Anthem Blue Cross Blue Shield of Georgia has reviewed commercial ABA against MCG B-806-T (Behavioral Health Care, Applied Behavioral Analysis) since June 1, 2024, when it stopped using clinical guideline CG-BEH-02 for these reviews. That sits on top of Georgia's autism insurance mandate — Ava's Law. The combination matters: the criteria define what's medically necessary, while the mandate (and federal parity law) defines what plans must offer and which caps are actually enforceable. Intake teams that understand both catch coverage that others write off.
Anthem announced that effective June 1, 2024 it "will transition from CG-BEH-02 (Adaptive Behavioral Treatment) and MCG W0153 (Behavioral Health Care Applied Behavioral Analysis), to MCG B-806-T Behavioral Health Care Applied Behavioral Analysis (Original MCG Guideline), for medical necessity/clinical appropriateness reviews." MCG criteria are licensed and not published, so the exact tests a Georgia commercial ABA request must pass cannot be reprinted here — ask Anthem for the criteria applied to your request at authorization or peer-to-peer. The parameters many providers remember from CG-BEH-02 — a 20-combined-hour cap on the initial behavior-identification assessment, a 40-hour weekly ceiling, up to 2 hours of protocol modification per 10 direct hours (at most 8 a week), and a standardized developmental assessment at least every 2 years — came from the retired guideline and are not confirmed as current Anthem rules.[3][2]
Georgia's autism mandate (O.C.G.A. § 33-24-59.10) requires state-regulated individual and group plans to cover ASD treatment — including ABA — for individuals 20 and under, with ABA nominally cappable at $35,000/year. Two big caveats every intake team should know: employers with 10 or fewer employees and self-funded ERISA plans are exempt from the state mandate; and federal mental-health parity (MHPAEA) generally makes the dollar and age caps unenforceable against covered large-group plans. A payer applying the $35K cap to a large-group member is a parity red flag worth escalating, not accepting.[5]
97151–97158 plus 0362T/0373T, with degree-level modifiers (HM/HN/HO). Technician-rendered services must show the supervising BCBA in Box 31 of the CMS-1500. The guide lists CPT codes only, no HCPCS H-codes (such as H0031, H0032 or H2019), for ABA.[2][4]
97155 alongside 97153 only when technician and QHP are both face-to-face and the QHP is directing.[2][4]
Expect the treatment plan to be "reviewed and/or updated at a min of every 6 months" (more often if the plan’s own guidelines require it). Anthem’s guide stresses "systematic and repeated evaluation of developmental status," with standardized assessments "early in the course of treatment and at reviews during treatment thereafter" used to document improvement. Intake sets this clock: the baseline data collected at the start is what every future review gets measured against. The guide names no graphed-data requirement and no data-recency window for a reauthorization request; the review criteria behind it are MCG B-806-T, which are licensed and not public, so ask Anthem's utilization management what a continued-care request must contain.[2]
Georgia licenses the practice: “The unlicensed practice of applied behavior analysis is prohibited in this state,” at a fine of $1,000 per violation (O.C.G.A. 43-7A-6, added by HB 412, effective July 1, 2023). A BCBA “residing and practicing in another state who temporarily provides applied behavior analysis services in this state to a resident of this state” may apply for a temporary license covering “not more than a total of 30 days within a calendar year” (43-7A-8), and the board licenses by reciprocity someone actively licensed in a state with comparable requirements that reciprocates with Georgia (43-7A-9). As enacted, Chapter 7A contains no telehealth exception.[8][2]
Anthem’s ABA Provider Resource Guide (June 2025) lists BCBAs among approved providers, alongside “other mental health service providers licensed or authorized by the state in which they practice and recognized by the affiliated health plan Anthem to be eligible for reimbursement,” and sends providers to the state-specific Credentialing with Anthem pages; for telehealth it points to Anthem’s Virtual Visits reimbursement policy for the allowed codes. It does not say which state’s license a remote BCBA needs, so confirm with Anthem credentialing before treating a member remotely from another state.[8][2]
Anthem does not publish either answer. Since June 1, 2024 it has reviewed commercial ABA against MCG B-806-T, which is licensed and not public, and its June 2025 ABA resource guide states no diagnosis-recency rule and lists “physician orders” and “referrals” only as items the medical record should contain when they exist. Ask Anthem utilization management which diagnostic documentation the review needs before relying on a referral letter.[3][2][9][10]
Ava’s Law sets the outer terms for a state-regulated plan: it must cover “any assessments, evaluations, or tests by a licensed physician or licensed psychologist to diagnose whether an individual has an autism spectrum disorder,” so a new evaluation is itself a covered benefit, and the plan may require “a licensed physician or licensed psychologist… to demonstrate ongoing medical necessity… at least annually.”[3][2][9][10]
Payment clock: Georgia’s prompt-pay statute (O.C.G.A. 33-24-59.14) gives an insurer or administrator 15 working days for an electronic claim and 30 calendar days for a paper claim to pay it, or to send written notice of why it is denied and what is needed, with interest of 12 percent a year on late payments; any undisputed part of a claim must be paid on that clock. A self-funded employer plan may sit outside Georgia insurance law, so confirm the funding type first.[3][2][9][10]
Filing deadline: Anthem's Georgia commercial manual (January 1, 2026) prints no number of days. “Claims must be submitted within the timely filing timeframe specified in the Provider or Facility Agreement,” claims filed late “will be denied, unless proof of timely filing can be demonstrated,” and “any rejected Claims must be corrected and resubmitted within the timely filing period.” So the deadline is the one in your Anthem agreement. A correction to a processed claim goes in as a full replacement claim (or a void/cancel for a claim billed in error) through Availity; a secondary (COB) claim filed on paper must include the primary carrier's EOB. Payment clock: for fully insured plans, Georgia's prompt-pay statute (O.C.G.A. 33-24-59.14) gives an insurer or administrator 15 working days for an electronic claim and 30 calendar days for a paper claim to pay it or send written notice of why not and what is needed, with interest of 12 percent a year on late payments. The manual publishes no check-run day or weekly submission cutoff.[1][10]
Disputes: a finalized claim is disputed in two steps. A Claim Payment Reconsideration (by phone, Availity or in writing) is due within 365 calendar days of the EOP issue date unless state law or your agreement says otherwise; a Claim Payment Appeal is due within 90 days of the reconsideration decision. Medical-necessity denials follow the separate clinical appeal route: 180 calendar days from notice of Anthem's initial decision, and a standard post-service clinical appeal is decided within 60 calendar days. Eligibility and benefits: Anthem points providers to Availity's Eligibility and Benefits Inquiry (or the X12 270/271 transaction); claim questions that cannot go through Availity go to the number on the back of the member ID card. Enter the member ID with its three-character prefix: the manual says the prefix “is critical for confirming Membership and coverage.” The manual sets no Electronic Visit Verification rule (EVV is a Medicaid requirement) and no taxonomy or referring-provider rule for ABA claims.[1][10]
The questions that decide whether a family can start with Anthem BCBS Georgia, and what they have to bring. Each maps onto something intake should ask on the first call.
Anthem’s commercial ABA provider resource guide (June 2025) publishes no age criterion — it covers credentialing, coding, place of service, documentation and telehealth, not eligibility age. The age term that bites in Georgia comes from Ava’s Law, which requires state-regulated individual and group plans to cover ASD treatment for individuals 20 years of age or under. Two carve-outs and one federal override matter: employers with 10 or fewer employees are exempt, self-funded ERISA plans are preempted, and federal mental-health parity generally makes the mandate’s age and dollar caps hard to enforce against covered large-group plans — so an age-based decline on a large-group member is an escalation, not an answer.[2][5]
Ask the plan: Plan funding type and employer size first, then a live benefits verification. Any age term inside MCG B-806-T, the licensed criteria Anthem has used for commercial ABA reviews since 6/1/2024, is applied at authorization.
No referral precondition is published for ABA. The resource guide treats “physician orders” and “referrals” as elements that must be present in the medical record when they exist, not as an entry gate, and Anthem gates ABA through authorization instead — reviewed against MCG B-806-T since 6/1/2024, with claims paid against the weekly approved units from 1/1/2026. Whether the member’s specific plan requires a PCP referral is a benefit-design question. State law adds no order requirement either: Ava's Law (O.C.G.A. § 33-24-59.10) defines covered treatment as care "prescribed, provided, or ordered" for an individual diagnosed with ASD without naming a required prescriber; what it does allow a fully insured plan to require is that a licensed physician or licensed psychologist demonstrate ongoing medical necessity for applied behavior analysis at least annually. Self-funded plans sit outside it. So: no statutory service order, but expect the plan to want an annual physician or psychologist medical-necessity statement — ask at benefits verification whether this plan requires one, and whether a PCP referral is needed on top of authorization.[2][3][4][5][9]
Ask the plan: The member’s benefit document and Anthem provider services — ask whether a PCP referral is required in addition to the authorization.
Anthem publishes the place-of-service half outright but makes the code list plan- and state-specific. Telehealth POS codes for ABA are “10 = Telehealth (member located in home while receiving services)” and “02 = Telehealth (member located outside of home while receiving services),” all “Subject to the member’s coverage and reviews by the plan.” For which codes actually pay, the guide redirects: “Please visit our Virtual Visits reimbursement policy that outlines our standard rules. Allowed codes may vary. Refer to the Allowed virtual services in addition to CPT Appendix P to obtain codes that are eligible for reimbursement in your state.” So the POS mechanics are settled and the payable code set is not. The Virtual Visits reimbursement policy (C-08002, last approved 03/26/2026) adds the claim rules: an audio-video professional claim needs POS 02 or 10, modifier 95 or GT, and a code from CPT Appendix P or Anthem’s Allowed Virtual Services list; audio-only takes modifier 93 or FQ. Elsewhere virtual visits pay at the non-office rate, but Georgia is an exception: Anthem Blue Cross and Blue Shield in Georgia “allows virtual visits for office-based reimbursement.” Whether 97151 (assessment) or 97155 (BCBA direction) is on the allowed list was not checked this review, because the Allowed Virtual Services list sits on Anthem’s state policy pages.[7][2]
Blocked on: Anthem’s Virtual Visits reimbursement policy and the Georgia “Allowed virtual services” list, plus the member’s benefit document, before scheduling remote ABA.
It depends on how the plan is funded. A fully insured Anthem Blue Cross and Blue Shield plan sold in Georgia follows the Ensuring Transparency in Prior Authorization Act. A standard request gets notice "within 7 calendar days of obtaining all necessary information to make such authorization or adverse determination" (O.C.G.A. 33-46-26). Urgent requests get notice "no later than 72 hours after receiving all information needed" (33-46-27). A missed deadline means "automatic authorization" of the service (33-46-29), with a narrow de minimis exception. Both clocks start only once the plan has everything it needs, so send a complete packet. The Act also binds DCH contracts under the State Health Benefit Plan. A self-funded employer plan is governed by ERISA instead: "not later than 15 days after receipt of the claim," with one 15-day extension, and 72 hours for urgent care. No reauthorization lead time is published for Anthem Blue Cross and Blue Shield ABA in Georgia.[12][13][14]
Ask the plan: Benefits verification with Anthem Blue Cross and Blue Shield: ask whether the plan is fully insured (Georgia prior-authorization law), self-funded (ERISA), or the State Health Benefit Plan, and the plan's reauthorization lead time.
Between two parents' group plans, Georgia's coordination-of-benefits rule uses the birthday rule: "The benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year." "Birthday" means month and day only. If the birthdays match, the plan that has covered the parent longer pays first. For separated or divorced parents, the order is the custodial parent's plan, then the step-parent's, then the non-custodial parent's, unless a court decree assigns health costs to one parent. That rule governs fully insured group plans. A self-funded employer plan sets its own order in its plan document. The Anthem Blue Cross and Blue Shield plan pays before Georgia Medicaid, which is payer of last resort and still wants its own ABS PA when secondary. It also pays before TRICARE, which pays only after other coverage. When the child also has CHAMPVA, the Anthem Blue Cross and Blue Shield plan pays first: "If you have any other type of other health insurance, CHAMPVA will pay secondary."[15][16][17][18]
Ask the plan: Anthem Blue Cross and Blue Shield member services / benefits verification: confirm funding type and the COB order in the plan document, and collect the other parent's plan, each parent's date of birth and any custody decree at intake.
Anthem’s ABA provider resource guide (June 2025) sets a treatment-plan clock rather than a diagnosis clock: “Documentation must show that the treatment plan was reviewed and/or updated at a min of every 6 months. Providers should review their guidelines if treatment plans are required more frequently.” It adds that standardized assessments are used “early in the course of treatment and at reviews during treatment thereafter,” but publishes no recency window on the ASD diagnostic evaluation and no re-diagnosis interval. On a state-regulated plan, Ava’s Law sets the outer terms: the plan must cover “any assessments, evaluations, or tests by a licensed physician or licensed psychologist to diagnose whether an individual has an autism spectrum disorder,” and it may require “a licensed physician or licensed psychologist… to demonstrate ongoing medical necessity for coverage… at least annually.”[2][3][9]
In licensed criteria: Any diagnosis-recency requirement sits in MCG B-806-T, the licensed criteria Anthem has applied to commercial ABA reviews since 6/1/2024 — ask Anthem utilization management at authorization.
The ABA provider resource guide (June 2025) lists who may RENDER ABA, not who may diagnose: “Approved service providers include psychiatrists (MDs), psychologists (PhDs), licensed clinical social workers (LCSWs), licensed professional counselors (LPCs), licensed marriage and family therapists (LMFTs) with special training and/or experience in applied behavior analysis, Board Certified Behavior Analysts (BCBA/BCBA-D), providers practicing under the direction and supervision of the BCBA, and other mental health service providers licensed or authorized by the state in which they practice and recognized by the affiliated health plan Anthem to be eligible for reimbursement.” Any diagnosing-provider requirement lives in Anthem’s medical-necessity criteria, which since 6/1/2024 are MCG B-806-T (licensed, not public). Georgia adds a licensure layer either way: HB 412 (2022) created O.C.G.A. Title 43, Chapter 7A, so the supervising analyst must hold a Georgia Behavior Analyst Licensing Board licence.[2][3]
In licensed criteria: Ask Anthem utilization management which diagnosing credentials MCG B-806-T accepts, at authorization.
Anthem names no required instrument. The June 2025 resource guide says only that “the use of standardized assessments and current clinical information facilitates consistent, systematic, and reliable evaluation early in the course of treatment and at reviews during treatment thereafter,” with the data used to document improvement. Which instruments satisfy Anthem’s medical-necessity review is not published.[2][3]
In licensed criteria: Anthem utilization management at authorization — the review criteria (MCG B-806-T since 6/1/2024) are licensed and not public.
Coverage decides whether Anthem BCBS Georgia 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.
Anthem’s commercial ABA guide (June 2025) — which names Georgia (Blue Cross Blue Shield Healthcare Plan of Georgia, Inc.) on its cover — defines supervision through what is billable rather than through a ratio: “A physician or other QHP billing for 97155 can only add code 97153 if both the technician and QHP are face-to-face with the patient at the same time and the QHP is directing the technician. Supervised or directed services billed with a QHP-performed procedure are subject to the Incident To Services and Billing reimbursement policy.” Approved ABA renderers include BCBA/BCBA-D and “providers practicing under the direction and supervision of the BCBA.” No percentage floor or caseload cap is published.[2]
Yes, on Anthem’s own terms: “A physician or other QHP billing for 97155 can only add code 97153 if both the technician and QHP are face-to-face with the patient at the same time and the QHP is directing the technician.” The permission is conditional on that simultaneous face-to-face direction — 97155 for analyst work away from the patient is outside it — and directed services fall under Anthem’s Incident To Services and Billing reimbursement policy.[2]
No Anthem per-day ceiling is published; the guide defers to CMS. “ABA codes may have associated MUE limits”; Anthem administers NCCI edits under its Code and Clinical Editing Guidelines reimbursement policy, and “NCCI edits are revised to align with CMS MUE updates once published.” The binding limit is weekly: effective January 1, 2026, “reimbursement for Applied Behavioral Analysis (ABA) services will be based on weekly approved units rather than total authorized units” for 97151–97158, 0362T and 0373T. “Claims should reflect the units rendered within each week, up to the weekly medically necessary prior approval,” and claims over the weekly limit “will be adjusted accordingly or otherwise ineligible for reimbursement.”[2][4]
Ask the plan: Which CMS MUE table (Practitioner vs. Medicaid NCCI) Anthem’s editor applies to a given Georgia product — confirm with Anthem provider services before modelling units.
Anthem signs by author identification and puts a clock on it. Each entry in the medical record must include author identification of the physician or other QHP — “a handwritten signature, unique electronic identifier, or initials and rendering provider credentials” — entered at the time of service or shortly thereafter, which “should not exceed 30 days,” with the signature date within 30 days of the date of service. All documentation must be legible to someone other than the writer and must support the services billed on each unique date. For timed ABA codes the record must carry total treatment time in minutes plus start and stop times.[2]
Anthem publishes the POS code list for ABA outright: 12 home, 11 office/clinic, 99 community, 03 school, 10 telehealth with the member at home, 02 telehealth with the member outside the home — all “Subject to the member’s coverage and reviews by the plan.” School and community are therefore codeable places of service, not excluded ones; group home is not listed.[2]
Ask the plan: Whether POS 03 school is payable on a specific Georgia member’s benefit — the code list is explicitly subject to plan review.
The supervising analyst goes in box 31. “ABA therapy performed by therapy assistants/behavioral technicians/paraprofessionals must show the supervising BCBA or other QHP in box 31 of the CMS claim form.” Credential level rides as a modifier: HM for less than bachelor’s level, HN bachelor’s level, HO master’s level.[2]
The Georgia commercial manual (January 2026) does not print a number: claims must be filed within the timely filing period in your Anthem Provider or Facility Agreement, rejected claims must be corrected and resubmitted inside that same period, and late claims are denied unless you can prove timely filing. Check your agreement.
Two steps: a Claim Payment Reconsideration within 365 calendar days of the EOP issue date, then a Claim Payment Appeal within 90 days of the reconsideration decision. Medical-necessity denials go to a clinical appeal instead, within 180 calendar days of the initial decision.
Under Anthem's Virtual Visits reimbursement policy (C-08002), an audio-video professional claim carries POS 02 or POS 10 (member at home) and modifier 95 or GT, for a code on CPT Appendix P or Anthem's Allowed Virtual Services list; Georgia virtual visits are paid at the office-based rate. Whether each ABA code is on the allowed list is plan- and state-specific, so confirm before scheduling remote sessions.
Anthem's commercial ABA provider resource guide lists only CPT 97151–97158, 0362T and 0373T (with HM, HN or HO degree modifiers) and no HCPCS H-codes.
Yes — Anthem reviews commercial ABA for medical necessity against MCG B-806-T, which replaced clinical guideline CG-BEH-02 for dates of service from June 1, 2024. Georgia's Ava's Law also mandates coverage in state-regulated plans for individuals 20 and under.
Not for commercial medical-necessity reviews. Anthem announced that for dates of service on or after June 1, 2024 it moved from CG-BEH-02 and MCG W0153 to MCG B-806-T. MCG criteria are licensed and not public, so ask Anthem for the criteria applied to your request. From January 1, 2026 Anthem also pays ABA claims against weekly approved units.
Against large-group plans covered by federal parity law, generally not — MHPAEA prohibits treatment limits on mental-health benefits that are stricter than medical/surgical benefits. Treat a payer applying the cap to a large-group member as a red flag to escalate.
Self-funded ERISA plans (federal preemption) and employers with 10 or fewer employees. That's why intake should always capture the employer and funding type, not just the insurance card.
Georgia prohibits unlicensed ABA practice (O.C.G.A. 43-7A-6); a temporary license of up to 30 days a year and reciprocity exist. Anthem’s ABA guide accepts BCBAs and providers “licensed or authorized by the state in which they practice”; confirm the license question with Anthem credentialing.
Anthem publishes no limit; its criteria (MCG B-806-T) are licensed and not public, so ask Anthem utilization management. On a state-regulated plan, Ava’s Law lets the plan ask a licensed physician or psychologist to show ongoing medical necessity at least once a year.
Anthem does not say. Its resource guide treats referrals as a record element, not a diagnosis standard, and its review criteria are licensed. Ava’s Law requires state-regulated plans to cover a diagnostic evaluation by a licensed physician or psychologist, so if Anthem asks for one, the evaluation is a covered service.
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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