AmeriHealth Caritas DC is one of the two DC Healthy Families plans DHCF lists, and since August 1, 2026 it also holds the former Wellpoint DC (Amerigroup) members. Its September 2026 provider manual does not mention ABA at all; the working rules for ABA sit in the plan’s online Prior Authorization Lookup Tool, which gives a code-by-code answer.
We queried the plan’s public lookup tool for every ABA code on October 7, 2026. 97151 (behavior identification assessment), 97153 (technician treatment) and 97155 (protocol modification) return "Yes, prior authorization is required," with requests and clinical documentation through NaviNet or by fax to 1-202-408-1031. 97152, 0362T and 0373T return "This code is not on the DC Medicaid Fee Schedule and prior authorization is required." 97154, 97156, 97157 and 97158 return no PA "if the service is performed in an outpatient setting, you are a participating provider and this is on your provider contract," with plan and benefit limits applying. The tool calls its results general information, "not a guarantee of coverage or authorization." Non-participating providers need PA for everything.[1][2][5]
Two timing rules matter. The lookup page warns that "Effective November 1, 2026, AmeriHealth Caritas DC will no longer routinely approve retrospective authorization requests for non-emergent services rendered before an authorization request is submitted and approved," so request before the first session. And for children who came from Wellpoint DC, DHCF’s transition notice makes AmeriHealth honor treatment Wellpoint authorized before August 1, 2026 through October 31, 2026, and honor other plans’ authorizations for at least 60 days.[1][2][5]
The manual says AmeriHealth must decide a standard request "no later than 14 calendar days after AmeriHealth Caritas DC receives the request" (extendable 14 days) and an expedited one within 72 hours. Federal rules have since tightened the standard limit to 7 calendar days for rating periods beginning on or after January 1, 2026. Members, or a provider acting for them, appeal within 60 calendar days of the notice. AmeriHealth is "the payer of last resort": bill other coverage first. Claims follow DHCF’s contract with every DC Healthy Families plan: filed within 365 days of service, 90% of clean claims paid or denied within 30 days.[3][9][7]
The 2026 provider manual’s claim rules: original claims are due "within 365 calendar days from the date services were rendered," claims first rejected for missing data must be resubmitted within the same 365 days, and a denied claim goes back as a corrected claim (frequency 6 or 7 with the original claim number); a claim first filed on time but denied is still timely if the resubmission arrives "within 365 days of the denial of the initial claim." Electronic claims "must be received by the EDI vendor by 9:00 p.m. in order to be transmitted to the Plan the next business day." AmeriHealth must pay or deny 90% of clean claims within 30 days and 99% within 90 days, with interest of 1.5% a month from day 31, 2% from day 61 and 2.5% after day 120 under the D.C. Prompt Payment Act. As payer of last resort it bills other coverage first and may recover payments when other insurance turns up; the manual sets no separate secondary-claim window or check-run schedule. Payment is by EFT through ECHO Health.[3][9][7]
The questions that decide whether a family can start with AmeriHealth Caritas District of Columbia, and what they have to bring. Each maps onto something intake should ask on the first call.
Under 21. The plan covers ABA within DC Medicaid’s EPSDT ASD benefit, available to beneficiaries under 21 (SPA 23-0009).[6][4]
The plan publishes nothing different, so the state list applies: physician, PA, psychologist, psychology associate, LPC, LICSW or APRN (SPA 23-0009).[3][6]
The plan names no instrument; the state requires the diagnostic evaluation to use "a validated assessment tool or instrument" (SPA 23-0009).[3][6]
The plan publishes nothing ABA-specific; the state requires ASD services to be "recommended by a physician or other licensed practitioner of the healing arts" (SPA 23-0009).[3][6]
The plan publishes no ABA telehealth rule, so DHCF’s guidance applies (it covers Medicaid managed care): same coverage as in person under D.C. Code § 31-3863, modifier GT (video) or 93 (audio-only), POS 10 home, 03 school or 02 other. No ABA telehealth code list was found.[8][12][3]
"As a Medicaid plan, AmeriHealth Caritas District of Columbia is the payer of last resort," and payments may be recovered if other coverage is found. Bill the primary insurer first.[3][10]
The manual says standard decisions come "no later than 14 calendar days" after receipt (plus up to 14), expedited within 72 hours. Federal law caps standard decisions at 7 calendar days for rating periods starting on or after January 1, 2026.[3][9]
Ask the plan: AmeriHealth Caritas DC UM, 202-408-4823: ask whether the 7-day federal limit applies to your request.
Coverage decides whether AmeriHealth Caritas District of Columbia 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.
The plan publishes no ABA supervision rule of its own. The state rule applies: an RBT works under a BCBA, BCBA-D or BCaBA, and a BCaBA under a BCBA or BCBA-D (SPA 23-0009), with no numeric ratio.[3][6]
Not addressed in the provider manual or the lookup tool.[3][1]
Ask the plan: AmeriHealth Caritas DC Provider Services or your Provider Network Account Executive: ask whether 97153 and 97155 may be billed for the same time.
The plan publishes no ABA unit limit; the lookup tool says "Member plan and benefit limits may apply" for codes without PA.[1]
Ask the plan: AmeriHealth Caritas DC UM, 202-408-4823 or 1-800-408-7510: ask how ABA units are authorized.
The manual publishes no ABA session-note signature rule.[3]
Ask the plan: AmeriHealth Caritas DC Provider Services, or the documentation terms in your provider agreement.
The lookup tool’s no-PA answers apply only "if the service is performed in an outpatient setting"; the plan publishes no other ABA setting rule.[1]
Ask the plan: AmeriHealth Caritas DC UM: ask which POS codes it pays for ABA in the home, clinic, school and community.
The manual publishes no ABA-specific rendering or supervising-provider rule. DHCF’s contract requires plans to use the same billing format and coding as fee-for-service Medicaid.[3][7]
Ask the plan: AmeriHealth Caritas DC credentialing (dcprovidernetwork@amerihealthcaritasdc.com, 877-759-6186): ask whether RBTs are billed under the supervising BCBA’s NPI.
Yes for electronic claims: they must reach the EDI vendor by 9:00 p.m. to be sent to the plan the next business day. Claims are due within 365 days of service (or of a timely claim’s denial for resubmissions), and 90% of clean claims are paid or denied within 30 days.
Yes. Its lookup tool says 97151 requires prior authorization, submitted through NaviNet or by fax to 1-202-408-1031.
97151, 97152, 97153, 97155, 0362T and 0373T. The tool says 97154, 97156, 97157 and 97158 do not, for a participating provider in an outpatient setting with the code on its contract.
Wellpoint members moved to AmeriHealth Caritas DC on August 1, 2026. Wellpoint authorizations are honored through October 31, 2026; request a new authorization from AmeriHealth before then and join its network (dcprovidernetwork@amerihealthcaritasdc.com, 877-759-6186).
Not routinely. From November 1, 2026 the plan says it will no longer routinely approve retrospective requests for non-emergent services, so get the authorization first.
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.
Carelu collects all of this automatically.
Every ID, document, and detail this payer requires — gathered conversationally the moment a family reaches out, with insurance verified before your team touches the file.
Get a Demo