPUS is always the primary payer," and CHAMPVA "assumes primary payer status" over Medicaid. [24][25][20][26][22][23][27][28]
- **Diagnosis recency** _(ask the plan)_: Not published. Neither the DMAHS newsletter nor Optum's New Jersey entry sets a maximum age for the diagnostic evaluation, and the state's written position runs the other way: Optum's NJ Medicaid entry says flatly that "A comprehensive diagnostic evaluation is not required to access ABA services," so there is no comprehensive evaluation whose recency could be gated. What is dated in New Jersey is the authorization rather than the diagnosis — Horizon issues 32 units of 97151 valid for 30 days, and treatment authorizations run in 6-month spans. [1][6][16]
  - Ask the plan: The member's MCO, or DMAHS's dedicated Autism Line for ABA and DIR services (609-588-8522 / MAHS.ASDinquiries@dhs.nj.gov).
- **Telehealth** _(ask the plan)_: The state is silent and the carrier layer is not. Neither the founding DMAHS newsletter nor the daily unit guide addresses telehealth, remote delivery, modifiers or place-of-service codes for ABA. The one published New Jersey position is Optum's, for its own line of business: BCBAs and licensed BH clinicians in contracted ABA practices may deliver ABA supervision and caregiver training by telehealth if the practice is an approved Optum virtual-visits provider (attestation on Provider Express) and flags virtual delivery to the Care Advocate at authorization — then bills "the same procedure code you would use for an in-person service, 97155 or 97156, on your claim with the “02” place of service code." Direct technician treatment is not in that carve-out. [1][15]
  - Ask the plan: The member's MCO — the state sets no ABA telehealth rule, so each plan answers for itself; DMAHS's Autism Line (609-588-8522) is the state-side route.

## Delivery and billing rules

Coverage decides whether NJ FamilyCare (New Jersey Medicaid) 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**: New Jersey names the supervisory relationship but publishes no percentage or caseload cap. An RBT — high school diploma or GED, the 40-hour training, a passed competency exam — “must practice under the close, ongoing supervision of a BCBA-D, BCBA or BCaBA”; a BCaBA “may only practice under the supervision of a BCBA or BCBA-D” and may in turn supervise an RBT. The economic definition of supervision is billing-side: supervisory time counts only as 97155, and only while the technician and the patient are both present. The state’s Medicaid rules add no supervision ratio of their own, so the BACB floor and your MCO contract are what bind. [1]
  - Ask the plan: Whether your MCO layers a ratio on top — the state newsletter does not.
- **Concurrent billing (97153 + 97155)**: New Jersey says yes, in writing, and draws the line precisely. “If the QHP is overseeing the activities of the technician, the time of direct supervision by the QHP shall be concurrently billable using code 97155.” But “billing for 97155 is limited to time where the QHP is either engaged directly with the patient or is directing a technician in implementing a modified protocol with the patient. Billing for supervision where the technician is not present is not allowed.” Two other concurrency rules ride along: 97156 may be billed while the RBT delivers direct treatment to the child “in a separate location”; and for 0373T “providers may not bill for the QHP time concurrently” and billing is limited to a single technician’s face-to-face time, never the combined time of multiple technicians (three technicians for two hours bills eight units, not twenty-four). [1]
- **Daily limits / MUEs**: New Jersey publishes its own table rather than adopting a CMS MUE regime, and labels it guidance: the limits “are for guidance purposes only and may be overridden when medically necessary based on individual need” under EPSDT. Per day, in 15-minute units: 97151 32, 97152 8, 97153 32, 97154 12, 97155 24, 97156 16, 97157 16, 97158 16, 0362T 8, 0373T 32. Treat them as soft ceilings the plans enforce as edits — a request above them needs explicit EPSDT medical-necessity framing rather than a quiet resubmission. [1]
- **Bill as provider**: New Jersey controls this through allowable provider specialties per code rather than a modifier set. 97152 and 97153 may be rendered by an RBT or BCaBA; 97151, 97155, 97157 and 97158 by a BCBA or BCBA-D; 97156 by a BCBA-D, BCBA or BCaBA; 97154 by either tier; 0362T and 0373T by a BCBA-D or BCBA “with 2 or more RBT or BCaBAs.” On the fee-for-service side the enrolled entity is the “Applied Behavior Analysis Treatment Provider,” which attests on an agency Experience Attestation to the qualifications of each named BCBA-D, BCBA, BCaBA, RBT and BT it employs — technicians are listed under the agency’s enrollment, not enrolled as billing providers in their own right. [1][3]
  - Ask the plan: Each MCO’s claim-submission requirements for rendering-provider identification — the state documents specify who may render, not which NPI goes in which claim field.
- **Place of service** _(plan-dependent)_: This one has moved and the two live sources disagree. The founding DMAHS newsletter is flat: “ABA services may be provided in the therapist’s office, a community setting or the child’s home. Services may not be provided within a school facility.” Optum’s ABA State Mandates document (annual review 7/2026), whose NJ Medicaid entry tracks the same state policy, now reads: “Services may be provided in the school setting as long as services are not provided during normal school hours.” Office, home and community are settled; school is plan-dependent and moving; group home is addressed by neither. [1][6]
  - Ask the plan: Confirm school-setting delivery with the specific MCO before building a school-based program — the 2020 state prohibition and the 2026 Optum entry cannot both be operative.
- **Session-note signature** _(ask the plan)_: Not addressed by the state. The founding newsletter sets codes, rates, unit guidance, provider specialties and place of service but carries no session-note signature rule and no timeframe.
  - Ask the plan: The member’s MCO provider manual; DMAHS’s dedicated Autism Line for ABA and DIR services (609-588-8522 / MAHS.ASDinquiries@dhs.nj.gov) is the state-side route.

## What intake should collect for NJ FamilyCare (New Jersey Medicaid)

- **MCO — or pending-enrollment status:** Horizon, Aetna, Fidelis, UHC, or Wellpoint decides the portal and process; a member still pending MCO assignment can start FFS with NO prior authorization.
- **ASD diagnosis + script:** F84.0–F84.9 from a physician or psychologist, plus the ASD script a QHP writes — the assessment authorization trigger. No comprehensive evaluation needed.
- **Requested hours vs. the unit guide:** MCOs run the state daily limits as MUE edits (97153 32u/day, 97155 24u/day) — requests beyond them need explicit EPSDT medical-necessity framing.
- **Supervising LBA licensure:** Confirm the NJ LBA (and LaBA where applicable) — the board treats supervision itself as licensed practice.
- **DCF/PerformCare check:** Member IDs starting "3560" are DCF children authorized through PerformCare, not an MCO.

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

## Verification of benefits (VOB) data

How NJ FamilyCare (New Jersey Medicaid) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00161
- **Payer ID (Change Healthcare / Optum):** NJMCD
- **Supports 270/271 eligibility:** Yes
- **Real-time eligibility:** Yes
- **Behavioral health administrator:** none (FFS / pending-enrollment ABA rides the medical FFS line, billed to Gainwell)
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No
- **Where the 271 carries MCO enrollment:** MCO enrollment surfaces in Loop 2110C when EB04='HM' (Health Maintenance Organization; EB04='MC' = straight Medicaid/FFS): the 2110C REF segment carries REF01='18' (Plan Number) → REF02 = the 3-digit Managed Care Plan Code, REF01='1W' → REF02 = Managed Care Member ID, and REF03 = Managed Care Plan Name; 2110C MSG01 carries managed-care messages; and Loop 2120C NM1 with NM101='PRP' (Primary Payer) carries the MCO organization name (NM103) with the MCO phone in the 2120C PER. During the pre-selection window a member shows as FFS Medicaid (EB04='MC') with no HM segment — the documented basis for the 'pending MCO enrollment = FFS' fast-start.
- **Eligibility span granularity:** Real-time (MEVS). Inquiry span up to 3 calendar months and not beyond the end of the month following the current month; "eligibility for claim payment is not guaranteed beyond the end of the current month" — i.e. a monthly guarantee — with begin/end dates returned as CCYYMMDD spans in DTP (single segment 2100C DTP03; multiple segments 2110C DTP03).

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 32 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97152 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 8 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97153 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 32 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97154 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 12 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97155 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 24 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97156 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 16 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97157 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 16 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97158 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 16 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 0362T | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 8 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 0373T | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 32 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |

### Medicaid rates

Source: NJ FamilyCare FFS ABA fee schedule (per 15-minute unit). 97153 $15.00 (raised from $11.20 eff 2/1/2022), 97155 $21.25, and 97156 $25.00 are CONFIRMED CURRENT via the NJMMIS Procedure Master Listing CY2026 Q2 (ProviderSpark). The remaining codes carry their launch-era values from the Aetna Better Health NJ 2020 rate sheet (which mirrored the state launch schedule) and are UNVERIFIED-as-current — the primary CY2026 Procedure Master Listing is a portal download on njmmis.com, not a fetchable URL. MCOs are not required to match this schedule. Effective 2022-02-01.

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | $25.00 | 15min | renderedBy: BCBA / BCBA-D (assessment); status: launch-era value; current status unverified — confirm in the CY2026 Procedure Master Listing |
| 97152 | $11.20 | 15min | renderedBy: RBT / BCaBA (supporting assessment); status: launch-era value; current status unverified |
| 97153 | $15.00 | 15min | renderedBy: RBT / BCaBA; status: verified current (CY2026 Q2); raised from $11.20 eff 2/1/2022 |
| 97154 | $4.80 | 15min | renderedBy: RBT / BCaBA (group); status: launch-era value; current status unverified |
| 97155 | $21.25 | 15min | renderedBy: BCBA / BCBA-D; status: verified current (CY2026 Q2) |
| 97156 | $25.00 | 15min | renderedBy: BCBA / BCBA-D (family guidance); status: verified current (CY2026 Q2) |
| 97157 | $12.40 | 15min | status: launch-era value; current status unverified |
| 97158 | $5.60 | 15min | status: launch-era value; current status unverified |
| 0362T | $25.00 | 15min | status: launch-era value; current status unverified |
| 0373T | $16.40 | 15min | status: launch-era value; current status unverified |

### Contacts

- **Provider services phone:** 1-800-776-6334
- **Phone menu path:** Gainwell Technologies Provider Services (general FFS line). For ABA/DIR-specific questions, DMAHS runs a dedicated Autism Line: 609-588-8522 (MAHS.ASDinquiries@dhs.nj.gov).
- **Portal:** [NJMMIS](https://www.njmmis.com)

Questions to ask on a verification call:

- Which of the 5 MCOs (or FFS) is this member enrolled in, and what is the 3-digit Managed Care Plan Code shown in their eligibility response? (our companion guide has no code-to-MCO crosswalk)
- Can you confirm today's per-15-minute rate for 97151, 97152, 97154, 97157, 97158, 0362T, and 0373T? (our reference for these 7 codes is the 2020 launch schedule, not the current CY2026 listing)
- Is the member still in the FFS pending-MCO-enrollment window (no PA required), or already enrolled with an MCO (assessment + treatment PA)?

### VOB data sources

- https://test.njmmis.com/downloadDocuments/5010_270-271_HIPAACompanionGuide.pdf (accessed 2026-07-23)
- https://web.archive.org/web/2023/https://www.nj.gov/humanservices/dmahs/news/Provider_Newsletter_for_Applied_Behavior_Analysis_Therapy.pdf (accessed 2026-07-23)
- https://www.njmmis.com/documentDownload.aspx?document=Applied_Behavior_Analysis.pdf (accessed 2026-07-23)
- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://www.optum.com/content/dam/o4-dam/resources/pdfs/guides/professional-claims-payer-list.pdf (accessed 2026-07-23)
- https://www.nj.gov/humanservices/dmhas/documents/pdf/resources/providers/DMAHS-BH-Integration-Points-of-Contact.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)
- https://www.providerspark.com/for-providers/medicaid-rates/new-jersey/ (accessed 2026-07-23)
- https://autismnj.org/news/autism-new-jerseys-advocacy-leads-to-medicaid-rate-increase-for-aba-services/ (accessed 2026-07-23)
- https://www.aetnabetterhealth.com/content/dam/aetna/medicaid/newjersey/pdf/Applied%20behavioral%20analysis%20program.pdf (accessed 2026-07-23; source document older than 18 months)

## Common questions

### Does NJ FamilyCare cover ABA therapy?

Yes — under EPSDT for members with autism (roughly 18 months to 21), delivered and prior-authorized through the five NJ FamilyCare MCOs since April 1, 2020.

### Does the ABA assessment need prior authorization in New Jersey?

Through an MCO, yes — the MCO authorizes a QHP assessment (Horizon, for example, issues 32 units of 97151 for 30 days). But members still fee-for-service pending MCO enrollment need no prior authorization at all — a real fast-start window for newly eligible children.

### What does New Jersey Medicaid pay for ABA?

FFS rates per 15-minute unit: 97153 $15.00 (raised from $11.20 in February 2022), 97155 $21.25, 97151 and 97156 $25.00, 0362T $25.00, 0373T $16.40. MCOs aren't required to match the FFS schedule, though Aetna Better Health published an identical one.

### Is a comprehensive diagnostic evaluation required for ABA in New Jersey?

No — per Optum's NJ Medicaid criteria, a plain ASD diagnosis (F84.0–F84.9) from a physician or psychologist suffices; a comprehensive diagnostic evaluation is not a prerequisite.

## Primary sources

1. [DMAHS Provider Newsletter Vol 30 No 06 — Provision of ABA services (4/1/2020)](https://web.archive.org/web/2023/https://www.nj.gov/humanservices/dmahs/news/Provider_Newsletter_for_Applied_Behavior_Analysis_Therapy.pdf)
2. [Autism NJ — Medicaid rate increase for ABA services](https://autismnj.org/news/autism-new-jerseys-advocacy-leads-to-medicaid-rate-increase-for-aba-services/)
3. [NJMMIS — ABA Treatment Provider FFS enrollment packet (May 2026, Gainwell)](https://www.njmmis.com/documentDownload.aspx?document=Applied_Behavior_Analysis.pdf)
4. [ProviderSpark NJ Medicaid rates (NJMMIS CY2026 Q2)](https://www.providerspark.com/for-providers/medicaid-rates/new-jersey/)
5. [DMAHS BH Integration Points of Contact V3.1 (per-MCO ABA contacts)](https://www.nj.gov/humanservices/dmhas/documents/pdf/resources/providers/DMAHS-BH-Integration-Points-of-Contact.pdf)
6. [Optum ABA State Mandates BH803ABASTM12026 — NJ Medicaid entry](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/scc/ABA_SCC_SM.pdf)
7. [P.L.2019, c.337 — Applied Behavior Analyst Licensing Act (N.J.S.A. 45:8B-91 et seq.)](https://web.archive.org/web/2024id_/https://pub.njleg.state.nj.us/Bills/2018/PL19/337_.PDF)
8. [N.J.A.C. 13:42B-1.2 — Definitions (paraprofessional technician incl. RBT)](https://www.law.cornell.edu/regulations/new-jersey/N-J-A-C-13-42B-1-2)
9. [BACB RBT 2026 Requirements (July 2025)](https://www.bacb.com/wp-content/uploads/2025/07/RBT-2026-Requirements_250723-a.pdf)
10. [NJ Board of Applied Behavior Analyst Examiners — FAQ](https://www.njconsumeraffairs.gov/abae/Pages/FAQ.aspx)
11. [NJ Division of Consumer Affairs — Criminal History Review Unit](https://www.njconsumeraffairs.gov/ocp/pages/chru.aspx)
12. [Streamline Verify — Exclusion screening guidance for NJ Medicaid providers (Jan 2023)](https://streamlineverify.com/updated-guidance-on-exclusion-screening-for-new-jerseys-medicaid-providers-and-plans/)
13. [Autism NJ — Quick Guide to ABA Licensure Regulations (N.J.A.C. 13:42B)](https://autismnj.org/article/quick-guide-to-aba-licensure-regulations/)
14. [Autism NJ — Behavior Analyst Licensure in New Jersey: Where We Are Now](https://autismnj.org/article/behavior-analyst-licensure-in-new-jersey-where-we-are-now/)
15. [Optum/UHC Community Plan — NJ FamilyCare ABA Provider Orientation (2022)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/njaba/NJ.FamilyCare.Medicaid.ABA.pdf)
16. [Horizon NJ Health — Overview of ABA Services (Dec 2020)](https://www.horizonnjhealth.com/sites/default/files/2020-12/Overview%20of%20ABA%20Services.pdf)
17. [NJ DMAHS — NJ FamilyCare Health Plans (current MCO roster)](https://nj.gov/humanservices/dmahs/providers-stakeholders/provider-resources/health-plans)
18. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/section-438.210)
19. [Horizon NJ Health — UM policy: Timeframes for Authorization Determination and Notification (last reviewed 12/10/2025)](https://www.horizonnjhealth.com/for-providers/resources/policies/health-services-policies/utilization-management/timeframes-for)
20. [Aetna Better Health of New Jersey — Provider Manual](https://www.aetnabetterhealth.com/content/dam/aetna/medicaid/new-jersey-medicaid/provider/pdf/aetna_provider_manual.pdf)
21. [Fidelis Care — 2026 NJ Medicaid/NJ FamilyCare Provider Manual (effective April 15, 2026)](https://www.fideliscarenj.com/content/dam/centene/wellcare/nj/pdfs/Prov/NJ_Medicaid_Provider_Manual_R.pdf)
22. [UnitedHealthcare Community Plan of New Jersey — Care Provider Manual (2025)](https://www.uhcprovider.com/content/dam/provider/docs/public/admin-guides/comm-plan/NJ-Care-Provider-Manual.pdf)
23. [Wellpoint New Jersey — Provider Manual (June 2025)](https://www.provider.wellpoint.com/docs/gpp/NJ_WLP_Provider_Manual.pdf)
24. [N.J.A.C. 10:49-7.3 — Third-party liability (TPL) benefits (LII)](https://www.law.cornell.edu/regulations/new-jersey/N-J-A-C-10-49-7-3)
25. [42 CFR 433.139 — Medicaid third-party liability, payment of claims (eCFR)](https://www.ecfr.gov/current/title-42/section-433.139)
26. [Horizon NJ Health — Provider Administrative Manual](https://www.horizonnjhealth.com/provider-admin-manual)
27. [32 CFR 199.8 — TRICARE double coverage (eCFR)](https://www.ecfr.gov/current/title-32/section-199.8)
28. [38 CFR 17.272 — CHAMPVA benefit limitations; Medicaid exception (eCFR)](https://www.ecfr.gov/current/title-38/section-17.272)

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.