In Maine, Anthem Blue Cross and Blue Shield is the trade name of Anthem Health Plans of Maine, Inc. Two Anthem documents govern ABA here: the Maine Precertification/Prior Authorization List (October 2026), which puts applied behavior analysis under Anthem’s own behavioral health review, and the multi-state ABA Provider Resource Guide, which names Maine among its states and sets coding, supervision and documentation rules.
Under both sits Maine’s autism mandate, which reaches fully insured plans and only children 10 and under. Establish funding type and the child’s age on every benefits check.
Anthem’s Maine Precertification/Prior Authorization List (ME-BCBS-CM-022999-26, October 2026) lists, under behavioral health services, inpatient admissions, partial hospital and intensive outpatient programs, intensive in-home services, TMS and "Applied behavior analysis (ABA)," with Anthem as the reviewer and the instruction "Contact Behavioral Health, Inc. at 800-755-0851." It adds that prior authorization requirements for psychological testing and outpatient services "vary by product and plan." On HMO plans "It is the participating physician’s or care provider’s responsibility" to obtain prior authorization, and the request "must come from the care provider or facility rendering the service"; without it, "the claim payment may be reduced or denied by the Plan and the member must be held harmless." On PPO plans the network provider is responsible, while a BlueCard or non-participating provider leaves it to the member.[1]
Anthem’s ABA Provider Resource Guide (June 2025) names Maine among its states. Approved providers include psychiatrists, psychologists, LCSWs, LPCs and LMFTs with ABA training, BCBAs and BCBA-Ds, "providers practicing under the direction and supervision of the BCBA," and other state-recognized mental health providers. 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." Technician services "must show the supervising BCBA or other QHP in box 31." Record start and stop times, sign within 30 days of the date of service, and update the treatment plan at least every 6 months. Anthem applies NCCI medically unlikely edits to ABA codes and lists POS 12 (home), 11 (office), 99 (community), 03 (school), and 10 and 02 (telehealth).[2]
Maine’s autism mandate is written three times, once for each kind of contract: 24-A M.R.S. § 2768 for individual health insurance, § 2847-T for group policies, and § 4259 for individual and group HMO contracts. The operative text is the same in all three. The plan "must provide coverage for autism spectrum disorders for an individual covered under a policy or contract who is 10 years of age or under." 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," and must cover treatment "when it is determined by a licensed physician or licensed psychologist that the treatment is medically necessary," with ongoing medical necessity demonstrable "at least annually." It "may not include any limits on the number of visits," but it "may limit coverage for applied behavior analysis to $36,000 per year" (the group and HMO versions add "to the extent allowed by federal law"), and payments for unrelated care may not count toward that cap. ABA is covered as a habilitative or rehabilitative service, and "To be eligible for coverage, applied behavior analysis must be provided by a person professionally certified by a national board of behavior analysts or performed under the supervision of" such a person. The mandate does not change a school’s obligations under an IEP or IFSP. The age ceiling was 5 until P.L. 2013, c. 597 raised it to 10 for policies issued or renewed from January 1, 2015. Two practical consequences: a child turns out of the mandate at 11, after which ABA depends on the plan’s own terms; and the mandate binds fully insured plans regulated in Maine, not self-funded employer plans, which answer to ERISA and their plan documents.[3][4][5][6]
Maine does not license behavior analysts. The BACB’s U.S. licensure table, which lists every state with a behavior-analyst licensure law and its board, does not include Maine, and Title 32 of the Maine Revised Statutes (professions and occupations) has no behavior-analyst chapter (chapter 141, sometimes cited for this, is the professional land surveyors chapter). The working credential is BACB certification, which the mandate itself requires for whoever provides or supervises ABA. Maine’s credentialing statute still helps: under 24-A M.R.S. § 4303(2)(D) a carrier must decide a completed credentialing application "within 60 days," must review a new application within 30 days and return an incomplete one "with a comprehensive list of all corrections needed," and "may not require that a provider have a home address within the State." Under § 4303(2-A), once credentials are granted the carrier pays claims for services rendered "from the date a complete application for credentialing is submitted," though you may not submit those claims until the carrier tells you the credentialing outcome and effective date. Commercial ABA rates are negotiated and unpublished, and the MaineCare ABA rate (Section 28, H2021 U1 HK) sits on a fee schedule we could not retrieve this month.[12][13][9][4][18]
Maine’s prompt-pay law, 24-A M.R.S. § 2436, makes a health claim "payable within 30 days after proof of loss is received"; a claim "neither disputed nor paid within 30 days is overdue" and bears interest at 1½% a month. A provider may submit a claim to every carrier that may be liable, primary and secondary, at the same time, and each must pay or deny "within 30 calendar days after the carrier has received all information needed," whether or not the other carrier has acted. A claim the carrier rejects for not using the standard claim form cannot be billed to the family; fix and resubmit it. After payment, § 4303(10) bars a carrier from retrospectively denying a paid claim more than 12 months after payment unless it gives the reason in writing and the claim falls within narrow exceptions (up to 36 months for duplicate payment, services not delivered, adjustment with another insurer or legal action; beyond that only for fraud or Medicaid/Medicare/CHIP claims). Appeals of an adverse treatment decision must be heard by a clinical peer who was not involved in the first decision (§ 4304(7)). The timely-filing limit itself is a contract term, not a statute. Anthem’s resource guide also points to its Documentation Standards and Code and Clinical Editing reimbursement policies; it does not state a filing limit, so use the one in your Anthem agreement.[10][9][7][2]
A child whose card comes from another state’s Blue plan is a BlueCard member, and Anthem is the local plan. Anthem’s Maine provider manual says that "If the Member’s home plan is not with Anthem, the applicable home plan will determine prior authorization requirements". Anthem’s prefix lookup tool identifies the home plan from the three-character prefix on the ID card. For medical policy and prior authorization rules, use Resources > Prior Authorization > "Medical Policy and Prior Authorization for Blue Plans" and enter the prefix. So an out-of-state child’s ABA assessment and treatment are authorized under the home plan’s ABA policy, not Anthem’s.[16]
On utilization-management appeals the manual says decisions "involving Pre-certification/Pre-authorization are the responsibility of the Blue Plan, insuring or administering benefits for non-Anthem Members (the Member’s Home Plan)". It also says that "Technically, the Member, not the Provider or Facility, is responsible for obtaining the necessary authorization prior to the delivery of non-inpatient admission services". In practice the ABA provider requests it on the family’s behalf. A claim-denial appeal goes to the local Anthem plan as a Claim Payment Dispute.[16]
The Maine manual spells the roles out: the Home Plan "determines all of their benefits and eligibility" and "makes policy and prior certification decisions," while the provider "files Claims with the local Plan," which reimburses the provider. Its contacts are the BlueCard Call Center at (877) 795-1881 and BlueCard Eligibility at (800) 676-2583.[16]
The questions that decide whether a family can start with Anthem Blue Cross and Blue Shield (Maine), and what they have to bring. Each maps onto something intake should ask on the first call.
Anthem’s Maine list requires precertification from the rendering provider (HMO) or network provider (PPO), not a physician referral, and Anthem’s 2026 Maine provider manual says “Members may access behavioral health services through self-referral, through Anthem Behavioral Health (ABH), or by referral from another practitioner or Provider.” Anthem publishes no ABA order form. For a fully insured Maine plan, the mandate covers treatment "when it is determined by a licensed physician or licensed psychologist that the treatment is medically necessary," and the plan may require that physician or psychologist to demonstrate ongoing medical necessity "at least annually." Self-funded ERISA plans sit outside the statute.[1][16][4]
Anthem publishes no ABA age limit in its Maine documents. For fully insured Maine plans, 24-A M.R.S. §§ 2768, 2847-T and 4259 require autism coverage for a covered person "10 years of age or under" and allow ABA to be capped at $36,000 a year; from age 11 the plan’s own terms decide. Self-funded ERISA plans are outside the statute.[1][3][4][5]
Ask the plan: Live benefits verification on the member ID: establish fully insured vs. self-funded, then the plan’s own age terms for a child 11 or older.
Anthem’s Maine documents do not say. For a fully insured plan, the mandate covers diagnostic "assessments, evaluations or tests by a licensed physician or licensed psychologist."[1][4]
Ask the plan: Anthem Behavioral Health, 800-755-0851.
Anthem lists POS 10 (telehealth in the member’s home) and 02 (telehealth elsewhere) for ABA, subject to coverage, and refers to its Virtual Visits reimbursement policy, where "Allowed codes may vary." For a fully insured Maine plan, 24-A M.R.S. § 4316 says a carrier "may not deny coverage on the basis that the health care service is provided through telehealth if the health care service would be covered if it were provided through in-person consultation," that "Prior authorization is required for telehealth services only if prior authorization is required for the corresponding covered health care service," and that "An in-person consultation prior to the delivery of services through telehealth is not required." Coverage may not be limited "on the basis of geography, location or distance for travel," and the carrier may not add telehealth-only credentialing. Self-funded employer plans are outside the statute.[2][8]
Ask the plan: Anthem Virtual Visits reimbursement policy and the member’s benefits: confirm which ABA codes are allowed by telehealth.
Depends on how the plan is funded. Fully insured Maine plans fall under 24-A M.R.S. § 4304(2): a provider’s prior-authorization request for a nonemergency service "must be answered by a carrier within 72 hours or 2 business days, whichever is less." The same clock restarts when the carrier asks for more information (from receipt of it) or says outside consultation is needed. "If a carrier does not grant or deny a request for prior authorization within the time frames required under this subsection, the request for prior authorization by the provider is granted." Once approved, the carrier "may not retrospectively deny coverage or payment for the originally approved service" absent fraudulent or materially incorrect information, and may not deny the claim when the service is delivered within 14 days before or after the approved date. Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1 instead: pre-service decisions "not later than 15 days after receipt of the claim," one 15-day extension. Anthem publishes no Maine-specific ABA turnaround or reauthorization lead time.[7][14]
Ask the plan: At benefits verification ask whether the plan is fully insured (Maine-regulated) or self-funded (ERISA), and what reauthorization lead time Anthem expects.
Maine lets a provider bill every potentially liable carrier at once: under 24-A M.R.S. § 2436(1-A) each carrier, primary or secondary, must pay or deny "within 30 calendar days after the carrier has received all information needed to pay or deny the claim whether or not another carrier with which it is attempting to coordinate has acted." If two carriers cannot agree on the order of benefits within 30 days of having everything they need, Bureau of Insurance Rule ch. 790 says they "shall immediately pay the claim in equal shares" and settle up afterward, with neither paying more than it would have as primary. We did not find Maine’s order-of-benefit (birthday-rule) text this month, so ask the carriers which plan is primary. If the child also has MaineCare, Anthem pays first: "MaineCare is the payer of last resort," and a medical-necessity denial from the commercial plan must be appealed before MaineCare will consider the claim (MaineCare Benefits Manual Ch. I, § 1.07-3). TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[10][11][15][19][20][21]
Ask the plan: Ask Anthem at benefits verification for the member’s coordination-of-benefits order (and whether a self-funded plan follows its own order), and record every other coverage the child has, including MaineCare.
Not published in Anthem’s Maine documents.[1][2]
Ask the plan: Anthem Behavioral Health, 800-755-0851: ask what diagnostic documentation and dates the review expects.
The resource guide stresses "standardized assessments and current clinical information" for tracking progress but names no diagnostic instrument.[2]
Ask the plan: Anthem Behavioral Health, 800-755-0851.
Coverage decides whether Anthem Blue Cross and Blue Shield (Maine) 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 publishes no numeric supervision ratio. It recognizes "providers practicing under the direction and supervision of the BCBA," and allows 97153 alongside 97155 only when the QHP and technician are both face-to-face with the patient and the QHP is directing the technician. The Maine mandate requires ABA to be provided by, or supervised by, a person certified by a national board of behavior analysts.[2][4]
"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 services billed with a QHP procedure fall under Anthem’s Incident To reimbursement policy.[2]
No Anthem-specific daily cap is published. "ABA codes may have associated MUE limits," and Anthem administers NCCI edits as CMS updates them. Authorized hours are set per precertification. The Maine mandate bars visit limits but allows a $36,000 annual ABA cap.[2][4]
Each entry must identify its author (signature, electronic identifier or initials, with credentials). Documentation is expected "at the time of service, or shortly thereafter and should not exceed 30 days," with a "Signature date within 30 days of the date of service." Start and stop times are required for timed codes.[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, all "Subject to the member’s coverage and reviews by the plan." The Maine mandate does not change a school’s IEP or IFSP obligations.[2][4]
"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."[2]
Yes. Applied behavior analysis is on Anthem’s Maine precertification list (October 2026), reviewed by Anthem Behavioral Health at 800-755-0851. Requirements can vary by product, so check the member’s card.
The mandate lets fully insured plans cap ABA at $36,000 a year and covers children 10 and under; it bars limits on the number of visits. Self-funded plans follow their own documents.
Yes, 97155 with 97153, but only when both are face-to-face with the patient at the same time and the BCBA is directing the technician.
For a fully insured Maine plan, within 72 hours or 2 business days, whichever is less; a request not decided in time is granted by law. Self-funded plans follow federal ERISA timelines (15 days for pre-service requests).
The child’s home plan. Anthem’s manual says that when the member’s home plan is not Anthem, "the applicable home plan will determine prior authorization requirements." Look the prefix up under Medical Policy and Prior Authorization for Blue Plans on Anthem’s provider site, request authorization from the home plan, and file the claim with Anthem as the local plan.
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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