Anthem Blue Cross and Blue Shield is Kentucky’s Blue, underwritten by Anthem Health Plans of Kentucky, Inc. An Anthem card in Kentucky is commercial (or Medicare): Anthem stopped being a Kentucky Medicaid MCO on January 1, 2025. Kentucky shares one commercial precertification list with Indiana, Missouri, Ohio and Wisconsin, and Anthem’s multi-state ABA provider resource guide covers Kentucky.
Anthem’s precertification list for Indiana, Kentucky, Missouri, Ohio and Wisconsin (updated January 1, 2026) lists, for "OH, IN, KY Blues products," all facility-based behavioral health care, intensive outpatient, partial hospitalization, residential care, ECT, TMS, intensive in-home behavioral health and "Applied behavioral analysis (ABA)," with Anthem as the responsible party. Anthem’s commercial ABA provider resource guide (June 2025, covering Kentucky) sets the billing rules: a QHP billing 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"; work by technicians "must show the supervising BCBA or other QHP in box 31"; HM, HN and HO modifiers mark the rendering level; and the record needs start and stop times, with signatures within 30 days of service and treatment plans reviewed at least every six months.[1][2]
Kentucky’s autism mandate is KRS 304.17A-142. Every health benefit plan "issued or renewed on or after January 1, 2019, shall provide coverage for the diagnosis and treatment of autism spectrum disorders," and treatment expressly includes "applied behavior analysis prescribed or ordered by a licensed health or allied health professional" and habilitative or rehabilitative care "including applied behavior analysis." The 2018 amendment removed the old age bands and dollar caps: coverage "shall not be subject to any maximum annual benefit limit, including any limits on the number of visits an individual may make to an autism services provider," and cost-sharing may be no less favorable than for other medical services. For ongoing outpatient treatment the insurer may request a utilization review "not more than once every twelve (12) months" unless the insurer and the treating physician or psychologist agree to more, may ask for records showing medical necessity and improved clinical status, and may request a treatment plan with diagnosis, type, frequency, anticipated duration, goals and update frequency; goals must be "clearly defined, directly observed, and continually measured." Plans need not pay for services in an IEP, IFSP or other publicly funded program, for services by a relative who would not otherwise charge, or for "services provided by persons who are not licensed as required by law." KRS 304.17A-144 also requires each insurer to give members an autism liaison who explains the ABA benefit, the prior-authorization process and documentation, ABA claim coding, and appeal rights. The mandate reaches fully insured plans; self-funded employer plans answer to ERISA instead.[4][5]
Kentucky licenses behavior analysts under KRS Chapter 319C through the Kentucky Applied Behavior Analysis Licensing Board (BACB lists Kentucky licensure since 2010). No one may practice or "render services designated as applied behavior analysis" in Kentucky without a license, except people delivering ABA in a public school setting, implementing ABA for an immediate family member or as a supervisee, other licensed health professionals within their own scope, and people providing Medicaid waiver services (KRS 319C.020). A licensed behavior analyst must hold and keep an active BCBA; a licensed assistant behavior analyst an active BCaBA, supervised by a certified behavior analyst (KRS 319C.080). The practice of ABA "shall not include diagnosis" (KRS 319C.010(8)), so the autism diagnosis must come from another licensed clinician. A BCBA licensed in another state can get a Kentucky license through KRS 319C.090 (valid license elsewhere, KRS 319C.080 requirements met, no pending discipline), but cannot simply treat a Kentucky child remotely: the board’s telehealth rule says "a person providing applied behavior analytic services via telehealth to a person physically located in Kentucky while services are provided shall be required to be licensed by the board" (201 KAR 43:100). For commercial telehealth, KRS 304.17A-138 likewise lets a plan require the telehealth provider to be licensed in Kentucky or under a recognized interstate compact. On rates, commercial ABA rates are negotiated and unpublished; the public benchmark is the Kentucky Medicaid fee-for-service schedule (2026: 97153 $12.18 per 15 minutes for an RBT; 97155 $21.99 for a licensed behavior analyst).[11][12][13][14][15][6][16][17]
DMS says that "Effective Jan. 1, 2025, Anthem is no longer a Medicaid Managed Care Organization, or MCO, in Kentucky," and DMS now contracts with Aetna, Humana, Passport by Molina, UnitedHealthcare and WellCare. A child who had Anthem Medicaid is now in one of those plans. Kentucky’s prompt-pay law requires an insurer to pay a clean claim, or send notice denying or contesting it, "within thirty (30) calendar days from the date that the claim is received" (KRS 304.17A-702), with interest added automatically on late clean claims at 12 percent a year for the first 30 days late, 18 percent for days 31–60, and 21 percent after that (KRS 304.17A-730). Self-funded ERISA plans are outside the state statute.[3][8][9]
Anthem’s 2026 Kentucky Commercial Provider Manual does not print a filing limit: "Claims must be submitted within the timely filing timeframe specified in the Provider or Facility Agreement," late claims are denied unless proof of timely filing is shown (a clearinghouse acceptance report, a dated claim copy, or an Anthem request for more information), and "Any rejected Claims must be corrected and resubmitted within the timely filing period." A correction goes in as a full replacement claim (frequency code 7 with the original claim number in REF F8), and a claim billed to Anthem in error as a void/cancel. Anthem publishes no check-run schedule; its BlueCard manual gives its "standard time for claims processing" as "less than 10 days."[20][21]
For a member of another Blue plan, Anthem’s BlueCard Program Provider Manual says you "submit claims for patients from other BCBS Plans … to your local BCBS Plan," which is "your sole contact for claims payment, adjustments and issue resolution": file to Anthem with the member ID exactly as printed, three-character prefix included. Check eligibility through Availity (HIPAA 270) or 1-800-676-BLUE (2583). Prior authorization belongs to the member’s home plan: use the "Medical Policy and Pre-Authorization/Pre-Certification Information Router" on anthem.com with the prefix, or Availity’s authorization tool, which routes out-of-state prefixes to the home plan. When another carrier is primary, send its name and address (and EOB when Anthem is secondary) with the claim, or the home plan must investigate and payment is delayed. The BlueCard manual Anthem posts is an older edition, so confirm current details with Anthem.[20][21]
The questions that decide whether a family can start with Anthem Blue Cross and Blue Shield (Kentucky), and what they have to bring. Each maps onto something intake should ask on the first call.
Anthem’s ABA documents require precertification, not a referral. For a fully insured Kentucky plan, KRS 304.17A-142 defines covered ABA as ABA "prescribed or ordered by a licensed health or allied health professional," so keep a signed order or prescription on file; the insurer may also request a treatment plan for continuing services. Self-funded ERISA plans sit outside the statute.[1][4]
Anthem’s ABA documents read set no age limit. For fully insured Kentucky plans issued or renewed on or after January 1, 2019, KRS 304.17A-142 carries no age limit and bars any maximum annual benefit or visit limit on autism treatment. Self-funded ERISA plans are outside the statute, so plan funding type decides whether that binds.[2][4]
Ask the plan: Availity benefits check: establish fully insured vs. self-funded ERISA first.
Anthem points to its Virtual Visits reimbursement policy and says "Allowed codes may vary"; ABA telehealth bills POS 10 (home) or 02. For fully insured Kentucky plans, KRS 304.17A-138 requires telehealth coverage equivalent to in person, bars an in-person requirement unless the provider decides it is necessary, and lets the plan require a Kentucky-licensed provider.[2][6]
Blocked on: Anthem’s Virtual Visits reimbursement policy (allowed virtual services list) for Kentucky, or provider services.
Depends on how the plan is funded. Fully insured Kentucky plans fall under KRS 304.17A-607: a utilization review decision on urgent care is due "no later than twenty-four (24) hours after obtaining all necessary information," and on non-urgent care "within five (5) days of obtaining all necessary information" (limited to face-to-face evaluation results, any required second opinion, and information the Department of Insurance designates). A missed deadline "shall be deemed to be a prior authorization for the health care services." For ongoing autism treatment, KRS 304.17A-142 limits utilization review to once every 12 months unless the insurer and the treating physician or psychologist agree otherwise. Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1: pre-service decisions "not later than 15 days after receipt of the claim," with one 15-day extension. Anthem publishes no Kentucky-specific ABA turnaround.[7][4][18]
Ask the plan: At benefits verification ask whether the plan is fully insured (Kentucky-regulated), a self-funded group, or a National Account.
For a child on two group plans, Kentucky follows the birthday rule: when the parents are married, are not separated, or share joint custody without a decree assigning coverage, the plan of the parent "whose birthday is earlier in the year" is primary; same birthday, the plan that has covered a parent longer; a court decree naming the responsible parent controls (806 KAR 18:030). If the plans cannot agree within 30 calendar days of having everything needed, they pay in equal shares and settle afterwards. That rule binds state-regulated group plans; a self-funded plan sets its own order. If the child also has Kentucky Medicaid, the commercial plan pays first: Medicaid MCOs "cost avoid" claims when other coverage is known (42 CFR 433.139).[10][19]
Ask the plan: Ask Anthem at benefits verification for the coordination-of-benefits order.
Not stated in the Anthem documents read. Anthem’s Kentucky provider news says that from June 1, 2024 ABA medical-necessity reviews moved from its public guideline CG-BEH-02 to "MCG B-806-T Behavioral Health Care Applied Behavioral Analysis," a licensed MCG guideline that cannot be read or republished.[2][25]
In licensed criteria: Anthem behavioral health utilization management (number on the member’s card) or Availity: ask what the MCG B-806-T review needs for this point; the guideline itself is licensed and not public.
Not stated in the Anthem documents read. Kentucky excludes diagnosis from ABA practice (KRS 319C.010(8)). Anthem’s Kentucky provider news says that from June 1, 2024 ABA medical-necessity reviews moved from its public guideline CG-BEH-02 to "MCG B-806-T Behavioral Health Care Applied Behavioral Analysis," a licensed MCG guideline that cannot be read or republished.[2][11][25]
In licensed criteria: Anthem behavioral health utilization management (number on the member’s card) or Availity: ask what the MCG B-806-T review needs for this point; the guideline itself is licensed and not public.
Not stated in the Anthem documents read; the guide stresses standardized assessments for evaluating progress. Anthem’s Kentucky provider news says that from June 1, 2024 ABA medical-necessity reviews moved from its public guideline CG-BEH-02 to "MCG B-806-T Behavioral Health Care Applied Behavioral Analysis," a licensed MCG guideline that cannot be read or republished.[2][25]
In licensed criteria: Anthem behavioral health utilization management (number on the member’s card) or Availity: ask what the MCG B-806-T review needs for this point; the guideline itself is licensed and not public.
Coverage decides whether Anthem Blue Cross and Blue Shield (Kentucky) 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 resource guide approves BCBAs and "providers practicing under the direction and supervision of the BCBA," and requires the supervising BCBA or QHP in box 31 for technician work; it sets no numeric ratio. Kentucky’s board rule (201 KAR 43:050) governs supervision of licensed assistants and temporary licensees.[2][23]
"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."[2]
Anthem administers NCCI edits, so ABA codes "may have associated MUE limits" aligned with CMS’s published MUEs. Kentucky’s mandate bars visit limits in fully insured plans. Since March 1, 2026 Anthem pays commercial ABA "based on weekly approved units rather than total authorized units": claims "should reflect the units rendered within each week, up to the weekly medically necessary limit as approved by prior approval," and units above the weekly limit "will be considered ineligible for reimbursement."[2][4][24]
Each entry needs author identification and rendering credentials; entries should be made at or shortly after the service and "should not exceed 30 days," with a "Signature date within 30 days of the date of service." Start and stop times are required, and treatment plans must be reviewed or updated at least every six months.[2]
POS codes Anthem lists for ABA: 12 home, 11 office/clinic, 99 community, 03 school, 10 telehealth in the home, 02 telehealth outside the home, "Subject to the member’s coverage and reviews by the plan."[2]
File claims for out-of-area Blue members to Anthem, your local plan, with the full member ID and prefix; Anthem pays you and handles adjustments. Get prior authorization from the member’s home plan through Anthem’s prefix router or Availity, and check eligibility at 1-800-676-BLUE. The filing limit itself is set in your Anthem provider agreement.
Yes. ABA is on Anthem’s January 2026 precertification list for Kentucky Blues products, with Anthem as the responsible party.
No. Anthem left Kentucky Medicaid managed care on January 1, 2025. Kentucky’s Medicaid MCOs are Aetna Better Health, Humana Healthy Horizons, Passport by Molina, UnitedHealthcare Community Plan and WellCare.
Only when the technician and the QHP are both face-to-face with the patient at the same time and the QHP is directing the technician.
If the plan is fully insured and issued or renewed on or after January 1, 2019, yes: ABA coverage with no age, annual-benefit or visit cap. Self-funded employer plans follow their own documents.
No. Since March 1, 2026 Anthem reimburses commercial ABA on weekly approved units, not the total authorization: bill the units delivered in each week up to that week’s approved limit, and units over the weekly limit are not reimbursable.
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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