Alabama Medicaid covers applied behavior analysis for children under 21 as an EPSDT-referred service. The state’s rule lists licensed behavior analysts among the "EPSDT-only" providers, and Chapter 37 of the Provider Billing Manual (Therapy: Occupational, Physical, Speech, and Applied Behavior Analysis) sets the coverage rules. Alabama has no Medicaid managed care plans that authorize or pay ABA. Every authorization goes to the Medicaid Agency and every claim goes to its fiscal agent, Gainwell. Since December 1, 2025 the Agency’s Mental Health Services program area runs the ABA section, at appliedbehavioranalysis@medicaid.alabama.gov.
For an agency entering the Alabama Medicaid market, four facts matter up front. Each child needs an EPSDT screening referral (Form 362) and a physician’s order. The BCBA must hold an Alabama behavior-analyst license and enroll, and the claim goes out under the BCBA. Since February 24, 2026 the enrolled service location must be a real facility with signage, not a home or virtual office. And the published rates are low (97153 $10.00 per 15 minutes), so model the economics before you staff up.
Alabama’s EPSDT rule (Ala. Admin. Code r. 560-X-11-.14, amended effective September 14, 2025) covers ABA from "a Licensed Behavior Analyst, a Licensed Assistant Behavior Analyst under the supervision of a Licensed Behavior Analyst, or by an unlicensed Registered Behavior Technician under the supervision of a Licensed Behavior Analyst or Licensed Assistant Behavior Analyst … for E.P.S.D.T. referred children under the age of 21." Services "must be ordered by a physician for an identified condition(s) noted during the EPSDT screening exam." Chapter 37 of the October 2026 Provider Billing Manual holds the program details: eligibility, documentation, the code list and telehealth.[11][1][5][6][13]
No managed care plan sits in between. The Alabama Coordinated Health Network (Chapter 40) splits the state into seven regions whose networks give care coordination through primary care physicians, social workers and nurses. Its referral section says a PCP or network referral is no longer needed for specialty services, "with the exception of Lock-in and EPSDT programs. EPSDT referrals will continue to be required." ABA prior authorizations go to the Medicaid Agency and claims to Gainwell. Do not confuse ABA with the Department of Mental Health’s Rehabilitative Autism Services (Chapter 110). That is a separate DMH-contracted program (behavior support H2019, in-home therapy, care coordination), and H2019 may not be billed together with the ABA codes 97151–97158, 0362T or 0373T. Chapter 110 tells ABA providers to use Chapter 37.[11][1][5][6][13]
Chapter 37 says "All ABA services require prior authorization based on medical necessity determination and submission of required assessments and treatment plans," and both the recipient and the provider get written notice. Its code table and the February 2026 fee schedule both mark 97151 (the behavior identification assessment) "No" for PA, and every other ABA code "Yes." An ABA Therapy Behavior Assessment Form is "required as part of the support documentation for the prior authorization request." Requests go through the Gainwell web portal or a 278 transaction. Supporting documents are uploaded or faxed with a barcode cover sheet, and paper is returned. Chapter 37 says to "allow 14 days for all PAs to be processed." Chapter 4 says that since January 1, 2026 Medicaid has 72 hours for expedited requests and seven calendar days for others. If the Agency asks for more documentation you have 14 calendar days, or the PA is denied.[1][2][10]
Authorizations do not roll over. "Continuation of Applied Behavior Analysis (ABA) treatment services requires submission of a new Prior Authorization (PA) request for each authorization period," filed before the current one expires, with updated documentation showing measurable progress (or a clinical reason it is limited), caregiver participation and coordination of care. If the new PA is not approved in time, "services must stop at the end of the authorization period," and claims after that date are denied. Changes to an approved PA (not reconsiderations, code changes or a new rendering provider) go on Form 471, faxed to (833) 536-2134 or (833) 536-2136; allow five business days.[1][2][10]
Chapter 37 says ABA "must be provided by or under the direct supervision of a qualified behavior analyst, psychologist, or psychiatrist," and that "a qualified behavior analyst must be licensed by the Alabama Behavior Analyst Licensing Board." Since February 26, 2026 that board is the Behavior Analyst Advisory Council within the Department of Mental Health (Act 2026-144); existing licenses carried over. Services are covered when provided by a licensed BCBA, a licensed BCaBA under a BCBA, or an RBT under a BCBA or BCaBA. "BCaBAs and RBTs must be employed by a BCBA and the BCBA assumes professional responsibility," supervision follows current BACB requirements, and "Claims must be submitted by the BCBA." Licensed psychologists and psychiatrists may add ABA specialty 175 to their enrollment.[1][14][11][12][4]
Enrollment runs through Gainwell. The EPSDT rule lets providers in Alabama, or in a bordering state within 30 miles of the Alabama line, enroll as EPSDT-only providers. Since February 24, 2026 an ABA enrollment location "must be a physical facility" with "visible signage bearing the name of the business." A home residence, a cubicle in an office, a shared space inside another business or a virtual office is no longer accepted, and Gainwell may make an unannounced site visit. Providers already enrolled at a location that fails the test had 30 days to fix it.[1][14][11][12][4]
Only with an Alabama license, and only from an approved site. Alabama Medicaid requires an Alabama behavior-analyst license (Chapter 37), and Alabama law bans unlicensed practice of behavior analysis in the state (Ala. Code § 34-5A-2). The telemedicine chapter adds that services "must be provided by a provider who is licensed, registered, or otherwise authorized to engage in his or her healthcare profession in the state where the patient is located," that Alabama law deems the service to take place "at the patient’s originating site within this state," and that providers "must indicate an in-state or qualifying bordering state site of practice address." EPSDT-only enrollment is open to providers in Alabama or within 30 miles of its border, and the ABA location must be a physical facility.[1][7][14][15][11][12]
A BCBA licensed elsewhere can get Alabama licensure through reciprocity, if their home state has comparable requirements and offers Alabama reciprocity, or with a temporary license for limited-period services to Alabama residents (90 days, extendable once, under the licensing rules). Even then, only 97155, 97156 and 97157 may be delivered remotely for Medicaid.[1][7][14][15][11][12]
The Agency publishes a separate ABA fee schedule (effective February 5, 2026), behind the CPT click-through on its Fee Schedules page. Per 15-minute unit: 97151 behavior identification assessment $25.00 (no PA); 97152 $12.50; 97153 adaptive behavior treatment $10.00; 97154 group $4.00; 97155 protocol modification $15.00; 97156 family guidance $30.00; 97157 multiple-family group $2.50; 97158 social skills group $5.00; 0362T $30.00; 0373T $20.00. Every code except 97151 requires PA. Telemedicine is paid "at parity" with face-to-face. There is no copayment on therapy services. Chapter 37 publishes no daily or annual unit caps for ABA. Units must be supported by the record, and claims go through NCCI procedure-to-procedure and medically-unlikely edits.[10][1][7][3]
File ABA claims on the CMS-1500 (or electronically) "within one year of the date of service." Exceptions: 120 days after a third party’s decision, one year after a retroactive eligibility award, or 120 days after a recoupment. ABA codes "cannot be span billed and must be submitted for each date of service." The rendering provider’s NPI goes in 24J on each line. Because the BCBA must employ the BCaBAs and RBTs and must submit the claim, the claim goes out under the BCBA. Valid places of service are 11 (office) and 12 (home, for ABA only). Telemedicine claims use one of those POS codes with modifier GT. Gainwell processes approved and denied claims through the financial cycle twice a month.[1][3][2][7]
Chapter 37 does not mention electronic visit verification for ABA; the Agency lists EVV under its long-term-care and waiver programs. If a PA is denied, you may ask Gainwell for reconsideration within 14 days of the denial letter, and a Fair Hearing request must arrive within 60 days. For ABA, Chapter 37 says second-level appeals go by mail, with all supporting documents, to the Associate Director, Mental Health Programs, P.O. Box 5624, Montgomery, AL 36103-5624. A licensed psychologist or psychiatrist reviews them. You may not bill the family for a service whose PA was denied.[1][3][2][7]
The questions that decide whether a family can start with Alabama Medicaid, and what they have to bring. Each maps onto something intake should ask on the first call.
Under 21. Chapter 37: "Children must be under the age of 21"; the EPSDT rule covers ABA "for E.P.S.D.T. referred children under the age of 21."[1][11]
Chapter 37 sets no age limit on the diagnosis. The dated requirement is the referral: Appendix A says "a new approval/EPSDT screening must be provided anytime the diagnosis, plan of care … or treatment changes," and a new screening and referral are needed once the referral expires. Each continuation PA needs updated clinical documentation.[1][8]
A diagnosis "as determined by a licensed physician, psychologist, or other qualified professional within their scope of practice" (Chapter 37).[1]
None is mandated. Chapter 37 gives examples: autism-specific tools (CARS-2, CAST, SCQ, SRS-2, ABC, GARS, Aberrant Behavior Checklist, ADOS-2, ADI-R, CHAT), adaptive measures (Vineland, ABAS), and cognitive tests (Leiter-R, Mullen, Bayley, K-ABC-II, WPPSI-III, WISC-IV, TONI-4). The treatment plan should name any standardized assessment used and its results.[1]
Yes. ABA is an EPSDT-referred service: the child needs an EPSDT screening (periodic or interperiodic well-child visit) and the Alabama Medicaid Referral Form (Form 362), completed by the screening physician "including the screening date that the problem was identified and the reason for referral," plus a physician’s or non-physician practitioner’s order. The referral can be the order: "The EPSDT referral form may be considered as the physicians’ order" when it carries "the date and signature of the provider, the service(s) ordered and the recipient’s name." Hard-copy referrals need the printed or typed name of the primary care physician with an original signature of the physician or a physician or non-physician designee; "stamped or copied signatures will not be accepted." Validity: "the maximum time an EPSDT referral remains valid is 12 months from the date of the EPSDT screening," the screening date "may not be backdated or future dated," and the form must state the number of visits or months to be valid. A new screening and referral are needed when the referral expires or "anytime the diagnosis, plan of care … or treatment changes." Without a completed referral in the record, "payments for these services will be recouped." No separate ACHN PCP referral is needed for specialty care. On the CMS-1500, put the EPSDT referring provider in block 17 and the referring NPI in 17b (used only for lock-in, EPSDT or maternity referrals), and enter "1" in block 24H for a service resulting from an EPSDT referral.[1][8][5][11][3]
Only 97155, 97156 and 97157 (the Chapter 37 table marks every other ABA code "Telehealth Allowed: No"), delivered by live audio-video with modifier GT and a POS of 11 or 12. The provider must enroll with telemedicine specialty 931 (Telemedicine Service Agreement), get the recipient’s consent first, and have trained staff who know the treatment plan "immediately available in-person to the recipient." A parent or guardian must attend for a minor. The provider must be licensed in Alabama (where the patient is) and practice from an Alabama or qualifying bordering-state site. Telemedicine is paid at parity.[1][7]
Chapter 4 says that since January 1, 2026 Medicaid has "72 hours to provide a response for expedited requests and seven calendar days" for others, matching the federal floor for state agencies (42 CFR 440.230(e)). Chapter 37 still tells ABA providers to "allow 14 days for all PAs to be processed." When more documentation is requested you have 14 calendar days. Reconsideration must reach Gainwell within 14 days of the denial letter; a Fair Hearing request within 60 days. Form 471 changes take about five business days. File continuation PAs before the current authorization ends, because services must stop when it lapses.[2][1][17]
Medicaid pays last. "Because Medicaid is the payer of last resort, the system confirms that a third party resource is not responsible." Claims after another payer go in with the TPL payment or denial. Denials on the Agency’s approved list are filed electronically; any other denial needs a paper claim showing a good-faith effort to collect from the primary payer. Claims over a year old are accepted within 120 days of the third party’s decision.[3][18]
Coverage decides whether Alabama Medicaid pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
A licensed BCaBA works under a BCBA; an RBT works under a BCBA or BCaBA. "BCaBAs and RBTs must be employed by a BCBA and the BCBA assumes professional responsibility for the services." The BCBA and BCaBA "must document supervision and direct observation according to the current requirements of the Behavior Analyst Certification Board." Alabama Medicaid publishes no ratio of its own; the BACB’s requirements are what it enforces.[1][11]
No daily or annual unit caps for ABA are published in Chapter 37 or on the fee schedule. Units are set per PA, the record must support every unit billed, codes are billed per date of service (no span billing), and claims pass through NCCI procedure-to-procedure and medically-unlikely edits.[1][10][3]
Each session note needs the CPT code, date, start and end time, location, the "signature and credentials of staff delivering service," and the "client or guardian signature," plus progress, supervisory documentation and fidelity monitoring. Entries "must be authenticated and dated (prior to being submitted for reimbursement)" by the person responsible. Handwritten, initials (for treatment plan reviews) or electronic authentication is accepted; "a stamped signature is not acceptable."[1]
POS 11 (office) and POS 12 (home, "for ABA therapy only"); telemedicine claims use one of those with modifier GT. Since February 24, 2026 the enrolled ABA location must be a physical facility with visible signage, not a home residence, a cubicle in an office, a shared space in another business or a virtual office.[1][12]
The BCBA. "Claims must be submitted by the BCBA" (Chapter 37), and the EPSDT rule says "Claims must be submitted by the Licensed Behavior Analyst." The supervising provider must employ the person delivering the service, and "the supervising therapist must assume full professional responsibility for services provided and bill for such services." The case record must name the person who delivered each service. The rendering NPI goes in block 24J.[1][11][3]
Not addressed. Chapter 37 (October 2026) and the ABA fee schedule list 97153 and 97155 as separate PA-required codes and say nothing about billing them for the same clock time, or about ABA at the same time as speech, occupational or physical therapy; the only overlap rule in the chapter is that 96125 is not billed with autism testing codes 96112 and 96113. Claims pass through NCCI procedure-to-procedure edits.[1][10]
Ask the plan: Ask the Alabama Medicaid ABA program in writing (appliedbehavioranalysis@medicaid.alabama.gov), or the Gainwell Provider Assistance Center, 1-800-688-7989, whether 97155 may be billed for the same minutes as a technician’s 97153 and whether ABA may overlap a speech or OT session.
Yes, for recipients under 21 referred through an EPSDT screening, with a diagnosis such as F84.0, F84.3, F84.5, F84.8 or F84.9. Every ABA code except 97151 needs prior authorization from the Medicaid Agency.
No. Alabama Medicaid pays ABA fee-for-service through Gainwell. The Alabama Coordinated Health Networks do care coordination; they do not authorize or pay ABA.
Per 15 minutes under the February 2026 fee schedule: 97151 $25.00, 97152 $12.50, 97153 $10.00, 97154 $4.00, 97155 $15.00, 97156 $30.00, 97157 $2.50, 97158 $5.00, 0362T $30.00, 0373T $20.00.
Only 97155, 97156 and 97157, by live audio-video with modifier GT, after enrolling in telemedicine specialty 931 and with staff available in person to the child. The 97151 assessment and technician 97153 must be in person.
Not without an Alabama behavior-analyst license. Medicaid requires the license, telemedicine providers must be licensed where the patient is, and EPSDT-only enrollment is limited to Alabama and providers within 30 miles of the state line. Out-of-state BCBAs can apply for reciprocity or a 90-day temporary license.
One year from the date of service, or 120 days from a primary payer’s decision for claims older than a year.
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.
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