---
title: WellSense Health Plan ABA coverage (MassHealth MCO + ACPPs).
url: "https://carelu.com/payers/wellsense-massachusetts"
markdown_url: "https://carelu.com/payers/wellsense-massachusetts.md"
state: MA (Massachusetts)
payer: WellSense Health Plan
kind: Medicaid managed care plan (MCO)
parent_program: MassHealth
description: "How WellSense (formerly BMC HealthNet) administers MassHealth ABA across its Essential MCO and eight ACPPs — in-house behavioral-health UM as of January 1, 2026 (insourced from Carelon), the Massachusetts Standard ABA PA Form it hosts, 3-month initial and 6-month continued authorizations."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# WellSense Health Plan ABA coverage (MassHealth MCO + ACPPs).

_Payer Guide · WellSense · Last updated September 2026 · 8 primary sources_

> Largest ACPP footprint (8 of 15) + Essential MCO; insourced BH from Carelon 1/1/2026, hosts the standard form.

WellSense Health Plan (formerly BMC HealthNet) carries the largest ACPP footprint in Massachusetts — eight of the fifteen Accountable Care Partnership Plans, from Boston ACO to Southcoast — plus the WellSense Essential MCO. That makes it, alongside MBHP, one of the two highest-volume MassHealth ABA payers. Effective January 1, 2026, WellSense brought behavioral-health administration in-house for all its Massachusetts products (Medicaid, Medicare, and ACA), ending its prior arrangement with Carelon — claims for BH services rendered on or after that date go directly to WellSense, not Carelon (Carelon continues to run off inpatient admissions that began before 1/1/2026 through discharge or 3/31/2026, whichever comes first). Requests still ride the Massachusetts Standard ABA PA Form (WellSense hosts the current version), and no plan-specific caps exist. The plan-specific layer is mechanics: portal, fax, and the 3-month initial / 6-month continued cadence spelled out on its form.

This plan administers the **MassHealth** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [MassHealth (Massachusetts Medicaid) guide](https://carelu.com/payers/masshealth-massachusetts-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — "Request for initial evaluation" on the standard form with the comprehensive diagnostic assessment attached; initial requests cover a 3-month timeframe [2]
- **Prior auth for treatment**: Required — continued services in 6-month timeframes; submit pages 1–7 of the standard form (portal or fax 857-264-2673) [2]
- **Autism diagnosis required?**: Yes — ASD via comprehensive DSM-aligned assessment; the plan's form also carries the 1/1/2026 Down syndrome pathway [2]

## At a glance

- **Plan type:** MassHealth MCO (WellSense Essential) + 8 ACPPs
- **Clinical rules:** State baseline — standard form + InterQual criteria + BH performance specs
- **BH administrator:** In-house (WellSense) as of 1/1/2026 — insourced from Carelon
- **Prior auth:** Required — initial requests 3 months; continued services 6 months
- **Submission:** HealthTrio Connect portal; ABA PA fax 857-264-2673
- **Hour caps:** None published — medical necessity based

## How WellSense runs ABA authorization

As of January 1, 2026, ABA for WellSense's MassHealth plans is authorized by WellSense's own in-house behavioral-health team, not Carelon — WellSense assumed BH administration for all Massachusetts products on that date (claims for dates of service before 1/1/2026 still route to Carelon for run-off). Requests still use the Massachusetts Standard ABA PA Form — WellSense hosts the current version (updated March 12, 2026), which already includes the Down syndrome pathway effective January 1, 2026 and doubles for its Clarity commercial product. Initial-evaluation requests check the dedicated box and attach the comprehensive diagnostic evaluation, with initial requests covering a 3-month timeframe; continued-services requests come in 6-month timeframes, submitting pages 1–7 of the form. Channels: the HealthTrio Connect portal, or ABA PA fax 857-264-2673 — confirm current fax/portal routing reflects the in-house team post-insourcing rather than legacy Carelon contacts. One paper-trail note: WellSense's medical PA matrix (effective 7/1/2026) doesn't list ABA codes at all — that's not an exemption; behavioral services route through the BH performance specs instead. [2][3][1]

## What the footprint means for intake

A family may name their ACO — Boston Children's ACO, Mercy, Signature, Tufts Medicine Care Alliance — without ever saying "WellSense," so intake should map ACPP names to the WellSense flow rather than treating each as a separate payer. All eight ACPPs plus the Essential MCO run the same ABA machinery. Since the 1/1/2026 insourcing, that machinery is WellSense's own UM rather than Carelon's — but the 2026 statewide supervision-ratio enforcement still applies here as everywhere: keep 97155 supervision at or above 1:10 against 97153 direct-treatment hours. [4][7]

## Intake gates

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

- **Age limit**: EPSDT sets the bound, and nothing else does. ABA is covered for MassHealth Standard and CommonHealth members under 21, and for Family Assistance members under 19 — with no lower age bound and no dollar, visit or unit-of-service cap underneath it. For the youngest referrals the binding rule is non-duplication rather than age: ABA cannot duplicate services the child already receives through Early Intervention. From 1/1/2026 the second diagnostic pathway (sole-diagnosis Down syndrome) rides the same age structure. [8]
- **Who may diagnose**: The standard form names them, and the list is broader than "send them to a developmental pediatrician." For autism it requires "A comprehensive assessment completed by a licensed physician (i.e. PCP, etc.), advanced practice registered nurse, physician's assistant, or psychologist experienced in the diagnosis and treatment of ASD with developmental or child/adolescent experience which aligns with DSM criteria across ASD core deficits." For the 1/1/2026 pathway it requires instead "A diagnosis of Down Syndrome (Trisomy 21) confirmed by genetic testing." Note the two signatures are different people: the diagnostician writes the assessment, while the form itself "should" be completed by the BCBA rendering and/or supervising the services — an analyst the performance specification requires to be a LABA licensed under 262 CMR 10.00. WellSense hosts this form, so these are the plan's own stated requirements, not an inherited reading. [2]
- **Diagnostic tools required**: No instrument is mandated. The standard form requires a comprehensive assessment "which aligns with DSM criteria across ASD core deficits" without naming ADOS-2, ADI-R, CARS-2 or any other tool, and the performance specification names no diagnostic battery either; the Down syndrome pathway replaces the instrument question entirely with genetic testing. Massachusetts puts its measurement requirement downstream of intake instead — in progress documentation and medical-necessity review, not in the diagnostic gate. [2]
- **Referral required?**: No referral and no physician order is a condition of authorization. The Massachusetts Standard ABA PA Form has no referral field and is completed by the rendering or supervising BCBA/LABA, and the performance specification's referral language is about timeliness rather than permission: "Fourteen calendar days from referral is the Medicaid standard of timely provision for services established in accordance with 42 CFR 441.56(e)," with a waitlist duty (and an obligation to hand caregivers other regional providers' contact information) where the provider cannot start inside it. What the state does require is PCP evidence in the chart rather than at the door: the complete medical record must hold "Referral and assessment documentation" and "Documentation confirming physical examinations by a PCP," and the continued-services pages ask for a dated primary-care care-coordination entry. WellSense's hosted form adds the setting grid instead of a referral: location per day is recorded as H (home), O (office) or C (community). [2][5]
- **Prior-auth decision time**: Published and on the federal clock. WellSense's 2026 manual (MassHealth ACO and MCO) promises standard pre-service decisions "no later than 7 calendar days after receipt of the request, with a possible extension not to exceed 14 additional calendar days." That extension is allowed only if the member or practitioner asks, or if WellSense can justify to EOHHS that it is in the member's interest and needs more information. Expedited requests are decided "no later than 72 hours after receipt of the request." Urgent concurrent requests are also answered "within 72 hours of the request." WellSense's October 31, 2025 notice made the 7-day standard effective January 1, 2026 ("previously 14 days"). WellSense "accepts authorization requests 24 hours a day, seven days per week (including holidays)," and the clock runs from receipt. The manual publishes no ABA-specific reauthorization lead time. The standard form allows continued-services requests in up to 6-month windows. [6][9][10][2]
  - Ask the plan: WellSense BH utilization management: the lead time it wants before an ABA authorization ends.
- **Other insurance (who pays first)**: WellSense pays last for MassHealth members. "MassHealth is always the payer of last resort; any other insurance will always be primary over these programs." The manual makes the provider "Obtain payment from all other liable parties prior to billing us." The claim to WellSense must include "the explanation of benefits, remittance advice, or denial letter from the other payer." The provider has "150 days to bill WellSense after receipt of the primary payer's determination for MassHealth." Other coverage is reported by listing the other carrier on the claim, by calling COB at 617-748-6188, or with the Coordination of Benefits Indicator Form for MassHealth. WellSense "will deny any claims received subsequent to verification of COB if we are the secondary payer." MassHealth's own rule also requires following the primary plan's authorization and network rules. A primary denial for missing PA or for being out of network forfeits the secondary payment (130 CMR 450.316(B)). TRICARE pays before MassHealth: "By law, TRICARE pays after all other health insurance, except for: Medicaid." [6][11][12]
  - Ask the plan: WellSense BH / TPL (617-748-6188): whether WellSense also requires its own ABA PA when it is secondary. The 2026 manual does not waive it.
- **Telehealth** _(ask the plan)_: Permitted at the family's request, with no code list and no POS rule. The ABA provider "may deliver services and consultation via a Health Insurance Portability and Accessibility Act (HIPAA)-compliant telehealth platform at the parent/caregiver's request and if the service can be effectively delivered via telehealth as part of the intervention when appropriate," with the rationale documented and the documentation reflecting "clinical considerations for appropriateness across any service components being delivered via telehealth." Two guardrails ride along: telehealth "must not replace in-person availability," and the member or family "may rescind consent for telehealth at any time without risk of interruption of services." No per-code restriction, modifier or place-of-service code is published. WellSense publishes no deviation from this MassHealth-wide position, and had not republished the specification under its own name as of this review. [5]
  - Ask the plan: WellSense provider services — confirm the in-house BH team applies the MBHP telehealth conditions verbatim.

## Delivery and billing rules

Coverage decides whether WellSense Health Plan 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.

- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: WellSense provider services / PolicyTech reimbursement policies. Note that WellSense’s posted ABA medical policy covers the MA Clarity (ConnectorCare) product, not the MassHealth line.
- **Place of service** _(ask the plan)_: Home and community, with school carved out. ABA “is delivered by a contracted and credentialed provider in a variety of settings within a Member’s home and community,” and “services provided in a school setting are distinct and separate from those covered by the health plan and are typically covered by the educational system’s special education resources as part of the Individualized Education Program (IEP) pursuant to Public Law 94-142.” Providers “must not direct, limit, or discourage access to other medically necessary or school-based services.” Transition planning contemplates moving a member “from a center based setting to home/community settings,” so centers are in scope. Group homes are not addressed. WellSense publishes no deviation from this MassHealth-wide position. [5]
  - Ask the plan: WellSense provider services.

## What intake should collect for WellSense Health Plan

- **ACPP name → WellSense:** Eight ACPPs plus Essential all route to the same Carelon/standard-form flow — map the plan name at intake.
- **Comprehensive diagnostic evaluation:** Attaches to the initial-evaluation request; the form also takes the Down syndrome genetic-testing pathway from 1/1/2026.
- **Pages 1–7, complete:** Continued-services submissions are pages 1–7 of the standard form — incomplete packets stall the 6-month clock.
- **Timeline expectations:** Initial authorizations cover 3 months; continued run 6 — plan reassessment touchpoints accordingly.

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

## Verification of benefits (VOB) data

How WellSense Health Plan ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 01399 — pVerify lists this payer under its legacy name, 'Boston Medical Center Healthnet Plan' (01399) — WellSense's current name was queried but not found in retrieved pVerify content this pass; confirm the ID still applies under the current name.
- **Payer ID (Availity):** 13337
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** In-house (WellSense) since 1/1/2026 — previously Carelon/Beacon Health Strategies — QA 2026-07-23 downgraded verified->unverified: the '1/1/2026 in-house since previously Carelon/Beacon' claim is not stated in any of the three cited sources, and the cited WellSense EDI Companion Guide (Mar 2024) actively contradicts it (still routes BH to Beacon Health Strategies). The insourcing is TRUE but its supporting source — WellSense's own BH provider page (wellsense.org/providers/behavioral-health, 'all other products for MA and NH on Jan. 1, 2026') — is not among the cited refs; add/confirm it before restoring 'verified'.
- **BH administrator payer ID:** n/a post-insourcing — routes through WellSense's own payer ID (13337); pre-1/1/2026 claims used Carelon/Beacon (43324 / BHOVO) — WellSense's own EDI Claims Companion Guide (March 2024) still names Beacon Health Strategies for BH claims — that document PRE-DATES the 1/1/2026 insourcing and is now out of date on this specific point; no post-insourcing WellSense EDI document was found confirming the current BH routing mechanics.
- **ABA rides on:** medical benefit — Inferred from the insourcing announcement, not confirmed against a post-1/1/2026 WellSense billing document.
- **Two-hop verification required:** No — Same as abaRidesOn.

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | — | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |
| 97152 | Yes (assumed covered under the comprehensive EPSDT benefit; not separately priced in the current 101 CMR 358.03 fee schedule — see Layer 4 rates) | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | — | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |
| 97153 | Yes | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | — | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |
| 97154 | Yes | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | 18 units/day (≤4.5 hrs), group size 2–8 members per day | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |
| 97155 | Yes | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | — | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |
| 97156 | Yes | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | — | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |
| 97157 | Yes | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | 18 units/day (≤4.5 hrs), group size 2–8 members per day | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |
| 97158 | Yes (assumed covered under the comprehensive EPSDT benefit; not separately priced in the current 101 CMR 358.03 fee schedule — see Layer 4 rates) | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | — | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |
| 0362T | Yes (assumed covered under the comprehensive EPSDT benefit; not separately priced in the current 101 CMR 358.03 fee schedule — see Layer 4 rates) | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | — | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |
| 0373T | Yes (assumed covered under the comprehensive EPSDT benefit; not separately priced in the current 101 CMR 358.03 fee schedule — see Layer 4 rates) | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | — | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |

Code notes:

- **97151, 97153, 97155, 97156:** WellSense insourced behavioral-health administration from Carelon effective 1/1/2026; no WellSense-published billing/coding manual specific to ABA was found post-insourcing, so this entry is inferred from the pre-insourcing statewide Carelon/MBHP pattern rather than confirmed against a current WellSense document.
- **97152, 97158, 0362T, 0373T:** Not separately priced in the current fee schedule — see Layer 4 for the individual-consideration note. WellSense insourced behavioral-health administration from Carelon effective 1/1/2026; no WellSense-published billing/coding manual specific to ABA was found post-insourcing, so this entry is inferred from the pre-insourcing statewide Carelon/MBHP pattern rather than confirmed against a current WellSense document.
- **97154, 97157:** Group-session cap and size come from the Carelon/MBHP performance spec, not a fee-schedule/coding source. WellSense insourced behavioral-health administration from Carelon effective 1/1/2026; no WellSense-published billing/coding manual specific to ABA was found post-insourcing, so this entry is inferred from the pre-insourcing statewide Carelon/MBHP pattern rather than confirmed against a current WellSense document.

### Contacts

- **Provider services phone:** 1-866-444-5155
- **Phone menu path:** This is Carelon Behavioral Health's line, per WellSense's current MA Provider Quick Reference Guide ("Behavioral Health Services: Call Carelon Behavioral Health, LLC"). For general (non-BH) provider services, call 1-888-566-0008. This QRG still listing Carelon is in tension with the 1/1/2026 in-house BH insourcing already noted in this guide's edi layer - confirm current BH routing before relying on either number.
- **Portal:** [WellSense Provider Portal (HealthTrio)](https://www.wellsense.org)
- **Fax:** 617-951-3464

Questions to ask on a verification call:

- Is ABA/behavioral health currently administered by Carelon Behavioral Health, or has WellSense fully insourced this function as previously indicated for 1/1/2026?
- Does ABA billing currently ride on the medical side (payer ID 13337) or through a separate BH hop?
- What is WellSense's current pVerify payer ID (the file on hand only has the legacy 'Boston Medical Center Healthnet Plan' listing)?
- Are there WellSense-specific per-code unit caps, POS rules, or billing modifiers for ABA codes 97151-97158/0362T/0373T?

### VOB data sources

- https://pverify.com/payer-list/ (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://www.wellsense.org/hubfs/Provider/Documents%20and%20Forms/Claims%20Resources/EDI_Claims_Companion_Guide_for_5010.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.mass.gov/doc/masshealth-standard-companion-guide-health-care-eligibilitybenefit-inquiry-and-information-response-270271-0/download (accessed 2026-07-23; source document older than 18 months)
- https://www.mass.gov/doc/rates-for-applied-behavior-analysis-effective-october-1-2024-0/download (accessed 2026-07-23; source document older than 18 months)
- https://providers.masspartnership.com/pdf/PerfSpec-ABA.pdf (accessed 2026-07-23)
- https://www.wellsense.org/hubfs/Provider/Training/Quick_Reference_Guide_MA.pdf?hsLang=en (accessed 2026-07-23)

## Common questions

### Does WellSense cover ABA therapy?

Yes — across the WellSense Essential MCO and its eight MassHealth ACPPs, on the state-baseline benefit: EPSDT under 21, no caps, PA on all services via the Massachusetts Standard ABA PA Form. Behavioral health, including ABA, has been administered in-house by WellSense since January 1, 2026 (previously Carelon).

### How do I submit an ABA authorization to WellSense?

Via the HealthTrio Connect portal or ABA PA fax 857-264-2673, using the standard form — initial-evaluation requests attach the diagnostic evaluation and cover 3 months; continued services submit pages 1–7 in 6-month timeframes.

### Why isn't ABA on WellSense's prior-authorization matrix?

Because the matrix covers medical services — ABA routes through the behavioral-health performance specifications and the Carelon process. PA is still required for all ABA services.

## Primary sources

1. [WellSense — Behavioral health insourcing FAQs](https://www.wellsense.org/providers/behavioral-health-insourcing/faqs)
2. [WellSense ABA PA Form (MassHealth, upd. 3/12/2026)](https://www.wellsense.org/hubfs/Forms/Provider_Forms/Applied_Behavioral_Analysis_Prior_Authorization_Form_MassHealth.pdf)
3. [WellSense Prior Authorization Matrix (eff. 7/1/2026)](https://www.wellsense.org/hubfs/Provider/Prior%20Authorization/MA_Prior_Auth_Matrix.pdf)
4. [MassHealth Managed Care Options — plan/BH-vendor map (April 2023)](https://abh.memberclicks.net/assets/docs/KeepingCoverage/2023%20MassHealth%20Accountable%20and%20Managed%20Care%20Options%20031723.pdf)
5. [Carelon/MBHP Performance Specifications — Applied Behavior Analysis (upd. Feb 15, 2026)](https://providers.masspartnership.com/pdf/PerfSpec-ABA.pdf)
6. [WellSense Health Plan — Massachusetts Provider Manual (eff. Jan. 1, 2026)](https://www.wellsense.org/hubfs/Provider/Provider%20Manual/MA_Provider_Manual.pdf)
7. [MassHealth ABA supervision audit & recoupment (Acuity News)](https://acuity.news/regulation/masshealth-aba-supervision-audit-recoupment-litigation-2026/)
8. [AIRC — MassHealth ABA Coverage factsheet](https://massairc.org/factsheets/masshealth-aba-coverage/)
9. [WellSense — Reduction of prior authorization decision timeframes (provider communication, Oct 31 2025)](https://www.wellsense.org/hubfs/Provider/News/WellSense_Mass_Provider_Communications_PA_Updates_10_31_25.pdf)
10. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/section-438.210)
11. [130 CMR 450.316 — MassHealth third-party liability: requirements (Cornell LII mirror)](https://www.law.cornell.edu/regulations/massachusetts/130-CMR-450-316)
12. [TRICARE — Using Other Health Insurance](https://tricare.mil/Plans/OHI)

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.