---
title: "UPMC Health Plan ABA coverage in Pennsylvania: the intake guide."
url: "https://carelu.com/payers/upmc-health-plan-pennsylvania"
markdown_url: "https://carelu.com/payers/upmc-health-plan-pennsylvania.md"
state: PA (Pennsylvania)
payer: UPMC Health Plan in Pennsylvania
kind: Commercial insurance
description: "How UPMC Health Plan commercial plans handle ABA in Pennsylvania — UPMC Health Plan Behavioral Health Services, what the provider manual does and does not say, telemedicine policy MP.148, coordination of benefits, Act 62, and what to verify by phone."
last_reviewed: September 2026
---

# UPMC Health Plan ABA coverage in Pennsylvania: the intake guide.

_Payer Guide · UPMC Health Plan · Pennsylvania · Last updated September 2026 · 11 primary sources_

> Western/central PA provider-owned plan: BH run in-house by UPMC Health Plan BHS with Community Care; no published ABA policy — verify by phone.

UPMC Health Plan is the provider-owned insurer of western and central Pennsylvania, and its commercial behavioral health benefit is run in-house by UPMC Health Plan Behavioral Health Services (BHS). Community Care Behavioral Health handles network credentialing and after-hours authorizations. For an ABA intake team the important thing is what UPMC does not publish: its policy manual has no ABA or autism medical policy, and its behavioral health provider chapter never mentions ABA.

This guide is therefore mostly a script for the phone call. It sets out what UPMC’s own documents do settle (telemedicine, coordination of benefits, record-keeping, the BHS authorization channel), what Pennsylvania’s Act 62 guarantees on mandated plans, and exactly what to ask BHS for everything else.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment:** Not published / unverified. Verify via: UPMC Health Plan BHS, 1-866-441-4185 (24/7), or Provider OnLine → Auth Entry/Inquiry — ask whether 97151/97152 need prior authorization on this member’s commercial plan. Any provider alert or ABA authorization guide should be requested via carelu.com/sources. [7][1]
- **Prior auth for treatment:** Not published / unverified. Verify via: UPMC Health Plan BHS, 1-866-441-4185 — ask whether ABA (97153–97158) needs prior authorization on this plan, for how long an authorization runs, and where to send the treatment plan. [1][13]
- **Autism diagnosis required?** _(plan-dependent)_: Depends on the plan. UPMC Health Plan publishes no ABA policy of its own. On Act 62 plans (insured, 51+ employees), the benefit covers diagnostic assessment and treatment of autism spectrum disorder for members under 21, so an ASD diagnosis is the gate. For individual, small-group and self-funded plans, UPMC publishes no ABA diagnosis rule. [8][7]
  - Ask the plan: UPMC Health Plan BHS, 1-866-441-4185 — ask whether ABA is a covered benefit on this plan and which diagnoses qualify.

## At a glance

- **Covers ABA?:** Required on Act 62 plans; UPMC publishes no ABA policy of its own — confirm per plan with UPMC Health Plan BHS
- **State mandate:** Act 62 of 2008 — Insurance Company Law § 635.2 (40 P.S. § 764h)
- **Mandate age:** Under 21 — diagnostic assessment and treatment of ASD, including ABA
- **Mandate caps:** Statutory annual max $51,908 (policies issued/renewed 2026; $53,310 in 2027), no visit limits — but PID treats autism as a mental health condition under MHPAEA and expects the cap to have no impact on coverage
- **Exempt from mandate:** Self-funded ERISA plans; individual and small-group (50 or fewer employees) policies; accident-only, fixed-indemnity, limited-benefit and other excepted policies
- **Licensure:** No behavior-analyst license in PA; the State Board of Medicine licenses Behavior Specialists (Act 62 § 635.2(g); 49 Pa. Code §§ 18.521ff.)
- **BH management:** UPMC Health Plan Behavioral Health Services (in-house), 1-866-441-4185, 24/7; Community Care handles credentialing and after-hours authorizations
- **Telehealth:** Policy MP.148 lists 97151–97158, 0362T, 0373T for commercial; audio-video mandatory, POS 02/10

## Who manages behavioral health for UPMC commercial members

UPMC’s commercial provider manual says it plainly: "Behavioral health and substance use disorder benefits are managed through UPMC Health Plan." Urgent after-hours authorization requests go to Community Care Behavioral Health, and providers reach UPMC Health Plan Behavioral Health Services (BHS) 24/7 at 1-866-441-4185 (members: 1-888-251-0083). Members may self-refer to a behavioral health provider — "Members do not have to obtain a referral from their PCP." [2][1][6]

Network providers submit behavioral health authorizations in Provider OnLine (Auth Entry/Inquiry); out-of-network providers call 1-866-441-4185. BHS uses InterQual Behavioral Health criteria for the levels of care it reviews. Community Care runs credentialing and provider relations for the BHS network, and providers keep their practice data current in Community Care’s ePortal. None of this applies to UPMC for You or UPMC Community HealthChoices (Medical Assistance), whose behavioral health is carved out to the county BH-MCO. [2][1][6]

## What UPMC does not publish about ABA

We read the full index of UPMC Health Plan’s Policies & Procedures Manual — 524 clinical, medical, prior-authorization and pharmacy policies — and it contains no ABA or autism medical policy. The behavioral health chapter of the provider manual (Chapter L, updated August 2025) has authorization tables for inpatient, residential, partial hospitalization, intensive outpatient and outpatient care, but none for ABA. Its outpatient table says in-network outpatient mental health treatment is "considered for payment without an authorization"; whether UPMC treats ABA as that kind of outpatient care is not stated. The Clinical Review Criteria policy (CRM.003) lists no ABA criteria set either. [7][1][12][13]

The only autism-specific document UPMC has posted is an old Act 62 notice. It told providers to send autism treatment plans to BHS ("Attn: Autism") and described Act 62 with the original $36,000 cap. The Medical Prior Authorization forms page still links it, but the file no longer loads. So for UPMC, prior authorization, hour limits, supervision and billing rules for ABA are questions for BHS, not facts we can cite. [7][1][12][13]

## Act 62 on UPMC plans

On UPMC commercial policies issued to groups of 51 or more employees (and on UPMC for Kids, which is CHIP), Act 62 requires coverage of the diagnostic assessment and treatment of ASD — including ABA — for members under 21. It sets a CPI-adjusted statutory maximum of $51,908 for 2026 policies ($53,310 in 2027), but the Insurance Department expects that cap to have no effect because autism is treated as a mental health condition under MHPAEA. Act 62 lets the insurer review the treatment plan once every six months, keeps diagnostic results valid for 12 months, forbids making coverage depend on an IEP, and requires the insurer to accept any MA-enrolled autism service provider in its service area that agrees to its terms. [8][9][14]

Individual, small-group and self-funded employer plans sit outside Act 62. For those, whether ABA is covered at all is a benefit question for BHS. [8][9][14]

## Telemedicine, records and rates

UPMC’s telemedicine policy MP.148 (effective October 2025) covers all commercial lines and lists 0362T, 0373T and 97151 through 97158 among its "Commercial, CHIP and Medicare Codes". For commercial members, audio-video is mandatory: "Audio-only (telephone) sessions will be denied as not medically necessary." Claims must carry POS 02 or 10, the platform must be HIPAA-compliant (Skype and FaceTime are named as not compliant), and the practitioner must be licensed where the patient is located. [5][1][15][11]

Chapter L’s record-keeping standards apply to every BHS network provider: each record carries the patient’s name and ID on every page, the responsible clinician’s name and professional degree, dated entries, progress toward treatment goals, and documentation "as soon as possible after the encounter". Records must be kept at least 10 years. UPMC publishes no commercial ABA rates; they are negotiated in the provider agreement. [5][1][15][11]

## Intake gates

The questions that decide whether a family can start with UPMC Health Plan in Pennsylvania, and what they have to bring.

- **Referral required?**: No PCP referral: "Members may self-direct care to a behavioral health provider … Members do not have to obtain a referral from their PCP." On Act 62 plans, treatment must be in a treatment plan developed by a licensed physician or licensed psychologist, and may be prescribed, ordered or provided by a licensed physician, physician assistant, psychologist, LCSW or CRNP. [2][8]
- **Telehealth**: Policy MP.148 (Telemedicine, effective 10/2025, all commercial lines) lists 0362T, 0373T, 97151, 97152, 97153, 97154, 97155, 97156, 97157 and 97158 among its commercial, CHIP and Medicare codes. Commercial: "Audio-visual sessions are mandatory. Audio-only (telephone) sessions will be denied as not medically necessary." Claims need POS 02 (not at home) or 10 (home) plus the telehealth modifier (95/GT for audio-video). The platform must be HIPAA-compliant, and the practitioner must be licensed where the patient is located. Being on the list does not by itself guarantee coverage. [5]
- **Other insurance (who pays first)**: UPMC publishes its own order for commercial members. For a child covered by both parents who are not separated, "The child’s primary insurance carrier is the parent or guardian whose birth date falls earlier in the calendar year" (the birthday rule). For divorced or separated parents: the custodial parent’s plan, then the stepparent’s, then the non-custodial parent’s — unless a court decree says otherwise. With Medical Assistance: "UPMC Health Plan’s commercial insurance is always primary over Medical Assistance", and MA is the payer of last resort. When UPMC commercial is secondary and the primary carrier authorized the service, "UPMC Health Plan authorizations/PCP referrals are not required." Federal rules: TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270). [3][17][18][19]
- **Age limit** _(plan-dependent)_: UPMC publishes no ABA age rule. On Act 62 plans (insured groups of 51+, and CHIP), ASD assessment and treatment are guaranteed for covered individuals under 21. Individual, small-group and self-funded plans are outside Act 62, and any age term there is set by the plan. [8]
  - Ask the plan: UPMC Health Plan BHS, 1-866-441-4185 — confirm the plan’s funding type and any age limit on its ABA benefit.
- **Diagnosis recency** _(plan-dependent)_: UPMC publishes no ABA-specific rule on how recent the diagnosis must be. On Act 62 plans the statute makes diagnostic-assessment results "valid for a period of twelve (12) months, unless a licensed physician or licensed psychologist determines an earlier assessment is necessary." [8]
  - Ask the plan: UPMC Health Plan BHS, 1-866-441-4185 — ask how recent the ASD evaluation must be for an ABA authorization or claim.
- **Who may diagnose** _(plan-dependent)_: UPMC publishes no ABA-specific list. On Act 62 plans the "diagnostic assessment" is one performed by a licensed physician, licensed physician assistant, licensed psychologist or certified registered nurse practitioner. [8]
  - Ask the plan: UPMC Health Plan BHS, 1-866-441-4185 — ask which evaluator credentials UPMC accepts behind an ASD diagnosis.
- **Prior-auth decision time** _(plan-dependent)_: UPMC publishes no ABA turnaround. Fully insured plans follow Act 146 (Insurance Company Law § 2155): non-urgent prior authorization "within 15 days"; urgent care not yet started "as soon as possible, but not more than 72 hours"; an ongoing urgent course requested at least 24 hours before it would be cut, within 24 hours; peer-to-peer offered on denial (UPMC’s line is 412-454-2765). Self-funded employer plans follow ERISA, 29 CFR 2560.503-1: 15 days for pre-service claims plus one 15-day extension, 72 hours for urgent. [10][16][7]
  - Ask the plan: UPMC Health Plan BHS, 1-866-441-4185 — confirm fully insured vs. self-funded, whether ABA needs authorization at all, and the lead time for renewals.
- **Diagnostic tools required** _(ask the plan)_: Not addressed. UPMC publishes no ABA policy naming required diagnostic instruments; BHS reviews use InterQual Behavioral Health criteria, which are proprietary. [1]
  - Ask the plan: UPMC Health Plan BHS, 1-866-441-4185 — ask whether a specific instrument (e.g. ADOS-2) must be documented in the evaluation.

## Delivery and billing rules

Coverage decides whether UPMC Health Plan in Pennsylvania 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.

- **Session-note signature**: Chapter L record-keeping standards apply to every BHS network provider: the patient’s name and ID on each page, "The responsible clinician’s name and professional degree are documented", "All entries are dated", progress toward treatment goals recorded, and documentation "as soon as possible after the encounter". Records are kept at least 10 years. These are general behavioral health standards, not ABA-specific signature rules. [1]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not addressed in any UPMC Health Plan document read — nothing on billing 97153 and 97155 for the same time. [7]
  - Ask the plan: UPMC Health Plan BHS claims support or the provider agreement — ask whether overlapping 97153/97155 time is payable.
- **Daily limits / MUEs** _(ask the plan)_: Not published. UPMC posts no ABA unit or hour ceiling. On Act 62 plans the statutory annual maximum ($51,908 for 2026 policies) is, per the Insurance Department, not expected to affect coverage under parity. [9]
  - Ask the plan: UPMC Health Plan BHS, 1-866-441-4185 — ask for any unit/hour limit on the ABA benefit for this plan.
- **Place of service** _(ask the plan)_: Not addressed. UPMC publishes nothing on home, school, clinic or community settings for ABA. Act 62 bars making coverage depend on coordination with an IEP, but does not require the insurer to cover a service just because it is in an IEP. [8]
  - Ask the plan: UPMC Health Plan BHS, 1-866-441-4185 — ask which settings (home, school, clinic, community) the plan pays ABA in.

## What intake should collect for UPMC Health Plan in Pennsylvania

- **Plan type and funding:** Employer group size and whether insured or self-funded (Act 62 applies only to insured 51+ groups), or individual/Marketplace. UPMC for You / Community HealthChoices members go to the county BH-MCO, not this guide.
- **Member ID + card photo:** Needed for the BHS benefit check at 1-866-441-4185 — the only way to learn whether ABA needs authorization on this plan.
- **Diagnostic evaluation:** ASD diagnosis with date and evaluator credentials — Act 62 treats results as valid for 12 months.
- **Treatment plan author:** On Act 62 plans the treatment plan must come from a licensed physician or licensed psychologist.
- **Telehealth need:** If any sessions will be remote, confirm video is possible — UPMC commercial denies audio-only.
- **Other coverage:** Both parents’ plans (UPMC applies the birthday rule) and any Medical Assistance, which is always secondary to UPMC commercial.

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

## Common questions

### Does UPMC Health Plan cover ABA therapy?

On insured employer plans with 51 or more employees, yes — Act 62 requires coverage of ASD treatment including ABA for members under 21. UPMC publishes no ABA medical policy, so for individual, small-group and self-funded plans confirm the benefit with UPMC Health Plan BHS at 1-866-441-4185.

### Who manages ABA for UPMC commercial members?

UPMC Health Plan Behavioral Health Services manages commercial behavioral health in-house. Community Care Behavioral Health handles network credentialing and after-hours authorizations. UPMC for You and Community HealthChoices members get behavioral health from their county BH-MCO instead.

### Can ABA be delivered by telehealth for UPMC members?

UPMC’s telemedicine policy MP.148 lists 97151–97158, 0362T and 0373T for commercial members, but audio-video is mandatory — audio-only sessions are denied. Bill with POS 02 or 10.

### What does UPMC Health Plan pay for ABA?

UPMC publishes no commercial ABA rates; they are negotiated in your provider agreement.

## Primary sources

1. [UPMC Health Plan Provider Manual — Chapter L, Behavioral Health Services (updated 08-20-25)](https://www.upmchealthplan.com/docs/providers/2025_ProviderManual_L.pdf)
2. [UPMC Health Plan Provider Manual — Chapter C, UPMC Health Plan Commercial](https://upmc.widen.net/s/rbn8crtscw/providermanual_c-2022_web)
3. [UPMC Health Plan Provider Manual — Chapter I, Member Administration (updated 07-03-25)](https://upmc.widen.net/s/mggshqdrrb/providermanual_i-2025_web)
4. [UPMC Health Plan Provider Manual — Chapter G, Utilization Management (updated 04-03-25)](https://upmc.widen.net/s/ll69cf5wvp/providermanual_g-2025_web)
5. [UPMC Health Plan Medical Policy MP.148 — Telemedicine (effective 10/25)](https://upmc.widen.net/content/4fbcjl0ork/original/MP.148.pdf)
6. [UPMC Health Plan Clinical Policy CRM.003 — Clinical Review Criteria (revised 05/26)](https://upmc.widen.net/content/emaibvbgtc/original/CRM.003.pdf)
7. [UPMC Health Plan — Policies & Procedures Manual (index)](https://www.upmchealthplan.com/providers/medical/resources/manuals/policies-procedures)
8. [Act 62 of 2008 (HB 1150, PN 4115) — Insurance Company Law § 635.2 enacted text](https://www.palegis.us/legislation/bills/text/HTM/2007/0/HB1150/PN4115)
9. [PA Insurance Department Notice 2026-06 — Autism coverage CPI-U adjustment and parity reminder (56 Pa.B. 1396)](https://www.pacodeandbulletin.gov/secure/pabulletin/data/vol56/56-10/352.html)
10. [Act 146 of 2022 — Insurance Company Law Art. XXI amendments incl. § 2155 prior authorization review (Justia)](https://law.justia.com/codes/pennsylvania/2022/act-146/)
11. [PA State Board of Medicine — Behavior Specialist Licensure Requirements Snapshot](https://www.pa.gov/agencies/dos/department-and-offices/bpoa/boards-commissions/medicine/behavior-specialist-licensure-snapshot)
12. [UPMC Health Plan — Medical Prior Authorization and Physician Forms](https://www.upmchealthplan.com/providers/medical/resources/forms/medical-pa)
13. [UPMC Health Plan — Autism Treatment Plan (Act 62 notice; archived copy, captured Dec. 2025)](https://web.archive.org/web/20251228221544/https://www.upmchealthplan.com/docs/providers/Autism_Treatment_Plan.pdf)
14. [PA Insurance Department Notice 2023-16 — Autism Spectrum Disorders Coverage and Parity (53 Pa.B. 6983)](https://www.pacodeandbulletin.gov/secure/pabulletin/data/vol53/53-44/1534.html)
15. [BACB — U.S. Licensure of Behavior Analysts (PA absent; checked September 2026)](https://www.bacb.com/u-s-licensure-of-behavior-analysts/)
16. [29 CFR 2560.503-1 — ERISA claims procedure](https://www.ecfr.gov/current/title-29/section-2560.503-1)
17. [55 Pa. Code § 1101.64 — Third-party medical resources (TPR)](https://www.pacodeandbulletin.gov/Display/pacode?file=/secure/pacode/data/055/chapter1101/s1101.64.html)
18. [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)
19. [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.