Ambetter from Peach State Health Plan is the Georgia Marketplace (ACA individual) product of Centene, underwritten by Ambetter of Peach State Inc. It is not the Peach State Health Plan Medicaid plan: different contract, different rules, and the family pays a deductible and coinsurance. The 2026 Evidence of Coverage is an Individual Member HMO contract, so services from a non-network provider "are not covered" except emergencies. Being credentialed in the Ambetter network matters before anything else.
Three facts drive intake. The contract covers applied behavior analysis with "No limitation" on the benefit, and with no age limit. Every ABA code except 97157 needs prior authorization, decided under Centene's CP.BH.104 criteria. Authorizations run six months, each renewal needs an updated assessment, treatment plan and progress data, and CP.BH.105 can recoup technician hours when protocol modification falls under 10%.
The contract's Autism Spectrum Disorder Benefits cover autism "when prescribed by a physician or behavioral health practitioner," including "Evaluation and assessment services," "Applied behavior analysis therapy," behavior training and management, habilitation, speech, occupational and physical therapy, psychiatric care and medications. "No limitation exists within the benefits for applied behavior analysis services. These services are subject to prior authorization to determine medical necessity. If multiple services are provided on the same day by different providers, a separate copayment and/or coinsurance amount will apply to each provider." ABA is also listed among the outpatient mental health benefits, and a member may "choose any network provider in our behavioral health and substance use provider network" without a PCP referral.[1]
It is an HMO. Services from a non-network provider "are not covered, except as specifically stated in this contract" (emergencies, and some care at network facilities). Deductibles, copayments and coinsurance apply under the member's Schedule of Benefits, the same way as for physical health.[1]
The Pre-Auth Needed tool (looked up November 15, 2026) returns "Pre-authorization is required for all providers" for 97151, 97152, 0362T, 97153, 97154, 97155, 97156, 97158 and 0373T, and "No pre-authorization is required" for 97157. The manual says "Failure to obtain the required prior authorization or pre-certification will result in a denied claim" and "All out of network services require prior authorization." Submit on the secure provider portal (the preferred route), by calling Utilization Management at 1-877-687-1180, or on the posted fax forms to 1-855-685-6508. Each request needs the member's name, date of birth and ID, the provider's Tax ID, NPI, taxonomy and phone number, the procedure codes and the clinical information. If the codes billed will differ from those authorized, call within 72 hours or before the claim goes in.[5][3][10][12]
Decision clocks (2026 manual, unchanged in the 2027 edition): prospective non-urgent within 7 calendar days of complete information, at most 15 calendar days from the request; prospective urgent within 72 hours, at most 3 calendar days; concurrent urgent 1 calendar day. Elective outpatient requests are due five days before the service date. Georgia's SB 80 (O.C.G.A. 33-46) sets the same 7-day and 72-hour clocks and makes a missed deadline an "automatic authorization."[5][3][10][12]
Authorization length: Centene's documentation policy refers to "the entire six-month authorization period," and CP.BH.104 requires an updated behavior assessment and treatment plan "at least every six months." The behavior assessment behind the first treatment request must be "completed no more than two months prior to the start of the initial treatment authorization." No separate length is published for the assessment authorization itself.[5][3][10][12]
Initial treatment: a confirmed DSM ASD diagnosis with severity level; a CDE from the past three years (or a diagnostic interview within 12 months if the CDE is three to five years old) built on at least one clinician tool and one parent tool; a recommendation for ABA; and a BCBA behavior assessment done no more than two months before the authorization starts, with record review, interviews, rating scales, direct observation and an FBA or skills assessment (VB-MAPP, ABLLS-R, AFLS, PEAK, EFL and others; a Vineland used as the skills tool needs a direct skills assessment as well). The treatment plan needs measurable goals with baselines and mastery criteria, a crisis plan, the setting and its rationale, justified hours (at most six a day and 30 a week unless documented), 10–20% protocol modification, two to four caregiver goals with about two hours a month of caregiver training, coordination of care, and a titration and discharge plan. Plans are signed by the responsible BCBA and the parent or guardian.[9]
Continuation: an updated behavior assessment and treatment plan at least every six months, the percentage of scheduled sessions completed (attendance under 80% of authorized hours needs a written explanation), graphed progress for behavior reduction and updated data for each skill goal across every setting, and, where progress is limited, what is changing in the plan. Services can be stepped down or stopped when goals are met, when there is no measurable progress for six months, or when services stand "in lieu of school, respite care, or other community-based settings."[9]
Every session note must be finished before the claim is submitted and show the organization and rendering provider at the top, the member's name on each page, the date and exact start and end time, any pauses, the location, the code, the rendering provider's or technician's signature, the techniques used, the child's response, progress toward goals and everyone who took part. "Billed units not fully supported by documentation may be subject to payment denial or recoupment." For 97155, 0373T and 97158 the note lists the protocol modifications made, or why none were needed. If protocol modification averages under 10% of direct hours across the six-month authorization, the unsupported share of 97153/97154 hours is denied or recouped. The policy gives a worked example where 7% protocol modification costs 30 of 100 technician hours.[10]
Discharge needs its own summary: referrals given, the reason for discharge with a progress summary, the rendering provider's and caregiver's signatures and the discharge date.[10]
Ava's Law (O.C.G.A. 33-24-59.10) requires coverage of autism treatment for individuals "20 years of age or under," lets a policy "limit coverage for applied behavior analysis to $35,000.00 per year," and does not apply to plans of employers with ten or fewer employees. The Ambetter contract is more generous than the mandate on both points: no age limit and no ABA limitation.[13][14][3]
Georgia licenses the practice: "The unlicensed practice of applied behavior analysis is prohibited in this state" (O.C.G.A. 43-7A-6, added by HB 412, effective July 1, 2023). Ambetter credentials BCBAs as behavioral health providers and recredentials every 36 months.[13][14][3]
Electronic claims go to payer ID 68069. Initial claims are due 180 calendar days from the date of service for participating providers (90 for non-participating). Reconsiderations and disputes are due 180 days (90 non-par) from Ambetter's explanation of payment. Secondary claims are due 180 days (90 non-par) from the primary payer's EOP. When the rendering NPI differs from the billing NPI, put it in box 24J (loop 2310B/2420A) with the rendering taxonomy. Telehealth claims carry POS 02 or 10 and the appropriate modifier.[3][11]
The questions that decide whether a family can start with Ambetter from Peach State Health Plan, and what they have to bring. Each maps onto something intake should ask on the first call.
None stated. The Evidence of Coverage's Autism Spectrum Disorder Benefits carry no age limit and say "No limitation exists within the benefits for applied behavior analysis services," and CP.BH.104 sets none. Georgia's Ava's Law (O.C.G.A. 33-24-59.10) is written for individuals "20 years of age or under" and lets a policy cap ABA at $35,000 a year, but this contract does not use either limit.[1][13]
Three years, with a bridge to five. To start treatment, CP.BH.104 needs a comprehensive diagnostic evaluation (CDE) "conducted in the past three years," or, if the CDE is three to five years old, "A diagnostic interview/evaluation has been conducted within 12 months of the authorization request." For continuation the CDE must be within the past five years, and a re-evaluation may be required sooner (provisional diagnosis, no formal psychological evaluation, or more than three years since diagnosis with no evidence of ongoing assessment).[9]
"The documented diagnosis of ASD is established by 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 class of provider makes the ABA recommendation, which "may be included within the CDE."[9]
Two instruments minimum: the diagnosis must rest on the CDE, "including at least one primary clinician tool and one parent/caregiver tool." Clinician tools: STAT, ADI-R, CARS/CARS-2, ASRS, ADOS/ADOS-2, EarliPoint, RITA-T or CSBS DP-ITC. Parent tools: M-CHAT/M-CHAT-R/F, SCQ, ASSQ, CAST, SRS-2 Parent Report, SWYC POSI or CSBS DP ITC. Other evidence-based tools are reviewed case by case. The report must list each test with scores and date and carry the evaluator's name, signature and credentials.[9]
A prescription and a recommendation, but no PCP referral. The Evidence of Coverage covers autism services "when prescribed by a physician or behavioral health practitioner," and for behavioral health a member "do[es] not need a referral from your PCP in order to initiate treatment." CP.BH.104 requires a "Recommendation for ABA" from a licensed physician, psychologist or other qualified licensed professional; it "may be included within the CDE" and is required whenever an initial or updated CDE is required. No Ambetter order form is published, and no validity period or signature-date rule is stated beyond those CDE time limits.[1][9]
The 2026 manual's Utilization Determination Timeframes follow Georgia's prior-authorization law: prospective non-urgent "Within 7 calendar days of obtaining all necessary information to make such authorization or adverse determination, not to exceed 15 calendar days from date of request"; prospective urgent "No later than 72 hours after receiving all information needed … not to exceed 3 calendar days from date of request"; concurrent urgent 1 calendar day (one extension to 3); retrospective 30 calendar days. The 2027 manual keeps the same table. Elective outpatient services need the request "five (5) days prior to the elective outpatient service date." Under O.C.G.A. 33-46 (SB 80) a missed deadline means "automatic authorization."[3][4][12]
Other coverage pays first, and Medicaid is never "other plan." The Evidence of Coverage excludes "Any services where other coverage is primary to Ambetter" until "first paid by the primary payor," defines "Other plan" to include group and individual policies, HMOs and self-insured group plans, and says "Other plan will not include Medicaid." Its Medicaid Reimbursement clause says benefits "will not be changed or limited" because a member is Medicaid-eligible, and Ambetter repays the state when Medicaid has already paid. The manual gives participating providers 180 days (non-par 90) from the primary payer's EOP to file the secondary claim. The contract prints no birthday rule.[1][3]
Covered, with no ABA code list published. The Evidence of Coverage covers medically necessary telehealth, and telehealth outside its Virtual 24/7 Care vendor carries "the same cost sharing as the same health care services when delivered to an insured in-person." CP.BH.104 names telehealth as an ABA modality, and CP.BH.105 says the monthly one-on-one protocol-modification 97155 is "Not delivered via telemedicine/telehealth unless allowed by state guidelines," and telehealth notes must confirm a HIPAA-compliant platform with camera and audio on. Telehealth claims use POS 02 or 10 with "the appropriate modifier."[1][10][3]
Ask the plan: Ambetter Utilization Management 1-877-687-1180: confirm which ABA codes (including 97151 and 97153) it will authorize by telehealth for this member.
Coverage decides whether Ambetter from Peach State Health Plan 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 range, set in CP.BH.104: the treatment plan must show "Adaptive Behavior Treatment with Protocol Modification occurs 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 provided (unless clinical documentation justifies)," and that treatment "will be delivered or supervised by an ABA-credentialed professional." CP.BH.105 enforces it: at least monthly one-on-one 97155 with the child "Rendered by ABA supervisor," and "Technician supervision only or team meetings do not constitute protocol modification." 97153/97154 units for "the entire six-month authorization period" that the 10% floor does not support "are subject to denial of payment or recoupment."[9][10]
No benefit cap, but a medical-necessity ceiling. The 2026 Evidence of Coverage: "No limitation exists within the benefits for applied behavior analysis services." CP.BH.104 sizes the request: treatment hours must "not exceed six hours per day up to a total of 30 hours per week" unless clinical documentation justifies more, and should be "less than 20 hours per week if attending school full-time." No per-code daily unit table is published.[1][9]
The rendering provider or technician signs each note. CP.BH.105 requires session notes "completed prior to claim submission" with the exact start and end time, pauses, location, the service code and the "Signature of qualified rendering provider/technician." Clinical documentation as a whole carries the signatures and printed names of the member, legal guardian, rendering clinician/technician and supervising practitioner "as applicable." A caregiver signature is "recommended" on caregiver-training notes. Treatment plans need the signature, credentials and role of the responsible BCBA and the parent or guardian (CP.BH.104).[10][9]
Home, clinic, school and community are all contemplated. CP.BH.104: "Services may be provided in various settings (e.g., home, clinic, school, community) and modalities (e.g., in-person, telehealth)." The treatment plan needs a "Treatment setting with rationale," and school-based ABA needs a detailed school plan (hours, operationally defined target behaviors, a titration plan for when school services can be reduced or stopped, school-specific graphs). ABA is not medically necessary for "Services that are otherwise covered under the Individuals with Disabilities Education Act (IDEA)," and may be discontinued when "Services are in lieu of school, respite care, or other community-based settings." Telehealth is billed with POS 02 or 10 (2026 manual).[9][3]
Not stated as a billing rule. CP.BH.105 says "97155 may be used to demonstrate new or modified protocol to a technician with the member/enrollee present," which implies 97155 time alongside a technician, but no Ambetter Georgia document says whether the technician's 97153 for the same minutes also pays.[10]
Ask the plan: Ambetter Utilization Management / Provider Services 1-877-687-1180: ask whether 97153 and 97155 both pay for the same clock time on the Marketplace plan.
Not settled by a published ABA rule. The 2026 manual's general CMS-1500 instructions put the rendering provider's NPI in box 24J (with the rendering taxonomy in the shaded part of 24J) when it differs from the billing NPI, and it lists BCBA among credentialed behavioral health provider types. It lists no technician or BCaBA type and does not say whose NPI carries RBT time. The Evidence of Coverage adds: "If multiple services are provided on the same day by different providers, a separate copayment and/or coinsurance amount will apply to each provider."[3][1]
Ask the plan: Ambetter Provider Services 1-877-687-1180 or your Provider Relations Representative, and your participation agreement: ask whether technician 97153 goes out under the supervising BCBA's NPI.
Yes. The 2026 Evidence of Coverage covers applied behavior analysis for autism when prescribed by a physician or behavioral health practitioner, and says "No limitation exists within the benefits for applied behavior analysis services." Prior authorization and the plan's cost sharing apply, and providers must be in the Ambetter network.
No. Ambetter from Peach State Health Plan is the Marketplace (ACA individual) HMO, underwritten by Ambetter of Peach State Inc. It has its own contract, network and prior-authorization rules, and members pay deductibles and coinsurance.
Yes. The Pre-Auth Needed tool requires authorization for 97151, 97152 and 0362T, and for every treatment code except 97157. Submit on the provider portal, by phone at 1-877-687-1180 or by fax to 1-855-685-6508.
Within 7 calendar days of receiving all the information it needs, and no more than 15 calendar days from the request. Urgent requests are decided within 72 hours. Submit elective requests at least five days ahead.
Six months. Centene's documentation policy refers to the "six-month authorization period," and an updated behavior assessment and treatment plan are required at least every six months. The first request needs a behavior assessment no more than two months old.
To start, the comprehensive diagnostic evaluation must be from the past three years, or three to five years old plus a diagnostic interview within 12 months. To continue, it must be within five years.
Not in practice. Ava's Law allows a policy to cap ABA at $35,000 a year and covers people 20 and under, but the Ambetter contract sets no ABA limitation and no age limit.
180 calendar days from the date of service for participating providers (90 for non-participating), and 180 days from the primary payer's EOP for secondary claims. The payer ID is 68069.
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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