AlohaCare is a Hawaii-based, Medicaid-focused QUEST Integration plan. The benefit is Med-QUEST’s — memo QI-2431 / FFS 24-13, for members under 21 with ASD — but since March 22, 2026 AlohaCare has its own ABA medical policy, MP-37, which is stricter than the memo in places: the diagnosis must rest on a standardized tool (ADOS-2, CARS-2 or ADI-R), the diagnosing-provider list is shorter, and requests above 30–40 hours a week need strong justification. MP-37 says that where it conflicts with Med-QUEST guidance, "MQD guidance prevails." AlohaCare’s PA lookup requires authorization for every ABA code, including the 97151 assessment.
MP-37 covers ABA under EPSDT for members under 21 when all its criteria are met. Eligibility needs a DSM-5 ASD diagnosis "including documentation of early developmental symptoms AND standardized diagnostic evaluation tools (i.e., ADOS-2, CARS-2, ADI-R)," made by a developmental-behavioral pediatrician, developmental pediatrician, pediatrician, neurologist, psychologist or psychiatrist. That list is shorter than the memo’s, which also allows "other licensed practitioner with specialized expertise in ASD"; MP-37 says MQD guidance governs where the two conflict, so raise it with AlohaCare if the diagnosis came from someone else. The treatment plan is written by a licensed behavior analyst and must include a functional behavioral assessment with operational definitions, baseline data for every goal area, the clinical reason for the requested intensity, a parent-training plan, a safety plan when needed, generalization strategies, and a titration (step-down) plan. It is updated at least every 26 weeks.[1][5]
Limits: 40 hours a week "is not automatically approved," and anything above 30–40 hours needs documented severe needs, a clinical reason, a step-down timeline and evidence of progress. Not covered: services that duplicate DOE, HCBS or custodial supports; services by family or household members; custodial care; experimental treatment; unsupervised services; telehealth used inappropriately (for example with no caregiver present when one is needed for safety); and services outside Hawaii without prior authorization.[1][5]
AlohaCare’s PA lookup, which the plan calls the most current source, lists 97151 through 97158, 0362T and 0373T as prior-authorization codes for QUEST, effective since 2018–2019 and confirmed on September 23, 2026. The diagnostic evaluation (for example 90791) needs no authorization. Requests go on the Request for Authorization and Notification form. AlohaCare reviews against its own policies and "nationally developed clinical criteria (such as MCG ...)," and asks for missing information twice before denying: within 2 days and then 7 days for a standard request.[2][4][3][6]
Timing: the September 2025 provider manual still prints the 14-calendar-day standard (plus a 14-day extension) and 72 hours for expedited requests. The federal managed-care rule has required 7 calendar days for standard decisions since rating periods starting January 1, 2026, so hold AlohaCare to that. AlohaCare’s published 2025 metrics show an average standard turnaround of 107 hours and a median of 28 hours.[2][4][3][6]
The questions that decide whether a family can start with AlohaCare (QUEST Integration), and what they have to bring. Each maps onto something intake should ask on the first call.
Under 21 — MP-37 eligibility 2.1: "Member is under 21 years of age."[1]
No recency window in MP-37 or the MQD memo. MP-37 does require a diagnostic evaluation with the initial request and progress reports every 26 weeks.[1][5]
Developmental behavioral pediatrician, developmental pediatrician, pediatrician, neurologist, psychologist or psychiatrist. The MQD memo also allows another licensed practitioner with ASD expertise, and MP-37 says MQD guidance governs if the two conflict.[1][5]
Required: DSM-5 criteria plus documented early developmental symptoms AND standardized diagnostic evaluation tools — ADOS-2, CARS-2 or ADI-R. The treatment plan then needs an FBA and baseline data for every goal area.[1]
No PCP referral is needed for in-network specialty care: the provider manual says specialty services "do not require a referral if the services are provided by an in-network/participating provider within the member’s home island." ABA is controlled by prior authorization, and the diagnostic evaluation needs no authorization.[3][2][1]
The September 2025 manual prints 14 calendar days (plus up to 14) for standard decisions and 72 hours for expedited ones, and treats a request as denied for missing information if nothing arrives within 14 calendar days (72 hours if expedited) after two requests. The federal limit for rating periods from January 1, 2026 is 7 calendar days (extendable by 14) and 72 hours expedited. Continuation requests are due at least two weeks before the period ends (MQD memo). AlohaCare’s 2025 average standard turnaround was 107 hours.[3][6][5][4]
MP-37 covers "Telehealth ABA consistent with MQD and BACB standards" and denies inappropriate use, for example no caregiver present when one is needed for safety. It does not list which codes may be delivered remotely; MQD’s QI-2527 requires audio-video with modifier 95, GT or GQ.[1][8]
Ask the plan: AlohaCare Provider Services (808) 973-1650 / 1-800-434-1002 — ask which ABA codes it pays via telehealth and with which POS.
AlohaCare "is always considered the payer of last resort." Bill the primary carrier first and send AlohaCare the claim with the primary EOB. Primary-plan denials must be appealed first, except denials for eligibility or non-covered services, and AlohaCare pays up to its own allowance minus the primary payment. The manual does not say whether AlohaCare PA is waived when it pays second, so get it. TRICARE pays after other coverage except Medicaid; CHAMPVA pays last.[3][7][9][10]
Ask the plan: AlohaCare Provider Services — confirm whether ABA PA is still required when AlohaCare is secondary.
Coverage decides whether AlohaCare (QUEST Integration) 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.
LBA supervision of RBTs and BCaBAs must meet current BACB and MQD requirements. For RBTs, at least 5% of total service hours must be supervised by an LBA and documented, including direct observation with the member, ongoing case review and feedback, and records of supervision in the clinical file. MQD’s memo sets the wider standard: 1–2 hours of case supervision per 10 RBT hours, at least one of them direct.[1][5]
97153 and 97155 may be billed concurrently only when an RBT or BCaBA is delivering 97153, the LBA is at the same time delivering 97155 with "actively performing medically necessary protocol modification," and the member needs real-time modification. Not allowed when the LBA is only observing or documentation doesn’t separate the two. Required: separate notes for each code, the clinical reason, the LBA’s modification activity, start/stop times for both, and supporting data.[1]
No per-day unit cap is published. Intensity must be individualized: 40 hours a week "is not automatically approved," and requests above 30–40 hours a week need documented severe needs, a clinical reason, a step-down timeline and evidence of progress.[1]
Records must show date, time, duration and location of each service, the goals targeted and the member’s response, progress data, start/stop times for time-based codes, "signatures of rendering provider (RBT/BCaBA) and supervising LBA," and supervision documentation meeting BACB and MQD standards. The initial treatment plan must be signed by an LBA.[1]
Settings follow the memo — clinic, home or community, as named in the treatment plan. Not covered: services that duplicate DOE, HCBS or custodial supports, and services outside Hawaii without prior authorization. Telehealth is covered when consistent with MQD and BACB standards.[1][5]
Bill with the CPT/HCPCS codes and modifiers in MQD Attachment C (QI-2431). An RBT works only under LBA supervision "and cannot bill independently"; a BCaBA works only under LBA supervision. The LBA must hold a Hawaii license and be credentialed with Medicaid. Payment goes to the licensed practitioner or the agency that employs or contracts with them.[1][5]
Yes — under EPSDT for members under 21 with ASD, following Med-QUEST memo QI-2431 and AlohaCare’s own ABA policy MP-37 (effective March 22, 2026).
Yes. AlohaCare’s PA lookup lists 97151, 97152 and 0362T as prior-authorization codes for QUEST. The diagnostic evaluation needs none.
A DSM-5 ASD diagnosis with documented early symptoms and a standardized tool — ADOS-2, CARS-2 or ADI-R — from a developmental-behavioral or developmental pediatrician, pediatrician, neurologist, psychologist or psychiatrist.
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.
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