AmeriHealth Caritas Ohio — the newest of Ohio's Next Generation plans — publishes no distinct ABA clinical policy, so expect utilization management driven by the state rule (OAC 5160-34). Its public pages name ABA as a prior-authorization service and give the submission channels, but publish no code-level list or authorization-period length, so the NaviNet portal and the UM line remain the source of truth for those: this guide covers the verified structure and flags what to confirm directly.
The clinical baseline is the state rule: PA on ABA services, DSM-5-TR diagnosis via comprehensive evaluation, 6-month review cycles. Authorization requests flow through the Jiva UM system via NaviNet, with UM at (833) 735-7700 and a standard decision due “no later than seven calendar days following receipt of the request for service” under OAC 5160-26-03.1 (effective 1/1/2026) — the plan’s January 2026 manual still prints “no later than 10 calendar days,” so 7 is the binding outer limit and 48 hours applies to expedited requests. Approved intensities in the 10–40 hours/week range track clinical necessity per the state framework. Because the plan's public documents can't be pulled programmatically, download the current behavioral-health PA guidance from the portal and re-check it quarterly; the OhioRISE rule applies as everywhere — ABA bills to AmeriHealth Caritas, never to OhioRISE.[2][11][3][12]
AmeriHealth Caritas Ohio publishes no ABA rate table. In-network ABA pays at the rate in your contract with the plan; ask your Provider Network Account Executive for it. The manual does publish the out-of-network rate: “For providers who are not contracted with AmeriHealth Caritas Ohio, reimbursement for covered services will be made at seventy-five percent (75%) of the applicable fee schedule amount,” for non-emergent services. Out-of-network services, emergencies aside, also need prior authorization. Ohio Medicaid’s own ABA rates are in the Ohio Medicaid guide.[3]
A provider is “not considered participating (and therefore [is] not eligible to provide services to members) until both credentialing and contracting have been completed.” Credentialing is centralized at ODM: Certified Ohio Behavior Analysts are credentialed by ODM under OAC 5160-1-42. The plan contract is separate. The manual recommends starting MCO contracting while you enroll and are credentialed at ODM, and you can mark AmeriHealth Caritas Ohio as a plan of interest in ODM’s PNM system, which sends your data to the plan to begin contracting. The plan publishes nothing saying whether its ABA panel is open or closed; ask Provider Services at 1-833-644-6001.[3][5]
Filing deadline: “Providers will have 365 days to timely file a claim, including any timely filing exceptions, in accordance with Ohio Administrative Code (OAC) rule 5160-1-19”; original claims must be received within 365 days of the date of service. Claims rejected for missing or invalid provider or member data do not count as received.[3][6][7]
Taxonomy: the required claim data include the NPI of the ordering, rendering and prescribing physician and the “NPI and Taxonomy.” Claim disputes (any provider disagreement with a claim decision): “within 12 months from the date of service or 60 calendar days after the payment, denial or partial denial of a timely claim submission, whichever is later.”[3][6][7]
EVV does not apply to ABA in Ohio. OAC 5160-32-01 lists the services subject to Ohio’s EVV program — named waiver services in the home care, MyCare, PASSPORT and developmental-disability waivers, plus state-plan home health, private duty nursing and RN assessment and consultation — and makes managed care entities responsible for applying it; ABA is not on the list, and services delivered by telehealth are exempt.[3][6][7]
Corrected and secondary claims: a corrected claim “must be submitted within 180 days of the paid claim date,” with the original claim number and the correct frequency code; claims carrying a primary insurer’s EOB “must be submitted within 180 days of the date the other insurer paid on the claim.” Payment clock: the manual defines a clean claim but prints no payment timeframe, so the state contract standard governs: ODM’s managed care provider agreement (Rev. 12/2025, App. L §10) requires every Ohio MCO — unless the MCO and the provider agreed an alternative payment schedule in the provider contract — to pay or deny 90% of clean claims within 21 calendar days of receipt, 99% within 60 calendar days and 100% of all claims within 90 calendar days; behavioral health claims are measured as their own category, and the standard applies to network and out-of-network providers alike. The same agreement requires the MCO to accept claims for 365 calendar days from the date of service under OAC 5160-1-19 (App. K §5a).[3][6][7]
The questions that decide whether a family can start with AmeriHealth Caritas Ohio, and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the Ohio Medicaid framework: the ASD diagnosis comes from a documented comprehensive diagnostic evaluation by a licensed physician, psychologist, or other clinician qualified to diagnose autism, demonstrating DSM-5-TR criteria.[2][1]
No referral or service order requirement is published, and AmeriHealth Caritas Ohio publishes no distinct ABA clinical policy — expect utilization management driven by the OAC 5160-34 framework. Authorization requests flow through the Jiva UM system via NaviNet, with UM at (833) 735-7700; standard decisions are due “no later than seven calendar days following receipt of the request for service” under OAC 5160-26-03.1 (the plan’s January 2026 manual still prints 10 calendar days), and authorization periods run 6 months. Because the plan’s public documents cannot be pulled programmatically, download the current behavioral-health PA guidance from the portal and re-check it quarterly.[2][1][1][12][3]
AmeriHealth Caritas Ohio’s January 2026 manual still prints the older standard clock: notice “no later than 10 calendar days after AmeriHealth Caritas Ohio receives the request,” extendable up to 14 calendar days. Expedited decisions: “no later than 48 hours after receipt of the request for service.” The manual points to OAC 5160-26-03.1, which has required 7 calendar days for standard decisions since 1/1/2026, so 7 days is the binding outer limit. No ABA reauthorization lead time is published. Ohio’s MCO rule sets the clock. For a standard request the MCO “must provide notice to the provider and member as expeditiously as the member’s health condition requires but no later than seven calendar days following receipt of the request for service,” extendable by up to fourteen calendar days (an MCO-requested extension needs ODM’s prior approval). An expedited decision is due “no later than forty-eight hours after receipt of the request for service” (OAC 5160-26-03.1, effective 1/1/2026). The 48 hours is stricter than the federal 72-hour managed-care cap.[12][3]
AmeriHealth Caritas Ohio’s manual: “before billing AmeriHealth Caritas Ohio when there is a Primary Insurer, healthcare providers are required to bill the Primary Insurer first and obtain an Explanation of Benefits (EOB) statement.” Then bill the balance with the EOB attached, within 180 days of the date the other insurer paid. Pay-first exception: providers “are not required to bill the third party” first when “the claim is for preventive pediatric services (including EPSDT/Healthchek) that are covered by the Medicaid program.” The plan then recovers from the other payer. The manual does not say whether ABA qualifies, or whether its own authorization is needed when a commercial plan pays first. Ohio’s MCO rule: “The MCE is the payer of last resort when a member has third party resources available.” Providers must “take reasonable measures to obtain all third party payments and file claims with all TPPs prior to billing the MCE.” That means a remittance from the other payer showing a valid non-payment reason (service not covered, applied to the deductible or copay, benefit maximum reached), a partial payment with its remittance, or no response within ninety days of submitting to the other payer. The MCO pays at most its allowed amount minus the other payments, and must allow at least ninety days from the other payer’s remittance to file. Exception: “The MCE, except SPBM, pays first for preventive pediatric services before seeking reimbursement from any liable third party.” Children in the custody of a county children’s services agency are exempt from TPL cooperation (OAC 5160-26-09.1).[3][13]
Ask the plan: AmeriHealth Caritas Ohio Provider Services (1-833-644-6001): whether ABA claims fall under the EPSDT/Healthchek pay-first exception, and whether a plan authorization is required when a commercial plan pays first.
Follows the Ohio Medicaid framework, which publishes no verifiable age bound for ABA; under-21 members carry EPSDT protections through the MCO. codes.ohio.gov now returns “No Ohio Administrative Code rule number corresponds to ‘5160-34’” (re-confirmed 10/1/2026) rather than refusing the connection, and the chapter remains absent from the Title 5160 index, so no in-force rule text exists to read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Per ODM’s 7/30/2026 provider stakeholder presentation, the rewrite was paused in 2025 for reevaluation (budget pressure, national ABA-spend scrutiny, other-state audit findings) and the draft (ERF188422B) still carries a “DRAFT — NOT FOR FILING” header and no JCARR filing, so draft content does not govern.[2][1]
Blocked on: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
No plan-specific recency rule found — the Ohio Medicaid framework requires a documented comprehensive diagnostic evaluation demonstrating DSM-5-TR criteria but publishes no verifiable window. Note that two Ohio MCOs do set one (CareSource: a symptom letter where the evaluation is over 24 months old; Buckeye: a CDE within 5 years), so do not assume this plan is silent — confirm in its portal. codes.ohio.gov now returns “No Ohio Administrative Code rule number corresponds to ‘5160-34’” (re-confirmed 10/1/2026) rather than refusing the connection, and the chapter remains absent from the Title 5160 index, so no in-force rule text exists to read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Per ODM’s 7/30/2026 provider stakeholder presentation, the rewrite was paused in 2025 for reevaluation (budget pressure, national ABA-spend scrutiny, other-state audit findings) and the draft (ERF188422B) still carries a “DRAFT — NOT FOR FILING” header and no JCARR filing, so draft content does not govern.[2][1]
Blocked on: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
No plan-specific instrument list found, and the state framework names none. Other Ohio MCOs do publish lists (CareSource: ADOS, ADI-R or CARS-2; Optum for UHC Community Plan: one validated screener plus one formal tool), so confirm in this plan’s portal rather than assuming. codes.ohio.gov now returns “No Ohio Administrative Code rule number corresponds to ‘5160-34’” (re-confirmed 10/1/2026) rather than refusing the connection, and the chapter remains absent from the Title 5160 index, so no in-force rule text exists to read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Per ODM’s 7/30/2026 provider stakeholder presentation, the rewrite was paused in 2025 for reevaluation (budget pressure, national ABA-spend scrutiny, other-state audit findings) and the draft (ERF188422B) still carries a “DRAFT — NOT FOR FILING” header and no JCARR filing, so draft content does not govern.[2][1]
Blocked on: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
No ABA-specific telehealth rule from the plan. Its January 2026 manual restates the OAC 5160-1-18 list of practitioners eligible to render telehealth — physicians, psychologists, behavioral health practitioners, therapists and others, plus “other practitioners if specifically authorized by ODM” — without naming behavior analysts, and says services that need prior authorization need it “whether they are delivered in-person or via telehealth” (ABA is on that list). ODM’s 2026 Telehealth Billing Guidelines list no ABA code among telehealth-eligible services and say the MCOs “cover the same telehealth services as in fee-for-service but may have different billing requirements.” Whether 97151 assessment or 97155 supervision may be done remotely for this plan’s members is therefore a question for its UM line.[3][4]
Ask the plan: AmeriHealth Caritas Ohio UM at 1-833-735-7700 or Provider Services at 1-833-644-6001 — ask which ABA codes (97151, 97155, 97156) it pays by telehealth, with which modifier and place of service.
Coverage decides whether AmeriHealth Caritas Ohio 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.
AmeriHealth Caritas Ohio’s provider manual (January 2026) publishes no ABA per-day unit table. The state rule it works under: ODM’s managed care provider agreement requires every MCO to “implement claims edits (e.g., … National Correct Coding Initiative [NCCI]) at the direction of ODM” (App. K §5c), and OAC 5160-1-19(B) has claims submitted pursuant to NCCI. The CMS Medicaid NCCI practitioner MUE table active 10/1–12/31/2026 sets 97151 at 32 units, 97152 at 16, 97153 at 32, 97154 at 18, 97155 at 24, 97156 at 16, 97157 at 16, 97158 at 16, 0362T at 16 and 0373T at 32 units per date of service. Those are claim edits; the weekly ceiling is whatever the prior authorization approves.[9][7][8]
Follows the Ohio Medicaid framework: independent practitioners are Certified Ohio Behavior Analysts (ORC Chapter 4783) or BACB BCBAs and BCBA-Ds enrolled with ODM as Provider Type 19, Specialty 190, with BCaBAs and RBTs delivering under supervision. The routing rule holds everywhere in Ohio: OhioRISE does not pay for ABA — ODM’s Mixed Services Protocol assigns ABA claims to the member’s MCO or fee-for-service even for OhioRISE-enrolled youth.[2][1]
Follows the Ohio framework, which sets no fixed ratio: OAC 4783-6-02 requires the COBA to write a supervision plan into each client’s treatment plan, consult before plan initiation and modification, and observe directly on a periodic basis, with frequency left to documented clinical judgment and assessment, plan development and efficacy review non-delegable. No plan-specific numeric ratio was found for this MCO — note that other Ohio plans do publish one (Optum 1–2 hours per 10 direct hours weekly; Buckeye 97155 at 10–20% of direct hours).[2][1]
Ask the plan: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
Not resolved. No state-level rule on billing 97153 and 97155 for the same clock time could be verified, and this plan publishes none. codes.ohio.gov now returns “No Ohio Administrative Code rule number corresponds to ‘5160-34’” (re-confirmed 10/1/2026) rather than refusing the connection, and the chapter remains absent from the Title 5160 index, so no in-force rule text exists to read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Per ODM’s 7/30/2026 provider stakeholder presentation, the rewrite was paused in 2025 for reevaluation (budget pressure, national ABA-spend scrutiny, other-state audit findings) and the draft (ERF188422B) still carries a “DRAFT — NOT FOR FILING” header and no JCARR filing, so draft content does not govern.[2][1]
Blocked on: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
No plan-specific session-note signature standard found, and none could be verified at state level. codes.ohio.gov now returns “No Ohio Administrative Code rule number corresponds to ‘5160-34’” (re-confirmed 10/1/2026) rather than refusing the connection, and the chapter remains absent from the Title 5160 index, so no in-force rule text exists to read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Per ODM’s 7/30/2026 provider stakeholder presentation, the rewrite was paused in 2025 for reevaluation (budget pressure, national ABA-spend scrutiny, other-state audit findings) and the draft (ERF188422B) still carries a “DRAFT — NOT FOR FILING” header and no JCARR filing, so draft content does not govern.[2][1]
Blocked on: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
No plan-specific place-of-service rule found. The confirmed Ohio boundary is the school one: the MCO is not responsible for payment of services provided through the Medicaid School Program under OAC Chapter 5160-35, 5160-35-04 and 5160-26-03.[2][1]
Ask the plan: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
Yes — under the Ohio Medicaid framework. "Behavioral Analysis Therapy for Autism Spectrum Disorder" is on the plan's prior-authorization list; submit through Jiva via NaviNet, fax 1-833-329-6411, or call UM at 1-833-735-7700. The plan does not publish its authorization-period length.
Standard decisions are due “no later than seven calendar days following receipt of the request for service” under OAC 5160-26-03.1 (effective 1/1/2026), and expedited decisions within 48 hours. The plan’s January 2026 provider manual still prints “no later than 10 calendar days” — treat 7 as the binding outer limit.
No ABA rate table is published. In-network rates are in your plan contract. A non-contracted provider is paid 75% of the applicable fee schedule amount for covered non-emergent services, and out-of-network care needs prior authorization.
You need ODM enrollment and credentialing (centralized at ODM for behavior analysts) plus a separate contract with the plan, and you are not participating until both are done. Start contracting while ODM processes your enrollment. Ask Provider Services at 1-833-644-6001 whether the ABA panel has openings.
365 days from the date of service; claim disputes within 12 months of the date of service or 60 calendar days after the payment or denial, whichever is later (AmeriHealth Caritas Ohio provider manual, January 2026).
Original claims within 365 days of the date of service; corrected claims within 180 days of the paid claim date; claims with a primary insurer’s EOB within 180 days of the date the other insurer paid. Payment follows ODM’s contract standard: 90% of clean claims within 21 calendar days, 99% within 60, all within 90, unless your contract says otherwise.
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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