---
title: "Priority Health ABA coverage in Michigan: the intake guide."
url: "https://carelu.com/payers/priority-health-michigan"
markdown_url: "https://carelu.com/payers/priority-health-michigan.md"
state: MI (Michigan)
payer: Priority Health (Michigan)
kind: Commercial insurance
description: "How Priority Health covers ABA in Michigan: Medical Policy 91615-R8, prior authorization on every ABA code, InterQual criteria, 1-per-15 BCBA supervision, school and household exclusions, Michigan’s mandate caps and exemptions, and what intake should verify."
last_reviewed: September 2026
---

# Priority Health ABA coverage in Michigan: the intake guide.

_Payer Guide · Priority Health · Michigan · Last updated September 2026 · 13 primary sources_

> Michigan carrier: PA on every ABA code incl. 97151, InterQual criteria, BCBA supervision 1 hr per 15 hrs.

Priority Health is a Michigan-based carrier. Its ABA rules live in one medical policy, No. 91615 "Autism Spectrum Disorders" (revision R8, effective March 1, 2026), which sets the diagnostic standard, sends authorization decisions to Behavioral Health InterQual, and sets its own supervision floor. Priority Health also runs a Medicaid plan, but its policy notes that autism services for Priority Medicaid and Healthy Michigan Plan members "are paid through Michigan’s Department of Community Mental Health" — see our Michigan Medicaid guide for those members.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — Policy 91615 lists 97151 and 97152 among "ABA treatment services – in center, office, or home – prior authorization required." [1]
- **Prior auth for treatment**: Required — every ABA code; authorization determined on Behavioral Health InterQual criteria, continued stays on measurable progress. [1]
- **Autism diagnosis required?**: Yes — ASD (F84.0, F84.5, F84.8, F84.9) from a multimodal evaluation consistent with the current DSM; a second opinion may be required. [1]

## At a glance

- **Covers ABA?:** Yes — ABA for ASD (F84.0, F84.5, F84.8, F84.9) under Medical Policy 91615
- **State mandate:** MCL 500.3406s (insurers; 2012 PA 100, amended 2016) and MCL 550.1416e (health care corporation certificates)
- **Mandate age:** Treatment coverage may be limited to members through age 18
- **Mandate caps:** Annual maximums allowed: $50,000 through age 6, $40,000 ages 7–12, $30,000 ages 13–18; no visit limits
- **Exempt from mandate:** Self-funded ERISA plans; exchange QHPs beyond essential health benefits; short-term policies of 6 months or less
- **Licensure:** Behavior analysts licensed by LARA (Public Health Code Part 182A, law since 2016; BACB certification required); technicians unlicensed
- **Prior auth:** Required for all ABA codes 97151–97158, "in center, office, or home"
- **Criteria:** Behavioral Health InterQual (licensed; via Prism)

## Priority Health’s autism policy (91615-R8)

Initial diagnostic evaluation, including psychological testing, is medically necessary, and the diagnosis must match the DSM standard at the time of evaluation. The evaluation must show a multimodal assessment (caregiver reports, records, collateral reports, standardized psychological tools and an observational assessment), and Priority Health "may require a second diagnostic opinion from a contracted, licensed PhD psychologist with specialized training in autism spectrum disorders." [1][2]

ABA authorization "is determined by the clinical findings and ABA indications recommended by Behavioral Health InterQual®," continued stays require documented measurable progress against InterQual criteria, the plan must be supervised by a BCBA, and line-staff supervision should be at least "1 hour of supervision for every 15 hours of treatment." The coding section marks every ABA code, 97151 included, "prior authorization required," in center, office or home; speech, physical and occupational therapy for autism need no PA. Exclusions include services that are a school program’s legal responsibility, services by family or household members, and unproven treatments (among them secretin, chelation, facilitated communication, sensory-based treatments, RDI, Floortime/DIR, and equine therapies). [1][2]

## The Michigan autism mandate: what it guarantees, and its age and dollar limits

Michigan’s autism mandate has two parallel statutes: MCL 500.3406s for insurers (added by 2012 PA 100, amended by 2016 PA 276, applying to policies delivered, issued or renewed beginning 180 days after its April 18, 2012 enactment) and MCL 550.1416e for health care corporation group and nongroup certificates. Both require coverage "for the diagnosis of autism spectrum disorders and treatment of autism spectrum disorders," including behavioral health treatment such as applied behavior analysis, and bar the carrier from limiting the number of visits, from denying coverage because treatment "is educational or habilitative in nature," and from applying dollar limits, copays, deductibles or coinsurance that do not apply to physical illness generally. [3][4]

Unlike newer mandates, Michigan’s still carries age and dollar ceilings the carrier may choose to apply: coverage for treatment may be limited "through 18 years of age" and to a maximum annual benefit of $50,000 through age 6, $40,000 from 7 through 12, and $30,000 from 13 through 18. Treatment must be "prescribed or ordered" by a licensed physician or licensed psychologist who finds it medically necessary, behavioral health treatment must be "provided or supervised by a board certified behavior analyst or a licensed psychologist," and the diagnosis means assessments "including the autism diagnostic observation schedule, performed by a licensed physician or a licensed psychologist." While a member is in treatment the carrier may require a treatment plan and treatment review, request the ADOS results, request that the ADOS be repeated no more than once every three years, and request an annual development evaluation. Utilization review, medical-necessity review, network requirements and coordination of benefits still apply. Exempt: self-funded ERISA employer plans (outside state insurance law), exchange qualified health plans to the extent the coverage exceeds essential health benefits, and, under 500.3406s, short-term policies of six months or less. [3][4]

## Licensure and rates

Michigan licenses behavior analysts through LARA’s Board of Behavior Analysts under Part 182A of the Public Health Code (Michigan’s licensure law dates from 2016). A license requires current BACB certification in good standing sent directly from the BACB, a criminal background check, human-trafficking and implicit-bias training, and renews every four years; assistant behavior analysts have their own LARA license and supervision verification. Technicians are not licensed by the state. Priority Health does not publish commercial ABA rates; they are set in the participating-provider agreement. [5][6][7]

## Intake gates

The questions that decide whether a family can start with Priority Health (Michigan), and what they have to bring.

- **Diagnosis recency**: No recency window. The policy requires the diagnosis to be "consistent with the standards of the Diagnostic and Statistical Manual of Mental Disorders at the time of evaluation" and "Priority Health may require a second diagnostic opinion from a contracted, licensed PhD psychologist with specialized training in autism spectrum disorders." Under the mandate a fully insured plan may request the ADOS be repeated no more than once every three years. [1][3]
- **Who may diagnose**: The policy does not list specialties; it requires a multimodal diagnostic evaluation and reserves the right to a second opinion from a contracted, licensed PhD psychologist with autism training. For fully insured plans the mandate defines the diagnosis as assessments, including the ADOS, "performed by a licensed physician or a licensed psychologist." [1][3]
- **Diagnostic tools required**: "The diagnostic evaluation must include evidence of a multimodal assessment that contains caregiver(s) reports, records (e.g., medical, school, other evaluations), collateral reports (e.g., teachers, other treatment providers), data gathered from utilization of standardized psychological tools, and an observational assessment." No specific instrument is named; AI and app-based diagnostic devices (e.g., Canvas Dx) are excluded. [1]
- **Referral required?**: Priority Health’s policy states no referral or order requirement for ABA beyond prior authorization. For a fully insured Michigan policy the mandate adds an order requirement: covered treatment is care "prescribed or ordered for an individual diagnosed with 1 of the autism spectrum disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary," and the treatment plan is developed "when the treatment of an autism spectrum disorder is first prescribed or ordered." Self-funded ERISA plans sit outside the statute. [1][3]
- **Age limit** _(plan-dependent)_: Priority Health’s autism policy sets no age limit. Michigan’s mandate lets a fully insured carrier limit autism treatment coverage to members "through 18 years of age" and cap it at $50,000 a year through age 6, $40,000 for ages 7–12 and $30,000 for ages 13–18; whether a given plan uses those limits is in its certificate. Self-funded ERISA plans set their own terms. [1][3][4]
  - Ask the plan: Live benefits verification in Prism: fully insured vs. self-funded, and whether the certificate applies the mandate’s age-18 and annual-dollar limits.
- **Prior-auth decision time** _(plan-dependent)_: Turns on how the plan is funded. Fully insured Michigan insurance and HMO plans follow MCL 500.2212e: after May 31, 2024 a non-urgent prior authorization request "is considered granted" if the insurer does not grant it, deny it, or ask for more information "within 7 calendar days after the date and time of submission," and again within 7 calendar days after additional information is submitted; a request the provider certifies as urgent is considered granted if not acted on within 72 hours. An approved authorization "is valid for not less than 60 calendar days or for a duration that is clinically appropriate, whichever is later." The statute’s "health benefit plan" covers individual and group insurance, HMO contracts, and self-funded plans of the state or local governments, not private self-funded employer plans, which follow ERISA: pre-service decisions "not later than 15 days after receipt of the claim," one 15-day extension, urgent claims within 72 hours. [8][9]
  - Ask the plan: At benefits verification ask whether the plan is fully insured (Michigan-regulated) or self-funded (ERISA), then confirm the Priority Health turnaround and reauthorization lead time (Priority Health provider services or the Prism provider portal).
- **Other insurance (who pays first)** _(plan-dependent)_: Which plan pays first is set by Michigan’s Coordination of Benefits Act for state-regulated plans: for a dependent child whose parents are married or living together, "The plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (same birthday: the plan covering the parent longer); for divorced or separated parents a court order assigning health coverage controls, then the order in MCL 550.253. The autism mandate adds that a member with two policies covering autism gets benefits "subject to the limits of this section when coordinating benefits." If the child also has Michigan Medicaid, Priority Health pays first: Medicaid is payer of last resort and "is not liable for payment of services denied because coverage rules of the primary health insurance were not followed," so get Priority Health’s authorization even when Medicaid (the PIHP) will pay secondary. TRICARE pays after other coverage except Medicaid (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270). [10][3][11][12][13]
  - Ask the plan: Ask Priority Health at benefits verification for the member’s coordination-of-benefits order (Priority Health provider services or the Prism provider portal); self-funded plans set their own COB terms in the plan document. Record every other coverage the child has.
- **Telehealth** _(ask the plan)_: Not addressed in Policy 91615. [1]
  - Ask the plan: Priority Health provider manual telehealth policy or provider services — ask which ABA codes are payable via telehealth and with which POS/modifier.

## Delivery and billing rules

Coverage decides whether Priority Health (Michigan) 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**: "An ABA treatment plan must be supervised by a BCBA who oversees the treatment and coordinates with other medical professionals," and "Supervision of line staff by the BCBA should occur at a minimum of 1 hour of supervision for every 15 hours of treatment with the member." That is a lower floor than the 1-per-10 many payers use. [1]
- **Place of service**: ABA treatment services are covered "in center, office, or home" with prior authorization. Excluded: "Services or treatment that are the legal responsibility of a school program such as evaluations completed in an educational setting," and services provided by family or household members. [1]
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: Priority Health Billing Policy No. 054 (Behavioral Health) in the provider manual, or Priority Health provider services. [1]
- **Daily limits / MUEs** _(licensed criteria)_: No hour or unit limit is published in the policy. Authorization, and continued-stay approval, is decided on Behavioral Health InterQual criteria, which are licensed and viewable only through Priority Health’s Prism portal (Authorizations > Authorization Criteria Lookup). [1]
  - In licensed criteria: Prism > Authorizations > Authorization Criteria Lookup (InterQual Behavioral Health), or the authorization determination.

## What intake should collect for Priority Health (Michigan)

- **Plan type and funding:** Commercial vs. Priority Medicaid (routes to the PIHP), and fully insured vs. self-funded.
- **Multimodal diagnostic evaluation:** Caregiver and collateral reports, records, standardized tools and observation; a second opinion may be requested.
- **Assessment and treatment plan for InterQual review:** PA covers every ABA code including 97151.
- **Physician or psychologist order:** The Michigan mandate ties covered treatment to a prescription or order on fully insured plans.

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

## Common questions

### Does Priority Health require prior authorization for the ABA assessment?

Yes. Policy 91615 lists 97151 through 97158 under "ABA treatment services – in center, office, or home – prior authorization required."

### What supervision does Priority Health require?

A BCBA must supervise the treatment plan, with line-staff supervision of at least one hour for every 15 hours of treatment.

### My child has Priority Medicaid. Does Priority Health approve ABA?

No. Priority Health’s policy notes that these services for Priority Medicaid and Healthy Michigan Plan members are paid through the state’s community mental health system (the PIHP).

## Primary sources

1. [Priority Health Medical Policy No. 91615-R8 — Autism Spectrum Disorders (effective 3/1/2026)](https://priorityhealth.stylelabs.cloud/api/public/content/6b5c6f61d4a74c049b1748d514555243?v=8b411839)
2. [Priority Health — Medical policies index](https://www.priorityhealth.com/provider/manual/medical-policies)
3. [MCL 500.3406s — autism coverage (Insurance Code), Michigan Legislature](https://www.legislature.mi.gov/Laws/MCL?objectName=mcl-500-3406s)
4. [MCL 550.1416e — autism coverage (Nonprofit Health Care Corporation Reform Act), Michigan Legislature](https://www.legislature.mi.gov/Laws/MCL?objectName=mcl-550-1416e)
5. [LARA — Michigan Board of Behavior Analysts (Public Health Code Part 182A; R 338.1801–338.1835)](https://www.michigan.gov/lara/bureau-list/bpl/health/hp-lic-health-prof/behavior-analysts)
6. [LARA — Michigan Behavior Analyst Licensing Guide (rev. 1/26/2026)](https://www.michigan.gov/lara/-/media/Project/Websites/lara/bpl/Behavior-Analysts/Licensing-Info-and-Forms/Behavior-Analyst-Licensing-Guide-FAQ-12626.pdf)
7. [BACB — U.S. Licensure of Behavior Analysts](https://www.bacb.com/u-s-licensure-of-behavior-analysts/)
8. [MCL 500.2212e — prior authorization process and timelines, Michigan Legislature](https://www.legislature.mi.gov/Laws/MCL?objectName=mcl-500-2212e)
9. [29 CFR 2560.503-1 — ERISA claims procedure](https://www.ecfr.gov/current/title-29/section-2560.503-1)
10. [MCL 550.253 — Coordination of Benefits Act, order of benefit determination](https://www.legislature.mi.gov/Laws/MCL?objectName=mcl-550-253)
11. [Michigan Medicaid Provider Manual (July 1, 2026) — Coordination of Benefits chapter](https://www.mdch.state.mi.us/dch-medicaid/manuals/MedicaidProviderManual.pdf)
12. [10 U.S.C. 1079(i)(1) — TRICARE pays after other coverage except Medicaid](https://www.govinfo.gov/content/pkg/USCODE-2023-title10/html/USCODE-2023-title10-subtitleA-partII-chap55-sec1079.htm)
13. [38 CFR 17.270 — CHAMPVA is the last payer](https://www.ecfr.gov/current/title-38/section-17.270)

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.