--- title: "Advanced Health ABA coverage: the intake guide." url: "https://carelu.com/payers/advanced-health" markdown_url: "https://carelu.com/payers/advanced-health.md" state: OR (Oregon) payer: Advanced Health kind: Medicaid managed care plan (MCO) parent_program: Oregon Health Plan (Coordinated Care Organizations) description: "How Advanced Health covers ABA for OHP members in Coos and Curry counties: its behavioral health authorization form, decision timeframes, timely filing, other-insurance rules, and the OHP rules it applies." last_reviewed: October 2026 --- # Advanced Health ABA coverage: the intake guide. _Payer Guide · Advanced Health · Last updated October 2026 · 17 primary sources_ > Coos and Curry County CCO: ABA requests go on its Behavioral Health Authorization form; 7-day decisions; 120-day timely filing. Advanced Health is the OHP CCO for Coos and Curry counties. It publishes no ABA-specific policy, but its Behavioral Health Authorization Request form (rev. 10/25) names ABA as a request type, and its 2026–2027 provider manual sets the authorization and claims rules. This plan administers the **Oregon Health Plan (Coordinated Care Organizations)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Oregon Health Plan (Medicaid) guide](https://carelu.com/payers/oregon-medicaid). ## Prior authorization and diagnosis at a glance - **Prior auth for the assessment:** Not published / unverified. Verify via: Advanced Health Medical Management, 541-269-7400: ask whether 97151 and 97152 need authorization. [2][3] - **Prior auth for treatment:** Not published / unverified. Verify via: Advanced Health Medical Management, 541-269-7400: confirm which ABA codes require authorization. [2] - **Autism diagnosis required?**: Yes. Advanced Health publishes no ABA criteria of its own and reviews coverage against the Prioritized List, so the OHP rule applies: ASD on the HERC ASD line or stereotyped movement disorder with self-injury (OAR 410-172-0770) [3][7][16] ## At a glance - **Covers ABA?:** Yes, under OHP rules - **Service area:** Coos and Curry counties - **Authorization:** BH Authorization Request (ABA box), fax 541-269-7147 - **Decision clock:** 7 calendar days standard (plus up to 14) - **Timely filing:** 120 days; 365 days for listed exceptions - **Other insurance:** Advanced Health is payer of last resort ## Authorization and claims at Advanced Health Advanced Health’s Behavioral Health Authorization Request asks providers to "Mark one" of Hospital Inpatient, Residential, ABA or Out of Network OP visit, and to fax it to Medical Management at 541-269-7147 with a behavioral health treatment plan, assessment and supporting documentation; the instructions add that "In-network providers do not require prior authorization for outpatient visits." The provider manual (2026–2027, rev. 3.2026) says Advanced Health processes standard authorization requests "no later than 7 calendar days following receipt of the request," extendable by up to 14 days, and that "An authorization may be required if Advanced Health is secondary to primary health coverage," with Advanced Health as "a payer of last resort unless the Member also has Indian Health coverage." [1][2][3] Claims must reach Advanced Health "within 120 days from the date of service," or within 365 days for pregnancy, retroactive eligibility, secondary/tertiary claims and other approved delays. [1][2][3] OAR 410-141-3565 adds two rules every CCO must follow: a timely claim that needs correction or resubmission gets "a minimum of 180 days after the initial adjudication date," and the CCO "shall pay or deny at least 90 percent of valid claims within 30 days of receipt and at least 99 percent of valid claims within 90 days of receipt." No weekly payment cycle or submission cutoff is published. [1][2][3] ## Intake gates The questions that decide whether a family can start with Advanced Health, and what they have to bring. - **Age limit**: Advanced Health publishes no age limit. OHP rules require ABA beyond Guideline Note 75 when medically appropriate "including individuals age 13 and older," and under 21 EPSDT bars age-group-wide denials. [3][7][15] - **Diagnosis recency**: Advanced Health publishes no recency rule. The OHP rule dates only the physical exam and hearing test (OAR 410-172-0770(1)(h)–(i)). [3][7] - **Who may diagnose**: Advanced Health publishes nothing different, so the OHP rule applies: a physician, psychologist, or developmental-medicine NP or PA experienced in autism (OAR 410-172-0770(1), 0760(1)). [3][7][6] - **Diagnostic tools required**: Advanced Health publishes nothing different, so the OHP rule applies: a standardized, validated tool such as the ADOS plus developmental status such as the Vineland (OAR 410-172-0770(1)(b), (g)). [3][7] - **Referral required?**: Advanced Health adds no ABA referral rule of its own, so the OHP rule applies. Yes. Before services, OAR 410-172-0770(1)(k) requires "A referral for ABA treatment with or without specification of hours or intensity" that includes the diagnosis and a copy of the evaluation, from a physician, psychologist, or nurse practitioner or physician associate specializing in developmental medicine who has experience diagnosing and treating autism (OAR 410-172-0760(1)). [3][7][6] - **Telehealth**: Advanced Health publishes no ABA telehealth rule of its own. The state rule applies: "For purposes of behavioral health services, the Authority shall provide coverage for telemedicine services to the same extent that the services would be covered if they were provided in person" (OAR 410-172-0850(5)), using synchronous two-way video (telephone and e-mail only where HERC guidelines allow). OHA’s behavioral health fee schedule lists modifier GT ("Via Interactive Simultaneous Audio and Video Telecommunication Systems") as an allowable modifier on every ABA code it prices, 97151 through 97157, including the 97151 assessment and 97155 protocol modification. [3][9][10] - **Prior-auth decision time**: Standard authorization requests "no later than 7 calendar days following receipt of the request," extendable by up to 14 additional days when more information is needed or on request. [3][11] - **Other insurance (who pays first)**: Advanced Health is "a payer of last resort unless the Member also has Indian Health coverage," may still require an authorization when it is secondary, and needs no PA when Medicare is primary and covers the service. Secondary claims may be filed within 365 days. [3][14] ## Delivery and billing rules Coverage decides whether Advanced Health 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**: Advanced Health publishes no ABA supervision rule, so the state rule applies. OHA does not pay assistant behavior analysts or registered behavior analysis interventionists directly (OAR 410-172-0760(4)); they work under a directly payable Licensed Behavior Analyst, licensed health care professional or declarant. The licensing rule sets the interventionist supervision floor: direct and indirect supervision "for at least 5 percent of the interventionist’s service hours," including direct supervision at least once per calendar month, by a licensed behavior analyst, licensed assistant behavior analyst or licensed health care professional (OAR 824-040-0010). Direct supervision may be remote if it is synchronous audio and video (OAR 824-010-0005). [3][6][13] - **Session-note signature**: Advanced Health publishes no ABA session-note rule. The OHP floor applies: each note "signed or initialed by the individual providing the service" (OAR 410-172-0620(4)). [3][8] - **Bill as provider**: Advanced Health publishes no ABA rendering-provider rule; its form asks for the performing provider and NPI. The OHP rule applies: only a Licensed Behavior Analyst, licensed health care professional or declarant is eligible for direct payment (OAR 410-172-0760(3)–(4)). [2][6] - **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not addressed in Advanced Health’s provider manual or BH authorization form. [3][2] - Ask the plan: Advanced Health provider services (providerservices@advancedhealth.com) or your participation agreement. - **Daily limits / MUEs** _(ask the plan)_: Advanced Health publishes no ABA unit or hour limit. [3] - Ask the plan: Advanced Health Medical Management, 541-269-7400: ask how ABA units are authorized. - **Place of service** _(ask the plan)_: Advanced Health publishes no ABA setting rule. [3] - Ask the plan: Advanced Health provider services: ask which settings and place-of-service codes it pays for ABA. ## What intake should collect for Advanced Health - **Member ID:** Confirm Advanced Health (Coos or Curry county) on the date of service. - **BH assessment and treatment plan:** Required with the BH Authorization Request. - **Diagnostic evaluation and referral:** Meets OAR 410-172-0770; referral from a physician, psychologist, or developmental-medicine NP/PA. - **Other insurance:** Bill the primary first; Advanced Health may still require an authorization as secondary. Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf ## Common questions ### Does Advanced Health cover ABA? Yes, under OHP rules. ABA requests go on its Behavioral Health Authorization Request, faxed to Medical Management at 541-269-7147. ### What is Advanced Health’s timely filing limit? 120 days from the date of service, or 365 days for exceptions such as secondary claims and retroactive eligibility. ## Primary sources 1. [OAR 410-141-3565 — Managed Care Entity Billing (OHA, DMAP 143-2024, eff. 01/01/2025): §§ (1)(a)–(c), (6), (8)(b), (8)(d)](https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-141-3565) 2. [Advanced Health — Behavioral Health Authorization Request form and instructions (Rev. 10/25)](https://advancedhealth.b-cdn.net/wp-content/uploads/2025/12/MH-BH-AUTH-FORM-10.14.25.pdf) 3. [Advanced Health — Provider Manual 2026–2027 (Rev. 3.2026)](https://advancedhealth.b-cdn.net/wp-content/uploads/2025/12/26-27-Provider-Manual-20260414-1.pdf) 4. [Advanced Health — Provider resources (forms and manuals)](https://advancedhealth.com/providers/resources/) 5. [OHA — Coordinated Care Organization (CCO) Plans (CCO list by county, read from the page’s CCO Plan Details list)](https://www.oregon.gov/oha/HSD/OHP/Pages/Plans.aspx) 6. [OAR 410-172-0760 — Applied Behavior Analysis (OHA, eff. 01/09/2025)](https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-172-0760) 7. [OAR 410-172-0770 — Individual Eligibility for Applied Behavioral Analysis Treatment (OHA, DMAP 12-2017)](https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-172-0770) 8. [OAR 410-172-0620 — Documentation Standards, Medicaid behavioral health (OHA, eff. 6/26/2015)](https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-172-0620) 9. [OAR 410-172-0850 — Telemedicine for Behavioral Health (OHA, DMAP 67-2018)](https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-172-0850) 10. [OHA — OHP Fee-for-Service Behavioral Health Fee Schedule, Applied Behavior Analysis tab (update published 7/1/2026)](https://www.oregon.gov/oha/HSD/OHP/DataReportsDocs/bh-fee-schedule0726.xlsx) 11. [OAR 410-141-3835 — CCO Service Authorization (OHA, eff. 07/01/2026)](https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-141-3835) 12. [OAR 410-141-3565 — Managed Care Entity Billing (OHA, eff. 01/01/2025)](https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-141-3565) 13. [OAR 824-040-0010 — Training and Supervision of registered behavior analysis interventionists (eff. 2/1/2018)](https://secure.sos.state.or.us/oard/view.action?ruleNumber=824-040-0010) 14. [OAR 410-120-1280 — Billing (third-party resources; OHA as payer of last resort)](https://secure.sos.state.or.us/oard/view.action?ruleNumber=410-120-1280) 15. [OHA — EPSDT Provider Guide (March 2026)](https://www.oregon.gov/oha/HSD/OHP/Tools/EPSDT-Provider-Guide.pdf) 16. [HERC — Prioritized List Guideline Notes, 10/1/2026 (Guideline Note 75 ABA for ASD, Line 192; Guideline Note 126 ABA for self-injurious behavior, Line 436)](https://www.oregon.gov/oha/HPA/DSI-HERC/PrioritizedList/10-1-2026GL.txt) 17. [Advanced Health — Provider Updates (provider memos and Provider Pulse newsletter archive)](https://advancedhealth.com/providers/advanced-health-provider-newsletters/) Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 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.