---
title: "Utah Medicaid ABA coverage: the intake guide."
url: "https://carelu.com/payers/utah-medicaid"
markdown_url: "https://carelu.com/payers/utah-medicaid.md"
state: UT (Utah)
payer: Utah Medicaid
kind: State Medicaid program
description: "How Utah Medicaid covers ABA as a fee-for-service carve-out — why the ACO card doesn't matter, no PA on assessments, the 10-business-day PA grace period, adult coverage, published PRISM rates effective 7/1/2026, and the September 2026 High-Risk revalidation wave."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Utah Medicaid ABA coverage: the intake guide.

_Payer Guide · Utah Medicaid · Last updated September 2026 · 12 primary sources_

> FFS carve-out — ACO card irrelevant for ABA, no PA on 97151, adults covered, PRISM rates.

Utah Medicaid covers ABA through its state-plan Autism Spectrum Disorder services — and the single most important structural fact is that ABA is a fee-for-service carve-out. Utah runs four physical-health ACOs (Health Choice Utah, Healthy U, Molina, SelectHealth Community Care), but ABA never touches them: diagnosis documentation, prior authorization, and claims all go directly to Utah Medicaid, whatever card the family carries. Layer on no PA for assessments, a 10-business-day retroactive PA grace period, coverage regardless of age, and a published fee schedule, and Utah is one of the most intake-friendly Medicaid programs in our directory. One transparency note: parts of this guide rest on the archived July 2023 ASD manual corroborated against the live PRISM coverage lookup; the January 2026 manual has since been verified directly (cited in the staffing section below) — where editions conflict, the newer manual governs.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Not required — behavior identification assessments (97151) are exempt from PA; 1 assessment per 26 weeks, up to 24 units [8]
- **Prior auth for treatment**: Required — all treatment codes, 26-week periods via the PRISM portal; 10-business-day grace to submit after starting services [8]
- **Autism diagnosis required?**: Yes — written ASD diagnosis using evidence-based standardized measures; the completed diagnostic tool must accompany the initial PA [8]

## At a glance

- **Covers ABA?:** Yes — ages 1 and older, 'regardless of age'; adults with ASD included
- **Structure:** FFS carve-out — bill Utah Medicaid directly, even for ACO-enrolled members
- **Assessment PA:** None — 97151 needs no PA (1 assessment per 26 weeks, up to 24 units)
- **Treatment PA:** Required — 26-week periods via PRISM; 10-business-day grace after starting
- **Rates (per 15 min):** 97153 $19.67 · 97151/97155/97156 $37.51 (effective 7/1/2026)
- **Hour caps:** 97153 up to 30 hrs/week (780 hrs per 26 wks); supervision 84 hrs combined
- **Staff screening:** Techs fully certified before serving any member (RBT/QABA/BICC) — no grace period since Jan 2026
- **Watch:** High-Risk revalidation + fingerprinting notices phased from Sept 2026

## The carve-out: your ACO card doesn't matter for ABA

Utah's four ACOs handle physical health, and for autism-diagnosed members they also handle ASD-related PT, OT, and speech — but ABA and the autism diagnostic evaluation are carved out to state fee-for-service. The manual states that mental health evaluations and psychological testing for diagnosing developmental disorders are carved out of the managed-care entities and reimbursed fee-for-service, and the state's own family-facing FAQ confirms that ABA PA requests go to the Medicaid agency and providers bill Medicaid directly. Practically: intake never needs to route an ABA request by plan. Capture the ACO name only for coordinating PT/OT/ST — for ABA, every Utah Medicaid family follows the identical state workflow, and there is no per-plan portal, form, or criteria variation to track. [3][1][7]

## Assess first, authorize later: no PA on 97151 and the 10-day grace

The manual is explicit: ABA therapy requires prior authorization — but that requirement 'does not apply to initial or ongoing behavior identification assessments.' The live PRISM lookup confirms it: 97151 shows 'Prior Authorization Required? No,' limited to one assessment per 26 weeks at up to 24 units, with reassessment roughly every 6 months. So with a diagnosis in hand, intake can book and bill the assessment immediately. [1][2]

Treatment codes (97153, 97155, 97156, group codes, H0032) do need PA, submitted to the state PA unit through the PRISM portal on the ABA Services Prior Authorization Form, in 26-week authorization periods. Utah then adds a rare cushion: a 10-business-day grace period to submit the PA after starting services — initial and recertification alike — so a completed assessment can flow straight into treatment without an authorization gap. Miss the window and the authorization starts on the completed-submission date instead, so treat day one of treatment as the PA clock. The initial packet is substantial: the PA form, a copy of the written ASD diagnosis with the completed diagnostic tool, an order or prescription for ABA (renewed annually), and a treatment plan with assessment-tool copies, baseline data, measurable goals, weekly service amounts by code, and settings including telehealth hours. Reauthorization adds progress-versus-baseline data using the same measurement method, and requests above the maximum allowed units go to secondary medical review. [1][2]

## Rates, caps, and who's covered

Utah publishes its ABA rates in the PRISM coverage lookup. Effective July 1, 2026, per 15-minute unit: 97153 direct treatment pays $19.67, and 97151, 97155, and 97156 all pay $37.51 — 97155 reported with a credential modifier (HP psychologist/BCBA-D, HO BCBA, HN BCaBA/analyst-in-training) but a single published rate across tiers. The caps are generous: 97153 up to 780 hours per 26 weeks (30 hours/week), supervision (97155 plus H0032) capped at 84 combined hours per 26 weeks, with overage requests possible through secondary review. Parent training (97156) carries a recommended minimum of 3 episodes per 26 weeks. Supervision has a floor, too: the QHP must supervise at least 10% of technician direct-service time, at least half of it directly. [2][4][5]

Two eligibility facts set Utah apart. First, ASD services are available 'regardless of age' — PRISM shows allowed ages 1 and older with adult plans included, so adults with ASD can get ABA, which almost no state Medicaid program offers. Second, third-party liability is enforced: commercial insurance must be exhausted first, and if the provider isn't paneled with the member's private plan and no out-of-network benefit exists, a transition (or enrollment with the insurer) must occur within 6 months of discovering the coverage — so ask about other insurance at intake, not at the first denied claim. Also worth flagging: telehealth works for supervision and parent training but not for technician-delivered 97153/97154 or group 97158, and school-based ABA on an IEP routes through the School-Based Skills Development benefit instead of FFS. [2][4][5]

## Watch: the September 2026 High-Risk revalidation wave

Per the July 2026 Medicaid Information Bulletin (item 26-61), Utah has reclassified ABA providers as 'High Risk' for enrollment screening. Every existing ABA provider must revalidate within 18 months, with notices phased starting September 2026 — and revalidation now includes individual ownership reporting and fingerprint-based background checks. Failure to complete within 60 days of your notice risks enrollment closure, which would stop FFS claims cold, so treat the notice as a drop-everything item when it arrives. The same MIB (item 26-83) reconfirmed that group codes still require group-size modifiers (UN/UP/UQ/UR/US) or claims deny — and states explicitly that ABA modifier policy "will remain the same" under the new screening regime. As of this review the July 2026 MIB is confirmed still current (re-fetched directly; no amendment or delay language found), and a September 2026 MIB does not yet exist, so the phased-notice mailing itself can't yet be confirmed as underway — only that the policy as written remains in force. One adjacent item worth knowing: the same July 2026 MIB's item 26-62 is a separate, broader initiative — High-Risk billing providers generally (a category that now includes ABA per 26-61) get revalidation letters starting July 15, 2026 with a 90-day completion window, distinct from 26-61's September-phased/60-day timeline — so a provider could see either clock start depending on which notice arrives first. Sourcing note: the January 2026 ASD manual is verified and cited in this guide; the state lists a further 04/13/2026 update whose PDF was not retrievable at review time — where a determination hinges on the newest manual language, confirm with the PA unit (dmhfmedicalpolicy@utah.gov). Separately, an older-looking "Accessing ASD Services FAQ" (v2, dated 7/15/24) still live on medicaid.utah.gov states eligibility as "under 21" and CHEC/EPSDT-only — directly contradicting the regardless-of-age claim above, which rests on the stronger PRISM eligibility lookup and the ASD Related Services program page. Treat that FAQ as stale rather than authoritative, but confirm adult eligibility case-by-case in PRISM until the state reconciles the two documents. [6]

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

The January 2026 ASD manual update removed the technician on-ramp: behavior technicians must be fully certified before performing any services for a Utah Medicaid member — the manual states there is 'no grace period granted between a technician's initial hire date and the date in which the technician receives certification,' ending the prior policy that allowed a 40-hour training plus competency assessment within 120 days of hire. Utah accepts technician certification from any NCCA-accredited body, naming the BACB (RBT), QABA, and BICC as examples, and the current certificate is submitted to Medicaid as part of provider enrollment. That changes the hiring math: an uncertified hire cannot touch a Medicaid caseload while training. The BACB floor beneath the RBT credential: age 18+, high-school education, a criminal background check and an abuse registry check — both confirmed by an attesting certificant no more than 180 days before the RBT application — the 40-hour training, the exam, and ongoing supervision of at least 5% of behavior-analytic service hours each calendar month. [8][6][9][10][11][12]

Utah runs no separate state background check on ABA technicians — the criminal and abuse-registry screening rides entirely on the required national certification. The state's screening energy points at owners instead. Effective July 1, 2026, MIB item 26-61 reclassified ABA providers to the 'High Risk' screening category (Utah invoked 42 CFR 455.450(e) on May 1, 2026, citing national fraud trends). Every existing ABA provider must revalidate within 18 months; notices mail in phases beginning September 2026, and the screening must be completed within 60 days of the notice date or enrollment closes. High-Risk screening means: reporting every individual or corporation with a 5%-or-greater direct or indirect ownership interest; FBI fingerprint-based criminal background checks for those 5%+ individual owners (via FBI channelers); unannounced pre- or post-enrollment site visits; and the $750 federally mandated 2026 enrollment fee — waived only with proof of active enrollment and fee payment to Medicare or another state's Medicaid program. DHHS has committed to CMS to screen 4,644 high-risk billing providers by June 2028, so this wave will reach every ABA agency; have ownership disclosures, licenses, and certifications current and uploadable in PRISM before your letter arrives. [8][6][9][10][11][12]

On the supervisor side, practicing behavior analysis requires a Utah license under the Behavior Analyst Licensing Act (Utah Code Title 58, Chapter 61, Part 7): behavior analyst (LBA) — current good-standing BCBA certification qualifies outright, or a master's/doctorate plus 1,500 supervised hours and the exam — and assistant behavior analyst (LaBA), and the ASD manual requires supervising BCBAs and BCBA-Ds to hold the Utah license. Rule R156-61a adds a written supervision contract with per-meeting documentation and makes supervising without one unprofessional conduct. The Medicaid ratio that binds staffing: the QHP must supervise at least 10% of the time a member receives direct services from a technician or assistant analyst, at least 50% of it direct supervision — an additional 10% of direct supervision can be prior-authorized with documented medical necessity — and remote supervision counts only via synchronous two-way audio/video. Services by a 'behavior analyst in training' (enrolled in a BACB-approved course sequence) are also billable under the licensure exemptions in Utah Code 58-61-707(10)–(12) when supervised by a psychologist or behavior analyst. And because ABA is a FFS carve-out, none of the four ACOs credential or screen ABA staff — certification, licensure, and the new High-Risk screening all run through state enrollment in PRISM. One unverified item: DOPL's behavior-analyst application page (which carries license fees) blocks automated retrieval, so confirm current licensing fees with DOPL directly. [8][6][9][10][11][12]

## Intake gates

The questions that decide whether a family can start with Utah Medicaid, and what they have to bring.

- **Age limit**: No upper age limit. Utah offers ASD-related services regardless of age, and the PRISM coverage lookup shows allowed ages 1 and older with Traditional Adult and Targeted Adult plans among the covered eligibility groups — so adults with ASD are in scope, which almost no other state Medicaid program offers. One caveat: an older family-facing FAQ still live on medicaid.utah.gov (v2, 7/15/24) states eligibility as under 21 and CHEC/EPSDT-only, contradicting this; the PRISM lookup and the program page are the stronger sources, but confirm adult eligibility case-by-case in PRISM until the state reconciles the two documents. [2][4]
- **Diagnosis recency**: No recency window could be sourced. The ASD manual's initial prior-authorization checklist requires a copy of the written ASD diagnosis and the screening or evaluation instruments used, but states no maximum age for that diagnosis; what the manual does date is the ABA order (renewed annually) and the reassessment cadence (assessments generally at initiation and every six months thereafter). [8]
- **Who may diagnose**: Utah names no specialty list. The manual states that clinicians authorized under the scope of their licensure and trained in the use and interpretation of the selected assessment tool may render the ASD diagnosis, and the initial PA requires a copy of a written ASD diagnosis by a clinician authorized under the scope of their licensure to render a diagnosis. Note that the diagnostic evaluation itself is carved out of the ACOs to fee-for-service, so it does not route through the member's health plan. [1][8]
- **Diagnostic tools required**: No specific instrument is mandated, but standardized measurement is. The diagnostic evaluation must determine the presence of DSM-5 criteria for ASD using evidence-based standardized measures, on top of health, developmental, socioemotional and behavioral histories and a developmental, adaptive and/or cognitive evaluation. A copy of the medical records containing the ASD diagnosis and the screening or evaluation instruments used must be submitted with the initial prior-authorization request, and the treatment plan must attach a copy of the assessment tool(s) used to assess functional skills and maladaptive behaviors. [1][8]
- **Referral required?**: Yes. ASD services are covered based on the recommendation and referral of a qualified health care professional, and the initial PA packet must include an order (prescription) for ABA services from a licensed clinician authorized to prescribe ABA under their scope of licensure and training. For ongoing services a new order must be submitted annually — so the prescription is a recurring intake chase, not a one-off. [1][8]
- **Telehealth**: Covered for supervision of an assistant behavior analyst or behavior technician and for parent training when clinically appropriate (per Utah Administrative Rule R414-42), synchronous only — real-time two-way video and audio — with the provider delivering or supervising only one member or one group session at a time and documentation substantiating clinical appropriateness. Not covered by telehealth: adaptive behavior treatment administered by a technician, group adaptive behavior treatment administered by a technician, and group adaptive behavior treatment with protocol modification administered by a QHP. Remote services report Place of Service 02 on the CMS-1500, and the treatment plan must describe the settings including hours delivered via remote technology. [1][8]
- **Prior-auth decision time**: Utah Medicaid decides ABA prior authorization itself through PRISM, and neither the ASD Services manual nor Section I publishes a decision timeframe. The federal fee-for-service floor therefore governs: since January 1, 2026 the state agency must decide a standard request "in no case later than 7 calendar days after receiving the request," extendable by up to 14 calendar days, and an expedited one "in no case later than 72 hours after receiving the request." The clock effectively starts on a complete request: "When a prior authorization request is submitted without the required documentation, it will be returned to the provider without processing," and "The date a complete submission, with all necessary supporting documentation, is received will be the date posted on the prior authorization request." Only two additional-documentation rounds are allowed; incomplete after the third submission, the request is denied. Timing rules unique to ABA: at the start of services "providers will be permitted a 10-business day grace period to submit a request for prior authorization"; for renewals "The request for the new certification period must be received within 10 business days of the re-certification period start date," or the authorization "will begin on the day that the completed request and all required documentation is submitted." Authorizations run in 26-week periods. [8][13][14]
- **Other insurance (who pays first)**: Medicaid pays last, and Utah adds an ABA-specific rule. "When other insurance coverage is available and a provider under that insurance is available to deliver ABA services, those services must be exhausted prior to claims being submitted to Medicaid." If you are not paneled with the private plan and it has no out-of-network benefit, "a transition to a provider enrolled with the private insurance must be facilitated within six months of the discovery of the insurance" — or you keep serving under Medicaid while "actively seeking enrollment with the private insurance," also within 6 months. Billing order: "Submit the claim to the third party or parties," then Medicaid with the TPL payment shown; "If the third party denies the claim for any reason (non-covered benefit, patient not eligible, etc.) submit a claim to Medicaid" electronically with the TPL response. Medicaid pays only the difference up to its allowable, and the family owes no primary-plan cost share. Keep the Medicaid prior auth in place even when it pays second: "Medicaid can pay for services only if all conditions of coverage have been met, including but not limited to, the requirement for prior authorization." Wrong TPL on file goes to the Office of Recovery Services TPL unit, (801) 536-8798. Billing the primary first and missing the 365-day deadline is an accepted timely-filing exception. [8][13][15]

## Delivery and billing rules

Coverage decides whether Utah 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**: A QHP must supervise a minimum of 10 percent of the time the member receives direct services from a technician or assistant behavior analyst, and at least 50 percent of that supervision must be direct supervision. An additional 10 percent of direct supervision can be prior-authorized with documented medical necessity, and additional time approved for direct supervision cannot be used for indirect supervision. The QHP is responsible for all aspects of clinical direction, supervision and case management, must know each team member's ability before assigning clinical activities, and must observe the technician implementing the plan. Remote supervision counts only via synchronous two-way audio-video. [1][8]
- **Concurrent billing (97153 + 97155)**: 97155 is written to contemplate the QHP simultaneously directing a technician in administering the modified protocol while the member is present, with the QHP required to be onsite — onsite meaning immediately available and interruptible, not necessarily in the room. The manual's explicit prohibition runs the other way: when a behavior analyst or assistant behavior analyst personally provides the direct intervention under 97153 or 97154, the provider must not also bill for behavior-analyst-level services. Direct case supervision reports under 97155; indirect case supervision must be reported under HCPCS H0032, not 97155. [1][8]
- **Daily limits / MUEs**: Utah caps by authorization period, not by day — the Maximum Allowed column describes average utilization across the 26-week period and the provider must track it. Per 26 weeks: 97151, 1 assessment (up to 24 units); 97153, 780 hours (3,120 units), about 30 hours a week; 97155 and H0032 combined, 84 hours (336 units), at least half of it direct supervision; 97154, 52 episodes (up to 4 units each); 97158, 26 episodes; 97157, 3 episodes; 97156 carries a recommended minimum of 3 episodes (up to 4 units each). Alternative service-hour combinations may be requested at under 30 hours a week of combined technician individual and group therapy. Requests above the Maximum Allowed go to secondary medical review. [1][8]
- **Session-note signature**: The treatment plan submitted with the initial PA must carry the name and signature of the QHP who conducted the assessment and developed the plan; the continued-services treatment plan must carry the name and signature of the QHP conducting the reassessment, and reassessments and treatment-plan updates must be conducted by a QHP. Each PA also requires an attestation of medical necessity by the psychologist or behavior analyst. The assessment's total time or start and stop times must be noted in the medical record, and the provider must retain records of time spent in direct and indirect supervision. Charting or data collection occurring separately from the time documenting direct observations while working directly with the member is non-covered. [1][8]
- **Place of service**: ABA may be delivered in multiple settings on the same day: naturally occurring home and community settings, and clinic or center-based settings where the environment can be controlled or group services are provided. Schools are the exception — ASD-related services listed on a child's IEP must be provided through the Medicaid School-Based Skills Development Services benefit, and apart from the psychologist's or behavior analyst's participation in the annual IEP development meeting (billable fee-for-service), Medicaid will not reimburse fee-for-service ABA in school-based settings in addition to services listed on an IEP. School-based settings include LEA-funded charter schools but not privately funded schools. Telehealth reports POS 02. Setting-associated costs — resorts, spas, therapeutic programs, camps — and provider travel time are non-covered. [1][8]
- **Bill as provider**: Technicians are certified paraprofessionals who practise under the direct supervision of a QHP, who is responsible for all work performed; assistant behavior analysts likewise work under QHP supervision. Claims for services provided by a behavior analyst in training are covered when supervised by a psychologist or behavior analyst and delivered under the licensure exceptions at Utah Code 58-61-707(10)-(12). Direct and indirect case supervision must carry the modifier identifying the credentials of the clinician who performed the supervision: HP for a psychologist or BCBA-D, HO for a BCBA, HN for a BCaBA or behavior analyst in training. Group services must carry a group-size modifier (UN, UP, UQ, UR, US) or the claim denies. Because ABA is a fee-for-service carve-out, none of the four ACOs credential ABA staff — enrolment runs through the state in PRISM. [1][8][11]

## What intake should collect for Utah Medicaid

- **Written ASD diagnosis + completed diagnostic tool:** Both attach to the initial PA — the diagnosis must rest on evidence-based standardized measures, though no specific instrument is mandated.
- **Order / prescription for ABA:** Required in the initial packet and renewed annually — chase it at intake.
- **Other insurance:** TPL is enforced: commercial coverage must be exhausted first, with a 6-month transition clock once discovered.
- **Weekly hours by code + settings:** The treatment plan itemizes weekly service amounts per code, including telehealth hours — align intake and clinical planning early.
- **ACO name (for PT/OT/ST only):** Irrelevant to ABA routing, but the ACO handles ASD-related PT, OT, and speech for its enrollees.

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

## Verification of benefits (VOB) data

How Utah Medicaid ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 01324 — pVerify lists TWO Utah Medicaid FFS entries — "00672 Utah Medicaid" (Elig: Yes, Claim: No) and "01324 MEDICAID UTAH" (Elig: Yes). 01324 is used here; confirm with pVerify which is the live real-time 270/271 payer for FFS before automating.
- **Supports 270/271 eligibility:** Yes
- **Real-time eligibility:** Yes
- **Behavioral health administrator:** none — ABA is carved out of all four ACOs and the PMHPs to state FFS; the ACO/PMHP handles only ASD-related PT/OT/ST and MH/SUD. Claims go to Utah Medicaid (PRISM) on the medical FFS line.
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No
- **Where the 271 carries MCO enrollment:** Loop 2120C (Subscriber Benefit Related Entity Name), NM1 segment — the related MCO Plan is reported here by ORGANIZATION NAME (NM103), not a carrier code. Managed-care/capitated status is flagged in Loop 2110C EB01="3" (Active - Services Capitated); FFS = EB01 "1" (Active Coverage).
- **Eligibility span granularity:** Real-time (response <=20s) and batch; inquiry DTP03 accepts a single date or a date range not to exceed 3 months (up to 3 years retro); benefit issuance is monthly, out-of-pocket frequency quarterly. Utah Medicaid does NOT return eligibility at the procedure-code level (default STC "30"), so the 271 does not surface that ABA specifically bills FFS — the carve-out is applied from policy, not read off the 271.

### How the 271 reports ABA benefits

- **ABA benefit bucket (service type code):** 30 — Utah Medicaid's own 270/271 companion guide (UT_PRISM_COMPANION_GUIDE, already cited in this guide's edi.medicaid271Notes) states plainly that Utah Medicaid "does not return eligibility at the procedure code level" and defaults to the generic STC "30" (Health Benefit Plan Coverage) bucket — ABA-specific cost-share detail is NOT surfaced on the wire; the FFS carve-out is applied from policy knowledge, not read off the 271.
- **271 response quality for ABA:** low — Seeded 'low': the companion guide's own default-to-STC-30, no-procedure-level-detail statement means a real 271 for an ABA member returns only generic plan-active/inactive information, not service-level financial detail.

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | NOT required — behavior-identification assessments are exempt from PA (PRISM CSV: PA=No). | 1 assessment per 26 weeks, up to 24 units; reassessment roughly every 6 months per 26 weeks | home, clinic, community, school (school-based ABA on an IEP routes to the School-Based Skills Development benefit, not FFS), telehealth (per code — see telehealth) | — | — |
| 97152 | No — Not Covered on the Utah Medicaid fee schedule (PRISM PAC 166) | N/A | N/A per N/A | — | N/A | — |
| 97153 | Yes | Required — PA in 26-week periods via PRISM; 10-business-day grace to submit after starting services. | Up to 780 hours (3,120 units) per 26 weeks (30 hours/week) per 26 weeks | home, clinic, community, school (school-based ABA on an IEP routes to the School-Based Skills Development benefit, not FFS), telehealth (per code — see telehealth) | NOT allowed — technician-delivered 97153 must be in person (telehealth excluded for technician-delivered 97153/97154 and group 97158). | — |
| 97154 | Yes | Required — PA in 26-week periods via PRISM. | 52 episodes per 26 weeks per 26 weeks | home, clinic, community, school (school-based ABA on an IEP routes to the School-Based Skills Development benefit, not FFS), telehealth (per code — see telehealth) | NOT allowed — group technician-delivered treatment must be in person. | Group-size modifier required: UN=2 / UP=3 / UQ=4 / UR=5 / US=6+ (per MIB item 26-83) or the claim denies |
| 97155 | Yes | Required — PA in 26-week periods via PRISM. | Supervision (97155 + H0032) capped at 84 combined hours (336 units) per 26 weeks; >=50% must be direct supervision; overage via secondary review per 26 weeks | home, clinic, community, school (school-based ABA on an IEP routes to the School-Based Skills Development benefit, not FFS), telehealth (per code — see telehealth) | Allowed — supervision may be delivered via synchronous two-way audio/video. | HP (psychologist/BCBA-D), HO (BCBA), HN (BCaBA/analyst-in-training) |
| 97156 | Yes | Required — PA in 26-week periods via PRISM. | Recommended minimum 3 episodes per 26 weeks (up to 4 units/episode) per 26 weeks | home, clinic, community, school (school-based ABA on an IEP routes to the School-Based Skills Development benefit, not FFS), telehealth (per code — see telehealth) | Allowed — family/parent training may be delivered via synchronous two-way audio/video. | — |
| 97157 | Yes | Required — PA in 26-week periods via PRISM. | 3 episodes per 26 weeks per 26 weeks | home, clinic, community, school (school-based ABA on an IEP routes to the School-Based Skills Development benefit, not FFS), telehealth (per code — see telehealth) | Allowed — multiple-family group guidance may be delivered via synchronous two-way audio/video. | Group-size modifier required: UN=2 / UP=3 / UQ=4 / UR=5 / US=6+ or the claim denies |
| 97158 | Yes | Required — PA in 26-week periods via PRISM. | 26 episodes per 26 weeks per 26 weeks | home, clinic, community, school (school-based ABA on an IEP routes to the School-Based Skills Development benefit, not FFS), telehealth (per code — see telehealth) | NOT allowed — group treatment with protocol modification must be in person. | Group-size modifier required: UN=2 / UP=3 / UQ=4 / UR=5 / US=6+ or the claim denies |
| H0032 | Yes | Required — PA in 26-week periods via PRISM. | Counts toward the 84 combined supervision hours (336 units) per 26 weeks (with 97155) per 26 weeks | home, clinic, community, school (school-based ABA on an IEP routes to the School-Based Skills Development benefit, not FFS), telehealth (per code — see telehealth) | Allowed — treatment-planning/supervision activity may be delivered via synchronous two-way audio/video. | — |
| 0362T | No — Not Covered on the Utah Medicaid fee schedule (PRISM PAC 166) | N/A | N/A per N/A | — | N/A | — |
| 0373T | No — Not Covered on the Utah Medicaid fee schedule (PRISM PAC 166) | N/A | N/A per N/A | — | N/A | — |

Code notes:

- **97151:** Behavior-identification assessment (professional). Pays $37.51/15-min unit (see rates). No PA means intake can book and bill the assessment immediately with a diagnosis in hand.
- **97152:** Behavior-identification assessment BY A TECHNICIAN — Not Covered by Utah Medicaid (only the professional 97151 assessment is billable). Verified from the PRISM PAC-166 fee-schedule export.
- **97153:** Technician-delivered direct treatment — the volume code. Pays $19.67/15-min unit (see rates). Overage above the max allowed units goes to secondary medical review.
- **97154:** Group adaptive behavior treatment (technician-delivered). Pays $13.91/15-min unit (see rates). Group-size modifier is mandatory.
- **97155:** QHP protocol-modification / supervision code. Pays $37.51/15-min unit across credential tiers (single published rate; HP/HO/HN are reporting modifiers, not rate tiers — see rates). QHP must supervise >=10% of technician direct-service time, >=50% of it direct.
- **97156:** Family adaptive-behavior guidance (parent training). Pays $37.51/15-min unit (see rates).
- **97157:** Multiple-family group guidance. Flagged "Covered" on PRISM but priced $0.00 (rate last effective 7/1/2022 — NON-REIMBURSING at present; see rates). Confirm current reimbursement before relying on this code.
- **97158:** Group adaptive behavior treatment with protocol modification. Flagged "Covered" on PRISM but priced $0.00 (rate last effective 7/1/2022 — NON-REIMBURSING at present; see rates). Confirm current reimbursement before relying on this code.
- **H0032:** MH service-plan development (indirect supervision) code used alongside 97155; shares the 84-hour supervision cap. Pays $37.51/15-min unit (see rates).
- **0362T:** Not Covered by Utah Medicaid (last coverage-relevant date 7/1/2021; a $16.41 rate is listed but the code is flagged Not Covered). Utah bills the Category-I CPT set, not the legacy Category-III codes.
- **0373T:** Not Covered by Utah Medicaid (last coverage-relevant date 7/1/2021; a $16.41 rate is listed but the code is flagged Not Covered).

### Medicaid rates

Source: PRISM Coverage & Reimbursement fee-schedule CSV export (PAC 166, plan_type=Traditional), effective 7/1/2026 (every ABA row: EffectiveStartDate 07/01/2026, UpdateOn 06/12/2026) — fetched and parsed this pass; the authoritative current source. Single published rate per code; 97155 carries credential-reporting modifiers (HP/HO/HN) but one published rate across tiers. SPA UT-25-0007 was retrieved (Wayback) but its packet contains only the 4.19-B cover + CMS approval pages, not the ABA dollar table, so dollar confirmation is from the live PRISM export. NOTE: 97157 and 97158 are flagged "Covered" but priced $0.00 (rates last effective 7/1/2022) — non-reimbursing at present. Effective 2026-07-01.

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | $37.51 per 15-min unit | 15min | — |
| 97153 | $19.67 per 15-min unit | 15min | — |
| 97154 | $13.91 per 15-min unit (group, technician-delivered) | 15min | — |
| 97155 | $37.51 per 15-min unit (single rate across HP/HO/HN credential-reporting modifiers) | 15min | HP: $37.51 (psychologist/BCBA-D); HO: $37.51 (BCBA); HN: $37.51 (BCaBA/analyst-in-training) |
| 97156 | $37.51 per 15-min unit | 15min | — |
| 97157 | $0.00 — flagged Covered but priced $0.00 (rate last effective 7/1/2022; non-reimbursing at present) | 15min | — |
| 97158 | $0.00 — flagged Covered but priced $0.00 (rate last effective 7/1/2022; non-reimbursing at present) | 15min | — |
| H0032 | $37.51 per 15-min unit | 15min | — |

### Contacts

- **Provider services phone:** (801) 538-6155 (toll-free 1-800-662-9651 from UT/ID/WY/CO/NM/AZ/NV)
- **Phone menu path:** Phone menu: option 3, then 3, then select the appropriate program (per the Prior Authorization line on the provider contact page).
- **Hours:** Mon, Wed, Thu, Fri 8:00am-5:00pm MT; Tue 11:00am-5:00pm MT
- **Portal:** [PRISM](https://prism.health.utah.gov/)

Questions to ask on a verification call:

- Can the initial 97151 behavior-identification assessment be delivered via telehealth, or does it require an in-person visit?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months)
- https://medicaid-documents.dhhs.utah.gov/Documents/pdfs/EE-Health%20Care%20Eligibility%20Benefit%20Inquiry%20and%20Response%20Companion%20(270,%20271)%20SFY25.pdf (accessed 2026-07-23)
- https://health.utah.gov/stplan/lookup/output_csv.php (accessed 2026-07-23)
- https://web.archive.org/web/20240821082018/https://medicaid.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/Autism%20Spectrum%20Disorder%20Services/AutismSpectrumDisorder7-23.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23)
- https://health.utah.gov/stplan/lookup/CoverageLookup.php (accessed 2026-07-23)
- https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/Autism%20Spectrum%20Disorder%20Services/AutismSpectrumDisorder.pdf (accessed 2026-07-23; source document older than 18 months)
- https://web.archive.org/web/20260717062915/https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid+Information+Bulletins/Traditional+Medicaid+Program/2026/July2026-MIB.pdf (accessed 2026-07-23)
- https://web.archive.org/web/20260217123605/https://www.medicaid.gov/medicaid/spa/downloads/UT-25-0007.pdf (accessed 2026-07-23; source document older than 18 months)
- https://medicaid.utah.gov/contact-information-providers/ (accessed 2026-07-23)
- https://medicaid.utah.gov/accessing-prism/ (accessed 2026-07-23)

## Common questions

### Does Utah Medicaid cover ABA therapy?

Yes — as a state-plan ASD service, fee-for-service, regardless of age (PRISM shows ages 1 and older, adult plans included). No PA on assessments; treatment requires PA in 26-week periods, with a 10-business-day grace to submit after starting services.

### My client is on Molina / SelectHealth / Healthy U / Health Choice — where does the ABA request go?

To Utah Medicaid directly. ABA is carved out of all four ACO contracts to state fee-for-service — the ACO handles only ASD-related PT/OT/ST. There are no per-plan ABA portals, forms, or criteria in Utah.

### What does Utah Medicaid pay for ABA?

Published in the PRISM lookup, effective 7/1/2026 per 15-minute unit: 97153 pays $19.67; 97151, 97155, and 97156 each pay $37.51 (97155 with credential modifiers HP/HO/HN but one published rate).

### Can adults get ABA under Utah Medicaid?

Yes — Utah's ASD services are not an EPSDT child-only benefit. The state offers them regardless of age, and PRISM lists Traditional Adult and Targeted Adult plans among covered eligibility groups.

## Primary sources

1. [Utah Medicaid Provider Manual — ASD Services (July 2023 edition, archived)](https://web.archive.org/web/20240821082018/https://medicaid.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/Autism%20Spectrum%20Disorder%20Services/AutismSpectrumDisorder7-23.pdf)
2. [PRISM Coverage and Reimbursement Lookup (rates & PA flags)](https://health.utah.gov/stplan/lookup/CoverageLookup.php)
3. [Accessing Medicaid Autism Related Services — family FAQ (archived)](https://web.archive.org/web/20260106200503/https://medicaid-documents.dhhs.utah.gov/Documents/pdfs/Accessing%20ASD%20Services%20FAX%20V2,%207-15-24.pdf)
4. [ASD Related Services program page](https://medicaid.utah.gov/ltc-2/asd/)
5. [SPA UT-25-0007 — fee schedule (archived)](https://web.archive.org/web/20260217123605/https://www.medicaid.gov/medicaid/spa/downloads/UT-25-0007.pdf)
6. [July 2026 Medicaid Information Bulletin (archived)](https://web.archive.org/web/20260717062915/https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid+Information+Bulletins/Traditional+Medicaid+Program/2026/July2026-MIB.pdf)
7. [Utah Medicaid Managed Care page (ACO list)](https://medicaid.utah.gov/managed-care/)
8. [Utah Medicaid Provider Manual — ASD Services (updated January 2026)](https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid%20Provider%20Manuals/Autism%20Spectrum%20Disorder%20Services/AutismSpectrumDisorder.pdf)
9. [Utah DHHS — Medicaid SUD/ABA High-Risk announcement (June 23, 2026)](https://dhhs.utah.gov/featured-news/utah-dhhs-will-impose-medicaid-sud-enrollmentmoratorium-to-combat-fraud/)
10. [BACB RBT Handbook (updated 06/2026)](https://www.bacb.com/rbt-handbook)
11. [Utah Code Title 58, Chapter 61, Part 7 — Behavior Analyst Licensing Act](https://le.utah.gov/xcode/Title58/Chapter61/58-61-P7.html)
12. [Utah Administrative Rule R156-61a — Behavior Analyst Licensing Act Rule](https://adminrules.utah.gov/public/rule/R156-61a/Current%20Rules)
13. [Utah Medicaid Provider Manual — Section I: General Information (updated September 2026), ch. 10-1](https://medicaid-documents.dhhs.utah.gov/Documents/manuals/pdfs/Medicaid+Provider+Manuals/All+Providers+General+Information+Section+I/AllProvidersGeneralInfo_Section_1.pdf)
14. [42 CFR 440.230(e) — State Medicaid agency prior-authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-440/subpart-B/section-440.230)
15. [42 CFR 433.139 — Medicaid third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)

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.