Ambetter is Centene's ACA Marketplace (exchange) brand. In Indiana it shares a parent with MHS, the Centene Medicaid plan in its own guide (mhs-indiana), and the provider materials still carry the "Ambetter from MHS" name, but it is a separate product with its own Evidence of Coverage, prior authorization list, network and cost sharing. MHS Medicaid follows IHCP rules; Ambetter follows its EOC and Centene's ABA clinical policy CP.BH.104 as posted for Ambetter in Indiana.
The 2026 Indiana EOC covers applied behavior analysis therapy under Autism Spectrum Disorder Benefits "when prescribed by a physician or behavioral health practitioner" and says "No limitation exists within the benefits for applied behavior analysis services." Every ABA code needs prior authorization, the family pays the plan's deductible and coinsurance, and the clinical bar (diagnostic tools, a behavior assessment no more than two months old, six-month updates) is set by CP.BH.104.
An Ambetter card in Indiana is a Marketplace policy, not Medicaid. The 2026 provider manual describes Ambetter Health as "a Qualified Health Plan issuer in the Indiana Health Insurance Marketplace," and its own prior authorization list, network and timely-filing rules apply. Being in network for MHS Medicaid does not by itself put a practice in the Ambetter network, and the IHCP ABA rules (the Medicaid six-month PA request limit, IHCP provider specialties) do not carry across.[5][1][2]
Ambetter also sells "Ambetter Health Solutions," an individual-coverage HRA product with its own EOC (76179IN014-2026). Its Autism Spectrum Disorder Benefits text reads the same as the Marketplace EOC we cite here, but check which EOC the member's plan ID points to before quoting benefits.[5][1][2]
"Coverage is provided for autism spectrum disorders when prescribed by a physician or behavioral health practitioner," including evaluation and assessment services, "applied behavior analysis therapy," behavior training and behavior management, habilitation, speech, occupational and physical therapy, psychiatric care and medications. Then: "No limitation exists within the benefits for applied behavior analysis services. These services are subject to prior authorization to determine medical necessity." When several providers bill on the same day, "a separate copayment amount and/or coinsurance amount will apply to each provider." The EOC defines ABA as services designed and evaluated "by a board-certified behavior analyst."[1][10]
For an individual policy, Indiana's mandate (IC 27-8-14.2-5) requires the insurer to offer autism coverage for treatment prescribed by the treating physician under a treatment plan, without dollar limits, deductibles or coinsurance less favorable than for physical illness. The EOC is the document that puts ABA in this plan; quote the family's deductible status and coinsurance along with the benefit.[1][10]
Ambetter's Indiana prior authorization list (published under CMS-0057-F; list effective 12/31/2025) names "Applied Behavior Analysis (ABA)" with codes 0362T, 0373T and 97151–97158. The manual prefers the secure provider portal; requests also go by phone to Utilization Management at 1-877-687-1182 or by fax on the posted forms, and must carry the member's name, date of birth and ID, and the provider's Tax ID, NPI, taxonomy code, name and phone.[3][4][5][11][12]
Ambetter's ABA Prior Authorization Request Form (UM fax 1-866-279-1358) asks for the billing and supervising provider, the codes and units per week or month, school, IEP/504 and early-intervention status, and other therapies. For the initial assessment it wants "Comprehensive diagnostic information including standardized measures and referral from diagnosing provider for ABA services to include estimated duration of care." For the initial treatment plan: objective testing showing a significant behavioral deficit, coordination with school and other therapists, the proposed schedule "including the provider type who will render services," measurable goals with timeframes, a parent-training plan, relevant medical conditions and a copy of any IEP or IFSP. Subsequent requests need objective measures of current status and progress on each goal, the updated plan, and "Developmental testing which should have occurred within the first two months of treatment." The form is dated 8/21, so confirm Ambetter still uses it.[3][4][5][11][12]
Decision clock. The 2026 manual lists "Prospective/Urgent — Within 48 hours of receipt of the request" and "Prospective/Non-Urgent — Within 5 business days of receipt of the request," and retrospective decisions in 30 calendar days. Indiana law is tighter for a utilization review entity: 24 hours for an urgent request and 48 hours for any other, with weekends and state and federal holidays excluded (IC 27-1-37.5-23). Indiana also says an authorization "shall be valid for at least one (1) year" after the provider receives it (IC 27-1-37.5-26(b)), while Ambetter's policies run six-month review cycles; check the dates on each approval.[3][4][5][11][12]
Diagnosis. A confirmed DSM autism diagnosis with severity level, intellectual and language impairment noted, from "a licensed physician, psychologist, or other licensed professional with specialized training in diagnosis and treatment of ASD, or a provider otherwise authorized under state law/regulation." The comprehensive diagnostic evaluation (CDE) must document direct observation, a caregiver interview and a report with each instrument's scores and date, and the diagnosis must rest on "at least one primary clinician tool and one parent/caregiver tool": clinician tools include STAT, ADI-R, CARS-2, ASRS, ADOS-2, EarliPoint, RITA-T and CSBS DP-ITC; caregiver tools include M-CHAT-R/F, SCQ, ASSQ, CAST, SRS-2 Parent Report, SWYC POSI and CSBS DP ITC. Physical causes (hearing, speech, medical) must be ruled out.[6]
How recent. To start treatment, the CDE must be within the past three years, or three to five years old with a diagnostic interview/evaluation within 12 months of the request. For continuation, the CDE must be within the past five years, with re-evaluation sooner for a provisional diagnosis, no formal psychological evaluation, a discrepancy between the tools and the diagnosis, or transitions.[6]
Behavior assessment. Completed by a BCBA/BCBA-D (or a state-recognized equivalent) "no more than two months prior to the start of the initial treatment authorization," with record review, interviews, rating scales, direct measurement of behavior, and an FBA (descriptive, functional analysis or IISCA) for problem behavior and/or a skills assessment (VB-MAPP, ABLLS-R, AFLS, PEAK, EFL, SSIS, Socially Savvy). The Vineland alone does not count as the skills assessment.[6]
The plan must carry the signature, credentials and role of the responsible BCBA and the parent or guardian, individualized goals with baseline data and mastery criteria, a crisis plan, a school-based plan where services occur at school, and a transition and titration plan. Hours must consider school attendance ("less than 20 hours per week if attending school full-time") and "Do not exceed six hours per day up to a total of 30 hours per week" unless documentation justifies more; Ambetter "may authorize services at a lower intensity, frequency, or duration than requested." Protocol modification (97155) must occur "for at least two hours per week or 10% of the direct service hours provided, whichever is greater," and caregiver training ideally at least two hours a month.[6][7]
Continuation needs an updated behavior assessment and treatment plan "at least every six months," progress data with graphs, attendance as a percentage of scheduled sessions (below 80% of authorized hours needs justification), caregiver participation and coordination of care. CP.BH.105 enforces the protocol-modification floor at payment: 97153/97154 units for "the entire six-month authorization period" that are not supported by the 10% protocol-modification level "are subject to denial of payment or recoupment," and protocol modification above 20% of direct hours needs justification.[6][7]
Discontinuation criteria include no clinically significant progress "for a period of at least six months," services in lieu of school or respite, and services covered under IDEA, which CP.BH.104 lists as not medically necessary.[6][7]
Retrospective review is only for "extenuating circumstances (i.e., member was unconscious at presentation, member did not have their Ambetter ID card or otherwise indicated other coverage, services authorized by another payer who subsequently determined member was not eligible at the time of service)," and "If a claim is denied for lack of authorization for a service that requires authorization, Ambetter will not retrospectively review the request for authorization." When a review is warranted the decision comes within 30 calendar days of receiving all information.[5]
Timely filing (2026 manual): initial claims 180 days from the date of service for participating providers and 90 days for non-participating providers; reconsiderations and disputes 180/90 days from Ambetter's explanation of payment; coordination-of-benefits claims 180/90 days from the primary payer's EOP.[5]
The questions that decide whether a family can start with Ambetter of Indiana, and what they have to bring. Each maps onto something intake should ask on the first call.
None stated. The 2026 EOC's Autism Spectrum Disorder Benefits section and CP.BH.104 set no age limit, and the EOC says "No limitation exists within the benefits for applied behavior analysis services."[1][6]
To start: a comprehensive diagnostic evaluation within the past three years, or one three to five years old plus a diagnostic interview/evaluation within 12 months of the request. To continue: a CDE within the past five years, sooner for a provisional diagnosis, no formal psychological evaluation, a tools-versus-diagnosis discrepancy, or transitions. The behavior assessment must be no more than two months old at the start of the initial treatment authorization.[6]
"A licensed physician, psychologist, or other licensed professional with specialized training in diagnosis and treatment of ASD, or a provider otherwise authorized under state law/regulation"; the same group makes the ABA recommendation (which may sit inside the CDE). The EOC covers autism services "when prescribed by a physician or behavioral health practitioner."[6][1]
At least one primary clinician tool (STAT, ADI-R, CARS/CARS-2, ASRS, ADOS/ADOS-2, EarliPoint, RITA-T, CSBS DP-ITC, or another evidence-based tool reviewed case by case) and at least one parent/caregiver tool (M-CHAT/M-CHAT-R/F, SCQ, ASSQ, CAST, SRS-2 Parent Report, SWYC POSI, CSBS DP ITC, or another), with scores and dates in the report.[6]
Yes, in two places. The EOC covers autism services "when prescribed by a physician or behavioral health practitioner," and the ABA PA form asks, for the initial assessment, for "referral from diagnosing provider for ABA services to include estimated duration of care." CP.BH.104 requires an ABA recommendation from the diagnosing-level clinician (it may be in the CDE) whenever an initial or updated CDE is required. No Ambetter document we read sets an expiry for the referral or a required form; the PA form itself is dated 8/21.[1][4][6]
The 2026 manual: urgent prospective requests "Within 48 hours of receipt," non-urgent prospective "Within 5 business days of receipt," urgent concurrent 1 calendar day (one extension up to 3 days), retrospective 30 calendar days. Indiana law for utilization review entities is shorter: 24 hours urgent and 48 hours for other services, not counting weekends and state and federal holidays (IC 27-1-37.5-23).[5][11]
Allowed in principle but not code by code. CP.BH.104 lists telehealth among ABA modalities and tells providers to "refer to respective state allowances for telehealth services"; CP.BH.105 requires a HIPAA-compliant platform with the rendering provider's camera on, and the monthly one-on-one 97155 protocol work may not be by telehealth "unless allowed by state guidelines." The 2026 manual bills telehealth with POS 02 or 10, and the EOC applies in-person cost sharing to telehealth outside Virtual 24/7 care. Which ABA codes Ambetter pays remotely is not listed.[6][7][5]
Ask the plan: Ask Ambetter UM to note telehealth delivery on the authorization and confirm which ABA codes (97151, 97155, 97156) it will pay with POS 02/10.
The EOC follows the birthday rule for a child covered under both parents' plans when the parents are married or living together: the plan of "the parent whose birthday falls earlier in the calendar year" is primary (same birthday: the plan that covered the parent longer); a court decree controls for separated or divorced parents. A Medicaid state plan is one that "by law, provides benefits that are in excess of those of any" private plan, so Ambetter pays before Indiana Medicaid. COB claims are due 180 days (participating) or 90 days (non-participating) from the primary payer's EOP.[1][5]
Ask the plan: Collect every coverage the child has, both parents' birthdays and any custody decree at intake; confirm primacy with Ambetter and the other carrier.
Coverage decides whether Ambetter of Indiana 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.
Ambetter sets a protocol-modification floor rather than a supervision ratio: 97155 "for at least two hours per week or 10% of the direct service hours provided, whichever is greater", and no more than 20% of direct service hours unless clinical documentation justifies more (CP.BH.104; CP.BH.105). Monthly one-on-one protocol work (97155) must be "Rendered by ABA supervisor" and not by telehealth unless state guidelines allow. Treatment must be "delivered or supervised by an ABA-credentialed professional," and unsupported 97153/97154 units are subject to denial or recoupment.[6][7]
CP.BH.104 caps treatment hours unless justified: they "Do not exceed six hours per day up to a total of 30 hours per week," or clinical documentation justifies more (high-intensity behaviors or significant skill deficits), and hours should be "less than 20 hours per week if attending school full-time." The PA form asks for units per week or month for each code. No Ambetter document we read publishes per-code daily unit (MUE) ceilings.[6][4]
CP.BH.105: session notes "are completed prior to claim submission" and carry the rendering provider or technician's name at the top, the exact start and end time, pauses, location, the service code and the "Signature of qualified rendering provider/technician"; a note written on a later day must give its creation date and why. Clinical documentation is reviewed and updated at regular intervals with the signatures and printed names of the member, legal guardian, rendering clinician/technician and supervising practitioner (as applicable). Caregiver signature on 97156/97157 notes is recommended. Addenda need the reference, date and the clinician's signature and credentials; a discharge summary needs the rendering provider's and caregiver's signatures.[7]
CP.BH.104 says services may be provided "in various settings (e.g., home, clinic, school, community) and modalities (e.g., in-person, telehealth)," requires a stated treatment setting with rationale, and requires a "Detailed school-based plan" (hours, operationally defined target behaviors, a titration plan for reducing school services, school-specific graphs) when ABA is delivered at school. Services "otherwise covered under the Individuals with Disabilities Education Act (IDEA)" and services "in lieu of school, respite care, or other community-based settings" are not medically necessary. Telehealth is billed with POS 02 or 10 (2026 manual).[6][5]
Not stated in the Ambetter Indiana documents we read. CP.BH.105 describes 97155 as possibly used "to demonstrate new or modified protocol to a technician with the member/enrollee present" and says "Technician supervision only or team meetings do not constitute protocol modification," but neither CP.BH.104, CP.BH.105 nor the 2026 provider manual says whether 97155 and 97153 may be billed for the same minutes.[7]
Blocked on: Ambetter of Indiana provider services or the payment policies on its clinical and payment policies page: ask whether 97153 and 97155 may be reported for the same clock time by two providers.
The ABA PA form names a billing provider (Tax ID and NPI) and a separate supervising provider, and the HSPP or physician and the rendering provider each sign it; PA requests must include the provider's taxonomy code. No Ambetter Indiana document we read says whether a technician's 97153 goes out under the technician's or the supervising BCBA's rendering NPI, or whether a BCaBA may bill under its own NPI.[4][5]
Ask the plan: Ambetter of Indiana provider services (1-877-687-1182) or the provider contract: which NPI goes in the rendering field for technician-delivered 97153, and whether BCaBAs are credentialed to bill.
Yes. The 2026 Indiana EOC covers applied behavior analysis therapy for autism "when prescribed by a physician or behavioral health practitioner," says "No limitation exists within the benefits for applied behavior analysis services," and makes it subject to prior authorization. The family's deductible and coinsurance apply.
Commercial. Ambetter is a Marketplace (ACA exchange) policy with its own EOC, PA list and Centene clinical policy CP.BH.104. MHS, Centene's Indiana Medicaid plan, follows IHCP rules and has its own guide.
Ambetter's policies work in six-month cycles: CP.BH.104 requires an updated behavior assessment and treatment plan "at least every six months," and CP.BH.105 refers to "the entire six-month authorization period." Indiana law says an authorization "shall be valid for at least one (1) year" after the provider receives it (IC 27-1-37.5-26(b)). Read the start and end dates on each approval letter and ask UM if a span is shorter than you requested.
Yes. 97151 and 97152 are on Ambetter's Indiana PA list with the other ABA codes. Send diagnostic information with standardized measures and the diagnosing provider's referral, per the ABA request form.
Rarely. The 2026 manual limits retrospective review to extenuating circumstances (an unconscious member, no ID card or other coverage shown, another payer that later found the member ineligible) and says Ambetter will not retrospectively review a claim denied for lack of a required authorization.
180 days from the date of service for participating providers, 90 days for non-participating providers (2026 provider manual); secondary (COB) claims 180/90 days from the primary payer's EOP.
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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