---
title: "AmeriHealth Caritas DC ABA coverage: the intake guide."
url: "https://carelu.com/payers/amerihealth-caritas-district-of-columbia"
markdown_url: "https://carelu.com/payers/amerihealth-caritas-district-of-columbia.md"
state: DC (District of Columbia)
payer: AmeriHealth Caritas District of Columbia
kind: Medicaid managed care plan (MCO)
parent_program: District of Columbia Medicaid (DC Healthy Families)
description: "How AmeriHealth Caritas District of Columbia handles ABA for DC Healthy Families children: code-level prior authorization from its lookup tool, the Wellpoint DC transition, decision timeframes, claims and what intake should collect."
last_reviewed: October 2026
---

# AmeriHealth Caritas DC ABA coverage: the intake guide.

_Payer Guide · AmeriHealth Caritas · District of Columbia · Last updated October 2026 · 11 primary sources_

> The larger DC Healthy Families plan (took Wellpoint DC’s members 8/1/2026): PA on 97151, 97153 and 97155 per its lookup tool.

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.

This plan administers the **District of Columbia Medicaid (DC Healthy Families)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [District of Columbia Medicaid guide](https://carelu.com/payers/district-of-columbia-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Yes. The plan’s Prior Authorization Lookup Tool answers for 97151: "Yes, prior authorization is required," submitted through NaviNet or by fax to 1-202-408-1031. 97152 and 0362T return "not on the DC Medicaid Fee Schedule and prior authorization is required" [1]
- **Prior auth for treatment**: Yes for 97153 and 97155 (and 0373T, flagged not on the DC Medicaid fee schedule). 97154, 97156, 97157 and 97158 return "No, prior authorization is not required if the service is performed in an outpatient setting, you are a participating provider and this is on your provider contract" [1]
- **Autism diagnosis required?**: Yes. The plan publishes no ABA criteria of its own in its manual, so the state rule applies: ASD services follow "an ASD diagnosis … determined through a diagnostic evaluation" (SPA 23-0009) [3][6]

## At a glance

- **Covers ABA?:** Yes, under DC Medicaid’s EPSDT ASD benefit for members under 21
- **Prior auth:** Required: 97151, 97152, 97153, 97155, 0362T, 0373T. Not required (participating, outpatient, on contract): 97154, 97156, 97157, 97158
- **Submit via:** NaviNet, or fax 1-202-408-1031 / 1-877-759-6216; UM 202-408-4823 or 1-800-408-7510
- **Retro auths:** Not routinely approved for non-emergent services from Nov. 1, 2026
- **Decision clock:** Manual: 14 calendar days standard, 72 hours expedited; federal cap is 7 days from 1/1/2026 rating periods
- **Network:** Credentialing: dcprovidernetwork@amerihealthcaritasdc.com, 877-759-6186

## Prior authorization, code by code

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]

## Decision timeframes, appeals and claims

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]

## Intake gates

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

- **Age limit**: Under 21. The plan covers ABA within DC Medicaid’s EPSDT ASD benefit, available to beneficiaries under 21 (SPA 23-0009). [6][4]
- **Who may diagnose**: The plan publishes nothing different, so the state list applies: physician, PA, psychologist, psychology associate, LPC, LICSW or APRN (SPA 23-0009). [3][6]
- **Diagnostic tools required**: The plan names no instrument; the state requires the diagnostic evaluation to use "a validated assessment tool or instrument" (SPA 23-0009). [3][6]
- **Referral required?**: 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]
- **Telehealth**: 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]
- **Other insurance (who pays first)**: "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]
- **Prior-auth decision time** _(plan-dependent)_: 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.
- **Diagnosis recency** _(ask the plan)_: Not stated by the plan or the state. [3][6]
  - Ask the plan: AmeriHealth Caritas DC UM, 202-408-4823: ask how recent the diagnostic evaluation must be for an initial request.

## Delivery and billing rules

Coverage decides whether AmeriHealth Caritas District of Columbia 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 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]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: 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.
- **Daily limits / MUEs** _(ask the plan)_: 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.
- **Session-note signature** _(ask the plan)_: 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.
- **Place of service** _(ask the plan)_: 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.
- **Bill as provider** _(ask the plan)_: 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.

## What intake should collect for AmeriHealth Caritas District of Columbia

- **Member ID and plan:** Confirm AmeriHealth Caritas DC on the date of service; former Wellpoint DC members moved here on 8/1/2026.
- **Diagnostic evaluation:** ASD diagnosis by a DC-qualified diagnosing provider using a validated tool (state rule).
- **Treatment plan:** Needed for the 97153/97155 authorization; DC’s rule is a six-month plan with measurable goals and hours.
- **Prior plan’s authorization:** Wellpoint or MedStar authorizations are honored for a transition period; capture the approval letter.
- **Other insurance:** The plan pays last; bill the primary first.

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

## Common questions

### Is there a daily claim cut-off for AmeriHealth Caritas DC?

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.

### Does AmeriHealth Caritas DC require prior authorization for the ABA assessment?

Yes. Its lookup tool says 97151 requires prior authorization, submitted through NaviNet or by fax to 1-202-408-1031.

### Which ABA codes need PA with AmeriHealth Caritas DC?

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.

### I treated a Wellpoint DC child. What now?

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).

### Will AmeriHealth Caritas DC approve an authorization after services start?

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.

## Primary sources

1. [AmeriHealth Caritas DC — Prior Authorization Lookup Tool (code results queried 10/7/2026)](https://www.amerihealthcaritasdc.com/provider/resources/prior-authorization-lookup-tool)
2. [AmeriHealth Caritas DC — Prior authorization (provider page)](https://www.amerihealthcaritasdc.com/provider/resources/prior-auth)
3. [AmeriHealth Caritas DC — 2026 Provider Manual (revised September 2026)](https://www.amerihealthcaritasdc.com/content/dam/amerihealth-caritas/acdc/pdf/provider/manual.pdf.coredownload.inline.pdf)
4. [DHCF — Medicaid Managed Care Plans (MCPs): AmeriHealth Caritas DC, MedStar Family Choice DC, HSCSN (CASSIP)](https://dhcf.dc.gov/page/medicaid-managed-care-plans-mcps)
5. [DHCF Transmittal 26-19 (rev.) — Managed Care Plan Transition: Wellpoint DC enrollees to AmeriHealth Caritas DC (Aug. 6, 2026)](https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/publication/attachments/Transmittal%2026-19%20%28rev.%29%20-%20Managed%20Care%20Plan%20Transition.pdf)
6. [DC State Plan Amendment 23-0009 — Autism Spectrum Disorder services under EPSDT (approved Aug. 25, 2023; effective Oct. 1, 2023)](https://www.medicaid.gov/medicaid/spa/downloads/DC-23-0009.pdf)
7. [DHCF — DC Healthy Families Managed Care Contract CW99929 (public version, as of April 1, 2023)](https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/page_content/attachments/MCP%20Contract%20PUBLIC.pdf)
8. [DHCF — Telemedicine Provider Guidance (January 2023, Transmittal 23-11)](https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/page_content/attachments/Telemedicine%20Provider%20Guidance_January%202023%20-%20Transmittal%2023-11.pdf)
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. [AmeriHealth Caritas District of Columbia — Newsletters and Updates (provider newsletter and updates archive)](https://www.amerihealthcaritasdc.com/provider/newsletters-and-updates)
12. [D.C. Code § 31-3863 — Telehealth: Medicaid reimbursement](https://code.dccouncil.gov/us/dc/council/code/sections/31-3863)

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.