---
title: "AmeriHealth Caritas Delaware ABA coverage: the intake guide."
url: "https://carelu.com/payers/amerihealth-caritas-delaware"
markdown_url: "https://carelu.com/payers/amerihealth-caritas-delaware.md"
state: DE (Delaware)
payer: AmeriHealth Caritas Delaware
kind: Medicaid managed care plan (MCO)
parent_program: Delaware Medicaid (Diamond State Health Plan)
description: "How AmeriHealth Caritas Delaware covers ABA for Delaware Medicaid members: autism services under EPSDT, the conflicting 30-unit and DDDS/DSCYF language, the behavioral health PA form, 120-day filing, and what intake should collect."
last_reviewed: October 2026
---

# AmeriHealth Caritas Delaware ABA coverage: the intake guide.

_Payer Guide · AmeriHealth Caritas · Delaware · Last updated October 2026 · 12 primary sources_

> DSHP MCO that lists ABA among autism services; its pages disagree on the under-18 30-unit cap (DDDS vs DSCYF).

AmeriHealth Caritas Delaware is one of the three Diamond State Health Plan MCOs. Its member benefits page lists "Applied behavior analysis" among autism services, alongside family counseling, parent training and speech, occupational and physical therapy. Its 2026 provider manual says nothing ABA-specific, and two of its web pages describe the yearly behavioral health cap for children under 18 differently.

This plan administers the **Delaware Medicaid (Diamond State Health Plan)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Delaware Medicaid (DMAP / Diamond State Health Plan) guide](https://carelu.com/payers/delaware-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required. AmeriHealth Caritas Delaware’s prior authorization lookup (checked 10/11/2026 for dates of service that day) answers for 97151 and 97152: "This code is not on the Delaware Medicaid Fee Schedule and prior authorization is required. Please submit your request with supporting clinical documentation through Navinet ... or via fax to 1-866-497-1384." 0362T returns the same message [13][4]
- **Prior auth for treatment**: Required for every ABA code. The prior authorization lookup (checked 10/11/2026) answers "Yes, prior authorization is required" for 97153, 97155 and 97156, and "not on the Delaware Medicaid Fee Schedule and prior authorization is required" for 97154, 97157, 97158 and 0373T; requests go through NaviNet or fax 1-866-497-1384. Separately, the provider behavioral health page says that after 30 behavioral health units in a calendar year for a member under 18, providers "should obtain a prior authorization and payment for future applied behavioral analysis (ABA) services from" DDDS (see the 30-unit section: the member page says DSCYF instead) [14][2]
- **Autism diagnosis required?**: Yes. The plan lists ABA among services "if you have autism spectrum disorder," and the state plan covers ASD services for members with an ASD diagnosis [3][6]

## At a glance

- **Covers ABA?:** Yes, listed among autism services; state plan covers ASD services under 21
- **Under-18 cap:** Provider page: 30 units/year, then ABA via DDDS. Member page: first 30 outpatient hours/year, then DSCYF
- **Prior auth:** Required for 97151–97158, 0362T and 0373T (plan PA lookup, 10/11/2026); BH PA form via NaviNet or fax 877-234-4273
- **Decision clock:** Manual prints 10 calendar days; federal limit is 7 for rating periods from 1/1/2026
- **Timely filing:** 120 days from date of service; primary EOB within 60 days
- **Licensure:** None in Delaware; BACB certification governs

## Coverage and the 30-unit question

The member page lists ABA under "Autism services" and says AmeriHealth Caritas Delaware "covers the first 30 outpatient hours per year. Hours above 30 are provided through DSCYF." The provider behavioral health page says instead that the benefit for members under 18 "is limited to thirty (30) units per calendar year," after which "providers should obtain a prior authorization and payment for future applied behavioral analysis (ABA) services from the Delaware Division of Developmental Disabilities Services (DDDS)." The 2026 provider manual’s benefit table gives children "30 outpatient visits per year; visits above 30 are provided through" DSCYF and does not mention ABA. The pages differ on the unit (units, hours or visits) and on which agency picks up. The other two MCOs say ABA is outside the cap. Before planning a child’s hours, get the plan’s answer in writing. [3][2][1]

## Authorization, claims and appeals

Behavioral health authorization requests go on the plan’s Behavioral Health Prior Authorization Request Form, "via our NantHealth/Navinet provider portal system or fax … at 877-234-4273," with the treatment plan and progress notes. The provider manual says standard decisions come "no later than 10 calendar days after AmeriHealth Caritas Delaware receives the request" (plus up to 14 more), and expedited ones within three business days. In-network claims are due "within 120 days from the date of service," and claims with a primary insurer’s EOB "within 60 days of the date on the primary insurer’s EOB." The plan says it pays or denies 90% of clean claims within 30 calendar days and 99% within 90. A provider claim complaint may be filed up to 12 months from the date of service or 60 calendar days after the payment, denial or recoupment, whichever is later. [4][1]

## Intake gates

The questions that decide whether a family can start with AmeriHealth Caritas Delaware, and what they have to bring.

- **Age limit**: Under 21 under the state plan (ASD services "only to Medicaid beneficiaries under age twenty-one"); the plan publishes no different age rule. [6][3]
- **Referral required?**: The plan publishes nothing different from the state plan, which requires a recommendation from a physician or other licensed practitioner and a medical/physical evaluation showing medical necessity before assessment or treatment. [1][6]
- **Telehealth**: The manual lists telehealth among basic covered services and publishes no ABA telehealth rule, so the state rule applies: DMAP covers covered services by telehealth with "The same procedure codes and rates," POS 02, the member’s home as an approved originating site (no originating-site fee), and enrolled providers at both ends. MCO-credentialed providers follow the plan’s billing procedures. [1][7]
- **Other insurance (who pays first)**: "Medicaid HMOs, such as AmeriHealth Caritas Delaware, are always the payer of last resort." Bill the primary insurer first, then submit the claim with the primary’s EOB "within 60 days of the date on the primary insurer’s EOB." [1][10]
- **Prior-auth decision time** _(plan-dependent)_: The 2026 manual says standard decisions are due "no later than 10 calendar days" after receipt (extendable up to 14 more days), expedited ones within three business days. Federal law sets a lower ceiling for rating periods starting on or after January 1, 2026: standard decisions "may not exceed 7 calendar days." [1][9]
  - Ask the plan: AmeriHealth Caritas Delaware UM: confirm whether the 7-day federal standard applies to your request.
- **Diagnosis recency** _(ask the plan)_: Not stated by the plan or the state. [1]
  - Ask the plan: AmeriHealth Caritas Delaware behavioral health UM: ask how recent the diagnostic evaluation must be.
- **Diagnostic tools required** _(ask the plan)_: Not stated by the plan or the state. [1]
  - Ask the plan: AmeriHealth Caritas Delaware behavioral health UM: ask which instruments it expects with the first request.

## Delivery and billing rules

Coverage decides whether AmeriHealth Caritas Delaware 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**: The plan publishes no ABA supervision rule of its own. The state plan applies: a BCBA may work independently, a BCaBA only under a BCBA, and an RBT only under a BCaBA or BCBA, with supervision requirements set by the BACB and no numeric ratio. [1][6]
- **Place of service**: The plan publishes no ABA setting rule. Under the state plan, ASD treatment is "designed to be delivered primarily in the home or in other community settings." [1][6]
- **Daily limits / MUEs** _(plan-dependent)_: No daily unit limit is published. The yearly cap for members under 18 is described inconsistently (30 units then DDDS for ABA on the provider page; first 30 outpatient hours then DSCYF on the member page). Under the state plan, more than 40 hours a week needs prior authorization. [2][3][6]
  - Ask the plan: AmeriHealth Caritas Delaware behavioral health UM: ask whether ABA counts toward the 30-unit limit and who authorizes ABA beyond it.
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not addressed in the provider manual, and the state publishes no rule either. [1]
  - Ask the plan: AmeriHealth Caritas Delaware Provider Services, 1-855-707-5818, or your provider agreement.
- **Session-note signature** _(ask the plan)_: The manual publishes no ABA session-note signature rule. [1]
  - Ask the plan: AmeriHealth Caritas Delaware Provider Services, 1-855-707-5818, or the documentation standards in your provider agreement.
- **Bill as provider** _(ask the plan)_: The manual publishes no ABA-specific rendering or supervising-provider rule. [1]
  - Ask the plan: Your AmeriHealth Caritas Delaware Provider Account Executive: ask whether RBT services are billed under the supervising BCBA’s NPI and which HN/HO/HP modifier applies.

## What intake should collect for AmeriHealth Caritas Delaware

- **Member ID:** Confirm AmeriHealth Caritas Delaware (DSHP) on the date of service.
- **ASD diagnosis + medical evaluation:** The state plan requires a medical/physical evaluation showing medical necessity before assessment or treatment.
- **Hours already used this year:** For children under 18, ask how many behavioral health units or hours are used, and who pays after 30.
- **Other insurance:** The plan pays last; bill the primary and send its EOB within 60 days.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Common questions

### Does AmeriHealth Caritas Delaware cover ABA?

Yes. Its member benefits page lists applied behavior analysis among autism services. The state plan covers ASD services for members under 21.

### What happens after 30 units for a child under 18?

The plan’s pages disagree. The provider page says to get prior authorization and payment for further ABA from DDDS after 30 units. The member page says the plan covers the first 30 outpatient hours and DSCYF covers the rest. Ask the plan in writing before planning hours.

### How do I request ABA authorization from AmeriHealth Caritas Delaware?

Use the Behavioral Health Prior Authorization Request Form through NaviNet or fax 877-234-4273, with the treatment plan and progress notes.

### Does AmeriHealth Caritas Delaware require prior authorization for the ABA assessment (97151)?

Yes. The plan’s online prior authorization lookup, checked 10/11/2026, says prior authorization is required for 97151 and 97152 and for every ABA treatment code. It also flags 97151, 97152, 97154, 97157, 97158, 0362T and 0373T as "not on the Delaware Medicaid Fee Schedule," so confirm how the plan wants the assessment coded before you submit. The lookup gives NaviNet or fax 1-866-497-1384; the behavioral health PA form gives fax 877-234-4273.

### What is AmeriHealth Caritas Delaware’s timely filing limit?

120 days from the date of service for in-network claims. Claims with a primary insurer’s EOB are due within 60 days of the EOB date.

## Primary sources

1. [AmeriHealth Caritas Delaware — Provider Manual 2026](https://www.amerihealthcaritasde.com/content/dam/amerihealth-caritas/acde/pdf/provider/provider-manual.pdf.coredownload.inline.pdf)
2. [AmeriHealth Caritas Delaware — Provider: Behavioral Health (30-unit limit; ABA after 30 units via DDDS)](https://www.amerihealthcaritasde.com/provider/behavioral-health/index.aspx)
3. [AmeriHealth Caritas Delaware — Member: Behavioral health benefits (autism services; first 30 outpatient hours, then DSCYF)](https://www.amerihealthcaritasde.com/member/eng/benefits/behavioral.aspx)
4. [AmeriHealth Caritas Delaware — Behavioral Health Prior Authorization Request Form (NaviNet or fax 877-234-4273)](https://www.amerihealthcaritasde.com/content/dam/amerihealth-caritas/acde/pdf/provider/provider-behavioral-health-prior-authorization-request-form.pdf.coredownload.inline.pdf)
5. [AmeriHealth Caritas Delaware — Provider Prior Authorization Guide (physical and behavioral health)](https://www.amerihealthcaritasde.com/content/dam/amerihealth-caritas/acde/pdf/provider/prior-auth-guide.pdf.coredownload.inline.pdf)
6. [Delaware State Plan Amendment 16-010 — Behavioral Services to Treat Autism Spectrum Disorder pursuant to EPSDT (approved Jan. 12, 2017; eff. Oct. 1, 2016)](https://www.medicaid.gov/State-resource-center/Medicaid-State-Plan-Amendments/Downloads/DE/DE-16-010.pdf)
7. [DMAP — Practitioner Provider Specific Policy Manual (rev. 03/17/2026; section 16.0 Telehealth)](https://medicaidpublications.dhss.delaware.gov/docs/DesktopModules/Bring2mind/DMX/API/Entries/Download?Command=Core_Download&EntryId=2112&language=en-US&PortalId=0&TabId=94)
8. [Delaware DHSS / DMMA — Diamond State Health Plan (three contracted MCOs)](https://dhss.delaware.gov/dmma/home/medicaid/diamond-state-health-plan/)
9. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-D/section-438.210)
10. [42 CFR 433.139 — Medicaid third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
11. [BACB — U.S. Licensure of Behavior Analysts (Delaware not listed)](https://www.bacb.com/u-s-licensure-of-behavior-analysts/)
12. [AmeriHealth Caritas Delaware — Newsletters and Updates (Connections provider newsletter archive)](https://www.amerihealthcaritasde.com/provider/newsletters-and-updates)
13. [AmeriHealth Caritas Delaware — Prior authorization lookup tool, 97151 (checked 10/11/2026)](https://priorauthlookup.amerihealthcaritas.com/api/CptCodeLookup?planname=acde&cptCode=97151&cptDate=2026-10-11)
14. [AmeriHealth Caritas Delaware — Prior authorization lookup tool, 97153 (checked 10/11/2026)](https://priorauthlookup.amerihealthcaritas.com/api/CptCodeLookup?planname=acde&cptCode=97153&cptDate=2026-10-11)

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.