Anthem Blue Cross is two regulated entities under one brand — Blue Cross of California (a DMHC-licensed health care service plan) and Anthem Blue Cross Life and Health Insurance Company (CDI-regulated) — plus self-funded employer groups it only administers. For ABA the brand behaves consistently: every ABA code needs precertification, and Anthem’s own behavioral health team (not Carelon) reviews it. What changes with the funding type is the rulebook: fully insured California plans are reviewed on American Academy of Child and Adolescent Psychiatry (AACAP) criteria to comply with SB 855, while self-funded plans use licensed MCG guideline B-806-T. Anthem Blue Cross is a separate company from Blue Shield of California.
Anthem’s California PPO precertification list (updated October 20, 2026, effective November 1, 2026) lists every ABA code — 97151–97158, 0362T, 0373T, H0031, H0032, H0046, H2012, H2014 and H2019 — with Anthem as the responsible party and "Contact Behavioral Health at the number on the member’s ID card." Its criteria column reads "American Academy of Child and Adolescent Psychiatry (AACAP)," with the comment "California Self-insured (ASO) benefit plans use MCG B-806-T Applied Behavioral Analysis." That is Anthem’s answer to SB 855’s requirement that fully insured plans use nonprofit-association criteria. Anthem’s national adaptive-behavior guideline (CG-BEH-02) is not on its California guideline index and is not cited for California. The list applies to "local fully-insured Anthem members and select members who are covered under self-insured (ASO) benefit plans" — not to HMO, BlueCard (out-of-state Blue cards follow the home plan), Medicare, Medicaid or FEP. Carelon is not the ABA reviewer on this list: the list names Carelon Medical Benefits Management only for cardiology, genetic testing, sleep, imaging, radiation oncology, musculoskeletal and similar programs, while every ABA row names Anthem.[2][3][12]
Anthem’s behavioral health group guide adds: "Always obtain authorization prior to rendering ABA services"; "ABA services are authorized by CPT® code, and claims will be processed by CPT code"; units must be whole numbers; and "Include the individual NPI of the rendering provider." Submit through Interactive Care Reviewer on Availity or "fill out the Adaptive Behavioral Treatment Request and fax the completed form to 866-582-2287." The current form is the Treatment Plan Request Form for Autism Spectrum Disorders (California commercial, April 2026): it asks who diagnosed the child, wants a diagnostic report by "a doctorate-level clinician or allowable qualified healthcare provider per state regulations" with DSM-5-TR criteria and a standardized tool (ADI-R, ADOS-2 or CARS-2 given as examples) for initial assessment requests, a treatment plan "dated within 30 days of the start date," and the BCBA's information and signature. Some Anthem plans carve mental health out to another company — the ID card says so.[2][3][12]
California’s mandate is Health & Safety Code § 1374.73 for DMHC-regulated health care service plans (every HMO and many PPO/EPO products) and Insurance Code § 10144.51, its word-for-word twin for CDI-regulated insurance policies. Enacted by SB 946 in 2011 with a sunset, made permanent by AB 796 in 2016 and last amended by SB 402 (effective January 1, 2026), it requires every plan covering hospital, medical or surgical care to cover "behavioral health treatment for pervasive developmental disorder or autism" — defined to include "applied behavior analysis and evidence-based behavior intervention programs" — "in the same manner and … subject to the same requirements" as mental health parity under § 1374.72. The statute has no age limit and no dollar or visit cap. Treatment must be "prescribed by a physician and surgeon" or "developed by a psychologist," follow a treatment plan with measurable goals "reviewed no less than once every six months" by the qualified autism service provider, and may not be used for "respite, daycare, or educational services." Plans may still use "case management, network providers, utilization review techniques, prior authorization, copayments, or other cost sharing."[4][5][15][6][16][17]
Three newer layers matter at intake. SB 855 (§§ 1374.72, 1374.721; Ins. §§ 10144.5, 10144.52) requires medical-necessity decisions under "generally accepted standards," using the criteria of "the nonprofit professional association for the relevant clinical specialty," supplied "at no cost" — and bars limiting coverage because services "should be or could be covered by a public entitlement program, including … special education or an individualized education program, Medicaid." SB 402 (carrying AB 951) says a contract issued, amended or renewed on or after January 1, 2026 "shall not require an enrollee previously diagnosed with pervasive developmental disorder or autism to receive a rediagnosis to maintain coverage" and "shall not discontinue or delay existing treatment while waiting for a rediagnosis." And every plan must keep "an adequate network" of qualified autism service providers. Exempt: self-funded ERISA employer plans (outside state law), Medi-Cal plan contracts, specialized plans that do not deliver mental health services, and — for CDI policies — accident-only, specified-disease, hospital-indemnity and Medicare supplement policies.[4][5][15][6][16][17]
California has no behavior analyst license — it is absent from the BACB’s licensure table, and SB 402’s new Business & Professions Code chapter (§§ 4999.200–4999.202) is definitional only. A qualified autism service (QAS) provider is a BCBA ("certified by a national entity, such as the Behavior Analyst Certification Board") or a listed California licensee; a QAS professional (BCaBA-level behavior service providers under 17 CCR § 54342, or — since SB 805 — associate MFTs, ACSWs, APCCs and psychological associates) works under the provider’s supervision; and a QAS paraprofessional — the technician — is "an unlicensed and uncertified individual" supervised "at a level of clinical supervision that meets professionally recognized standards of practice." Anthem’s H-code descriptors mirror those tiers (H2012 by a QAS provider, H0046 by a QAS professional, H2019 by a QAS paraprofessional, H0032 for supervision). Anthem publishes no ABA fee schedule; rates sit in the Commercial Behavioral Health and ABA Group Agreement, and Anthem says it is currently accepting requests to join from ABA providers.[18][19][10][2]
Anthem’s behavioral health group guide says: "Submit original claims within 90 days of performed services" (payer ID 47198, CMS-1500, the rendering provider’s individual NPI, ICD-10 autism diagnosis), adding that when behavioral health is carved out to another plan the filing limit may differ. Disagreements with an adjudicated claim go on the Provider Dispute Resolution Request form after customer service or an Availity secure message fails.[1][3][20][21]
For Blue Cross of California (the DMHC-licensed entity), the regulator sets the outer limits: a plan may not impose a filing deadline "less than 90 days for contracted providers and 180 days for non-contracted providers after the date of service"; since January 1, 2026 it must pay a complete claim within 30 calendar days of receipt, with 15% annual interest from day 31 (H&S § 1371 as amended by AB 3275 — the regulation’s 30 and 45 working days no longer control); and providers have 365 days from the plan’s action to file a provider dispute, which the plan must decide within 45 working days (28 CCR §§ 1300.71, 1300.71.38). CDI-regulated Anthem Blue Cross Life and Health policies follow the Insurance Code instead (Ins. Code § 10123.13, also 30 calendar days since 2026), and self-funded plans their own plan document.[1][3][20][21]
Out-of-network override (Anthem's single-case route): behavioral health professionals "not contracted with the Anthem network" request an "Out of Network Override or Benefit Exception," or an extension of a previously approved out-of-network request, on Anthem's Out of Network Override Request Form (January 2026) — through Availity or fax 877-521-4788. "Reviewing the request can take up to 15 business days," and "Prior Auth/Pre-Approval is required for all ONR requests." The form asks for the provider's tax ID, license, NPI, diagnosis, billing codes, telehealth and session frequency. Geographic and provider-access requests go to Member Services on the card instead.[14][3]
Network status: Anthem's California commercial behavioral health page says it is "currently accepting requests to join our network from ... providers who render ABA services"; requests go through digital provider enrollment on Availity with CAQH ProView.[14][3]
Disputes: after customer service, an Availity secure message and a supervisor, "submit a provider dispute" on the Provider Dispute Resolution Request form, which "is used to initiate the formal dispute process for a claim that has already been adjudicated or when a provider disagrees with a billing determination."[14][3]
The questions that decide whether a family can start with Anthem Blue Cross (California commercial), and what they have to bring. Each maps onto something intake should ask on the first call.
Doctorate-level clinician, or another provider the state allows. Anthem's California commercial Treatment Plan Request Form for Autism Spectrum Disorders (April 2026) says an initial assessment request (97151/97152/0362T only), or a request for a member with new coverage, should include a "Diagnostic evaluation/report completed by a doctorate-level clinician or allowable qualified healthcare provider per state regulations confirming the member's diagnosis," and the form asks "Diagnosed by whom." LCSW: not named. A licensed clinical social worker is not a doctorate-level clinician, so an LCSW diagnosis is acceptable only if Anthem treats the LCSW as an "allowable qualified healthcare provider per state regulations" — confirm with Anthem UM before relying on one. The statute separately requires BHT "prescribed by a physician and surgeon" or "developed by a psychologist" (H&S § 1374.73(d)(1)(A)). Self-funded (ASO) plans review on licensed MCG B-806-T.[12][4]
Anthem's California commercial Treatment Plan Request Form for Autism Spectrum Disorders (April 2026): the diagnostic report should include "Records showing how the patient meets criteria for Autism Spectrum Disorder (ASD) as per DSM-5-TR criteria" and "Standardized diagnostic tools (for example, Autism Diagnostic Interview, Revised (ADI-R); Autism Diagnostic Observation Schedule, Second Edition (ADOS-2); Childhood Autism Rating Scale, Second Edition (CARS-2))." The tools are examples, not one mandated instrument. For treatment requests it recommends "Baseline and updated assessments (for example, Vineland, VB Mapp, ABLLS-R)." Self-funded plans: licensed MCG B-806-T.[12]
No age limit on fully insured plans: Anthem’s California PA list and BH guide carry no age cap, and H&S § 1374.73 / Ins. § 10144.51 contain none. Self-funded (ASO) plans follow their own plan document and the licensed MCG B-806-T guideline.[2][4]
Ask the plan: Benefits verification on the member ID — fully insured vs. self-funded, then the employer plan’s own terms for ASO groups.
No recency window for the diagnosis. Anthem's California commercial Treatment Plan Request Form (April 2026) asks for the diagnostic evaluation with an initial assessment request "or if a member has new insurance coverage," and says the "Treatment plan should be dated within 30 days of the start date." It sets no maximum age for the diagnostic report. For fully insured contracts issued, amended or renewed on or after January 1, 2026, the plan "shall not require an enrollee previously diagnosed … to receive a rediagnosis to maintain coverage" and may not delay existing treatment waiting for one (H&S § 1374.73(c) / Ins. § 10144.51(c)). Self-funded plans run on licensed MCG criteria.[12][4][5]
Ask the plan: Anthem UM (800-274-7767) at the ICR request if a self-funded plan asks for a newer evaluation; for self-funded plans the answer sits in MCG B-806-T.
Anthem sets no referral or physician-order step of its own for commercial ABA. Its commercial BH/ABA group guide goes straight to pre-authorization: "submit an online request at https://Availity.com or fill out the Adaptive Behavioral Treatment Request and fax the completed form to 866-582-2287." The order that applies is the statute's: BHT must be prescribed by a physician or developed by a psychologist (H&S § 1374.73), so the diagnosing physician's or psychologist's recommendation serves as the order. HMO members may be routed through their medical group, so confirm on the card who manages behavioral health.[3][4][23]
Ask the plan: The behavioral health number on the member ID card. For an HMO member, ask whether behavioral health is retained by Anthem or delegated to a medical group, and whether that group requires a PCP referral before the ABA request.
No Anthem California ABA telehealth policy was found (its reimbursement policy library sits behind Availity). The statutory floor: DMHC plans must cover services "appropriately delivered through telehealth services on the same basis and to the same extent" as in person and pay the same rate (H&S § 1374.14; Ins. § 10123.855 for CDI policies). BCBAs and QAS professionals are telehealth providers under B&P § 2290.5; technicians are not named. Anthem’s California ABA Provider Resource Guide gives the place of service — POS 10 when the member is at home, POS 02 when the member is elsewhere — and sends providers to its Virtual Visits reimbursement policy and "Allowed virtual services" list for which codes and modifier apply.[24][25][13]
Blocked on: Anthem California commercial reimbursement policy "Virtual Visits" and its Allowed virtual services list in Availity (Payer Spaces > Anthem > Policies), and which 971xx codes may be remote at the ICR request.
Anthem California publishes no figure of its own, so the regulator’s clock applies. DMHC plans: H&S § 1367.01(h) — decisions "not to exceed five business days" from receipt of the information reasonably necessary, 72 hours when urgent, the provider told within 24 hours of the decision. CDI policies: Ins. § 10123.135(h), the same 5 business days / 72 hours. Self-funded (ASO) plans: 29 CFR 2560.503-1 — pre-service decisions "not later than 15 days after receipt of the claim," one 15-day extension, urgent within 72 hours. Reauthorization: the statute requires the treatment plan be reviewed at least every six months; the authorized date span is on the ICR approval.[7][8][26]
Ask the plan: At benefits verification ask whether the plan is DMHC, CDI or self-funded, then confirm the precertification turnaround with Anthem UM (800-274-7767).
No Anthem California ABA-specific COB rule. The regulator floor: DMHC plans follow 28 CCR § 1300.67.13 and CDI policies 10 CCR § 2232.56 — the employee’s plan before the dependent’s; for a child of non-separated parents, the plan of the parent whose birthday falls earlier in the calendar year; then court decree, custodial parent, stepparent, non-custodial parent. Medi-Cal is excluded from COB and pays last. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is "the last payer" (38 CFR 17.270(b)). BlueCard members are routed to their home plan. Self-funded plans use their own plan document.[27][28][29][30]
Ask the plan: Ask Anthem at benefits verification for the member’s COB order, and record every other coverage the child has.
Coverage decides whether Anthem Blue Cross (California commercial) 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 California ABA Provider Resource Guide: "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 procedure fall under Anthem’s Incident To Services and Billing reimbursement policy, and ABA codes are subject to NCCI edits under its Code and Clinical Editing Guidelines policy.[13]
No per-day hour cap is published; the ceiling is weekly. From January 1, 2026 Anthem California pays 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," and units over the weekly limit "will be considered ineligible for reimbursement" (97151–97158, 0362T, 0373T). ABA codes "may have associated MUE limits" under Anthem’s NCCI editing, and "billings with units that include fractions or decimals cannot be processed."[22][13][3]
Anthem’s California ABA Provider Resource Guide (citing its Documentation Standards for Episodes of Care policy): each entry must carry "author identification of the physician or other qualified healthcare provider," which may be a handwritten signature, unique electronic identifier, or initials with credentials; entries are expected at the time of service and "should not exceed 30 days"; "Signature date within 30 days of the date of service." Record total minutes for timed codes and "the start and stop times." Treatment plans must show review or update at least every six months.[13]
Anthem’s guide: "Include the individual NPI of the rendering provider" (CMS-1500, payer ID 47198), with ABA contracted under the Commercial Behavioral Health and ABA Group Agreement and credentialing via CAQH ProView. For SB 855 supervised associates: "We do not directly contract with these provider types; however, they can render services to members if the supervising licensed provider is contracted with Anthem. The claim form should only include the licensed, contracted provider information." The rendering NPI "should be the provider named in the authorization," and the California ABA Provider Resource Guide settles technician time: "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," with modifiers HM (less than bachelor’s), HN (bachelor’s) and HO (master’s) for the rendering level. Each BCBA "must have an individual NPI and a BCBA certification" to be added to the group.[3][13]
Anthem's California commercial Treatment Plan Request Form (April 2026) describes 97153 as treatment "administered by technician under direction of physician/QHCP, receiving 2 hours of supervision for every 10 hours of direct treatment" — a 20% supervision expectation, stated on the request form rather than in a policy. Its H-code descriptors encode the QAS tiers — H0031 assessment/plan by a "Qualified Autism Service Provider (licensed clinician or Board Certified Behavioral Analyst (BCBA))," H0032 "supervision of a Qualified Autism Service Professional or Paraprofessional by a Qualified Autism Service Provider," H0046 direct treatment by a QAS professional, H2019 by a QAS paraprofessional. The statute requires only supervision meeting "professionally recognized standards of practice." Anthem’s California ABA Provider Resource Guide adds one operational rule — 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" — and the form's signature line confirms "that any paraprofessional under my supervision has the appropriate education and training." No technician-to-BCBA caseload ratio is published.[12][13][2][19]
Blocked on: Anthem California Facility and Professional Provider Manual (Availity-gated) or the ABA group agreement.
Anthem’s California ABA Provider Resource Guide lists the POS codes "frequently used for ABA": 12 home, 11 office/clinic, 99 community, 03 school, 10 telehealth in the home and 02 telehealth outside the home — "Subject to the member’s coverage and reviews by the plan." The statute: the treatment plan may not be used "for … respite, daycare, or educational services" (§ 1374.73), but the plan "shall not limit benefits … on the basis that those services should be or could be covered by … special education or an individualized education program" (§ 1374.72(h)).[4][15][13]
Ask the plan: Anthem UM at the ICR request — whether school-setting (POS 03) hours are approvable for this member.
Through its Out of Network Override Request Form (January 2026): non-contracted behavioral health providers request an override or benefit exception, or an extension of an earlier one, via Availity or fax 877-521-4788. Review can take up to 15 business days, and pre-approval is required before services.
Yes — for autism, with precertification on every ABA code. Fully insured plans are reviewed on AACAP criteria to comply with SB 855; self-funded employer plans use MCG guideline B-806-T.
Through Interactive Care Reviewer on Availity, or by faxing the Adaptive Behavioral Treatment Request to 866-582-2287. UM questions: 800-274-7767.
Fully insured plans must cover behavioral health treatment, including ABA, for autism with no age or dollar caps, a treatment plan reviewed at least every six months, and — from 2026 — no forced rediagnosis to keep coverage. Self-funded ERISA and Medi-Cal plans are exempt.
Every ABA code needs precertification — 97151, 97152, 0362T for the assessment and 97153–97158, 0373T plus the QAS H-codes for treatment — and Anthem itself, not Carelon, is the responsible reviewer on the October 2026 list, using AACAP criteria for fully insured plans and MCG B-806-T for self-funded ones. Claims bill on an autism diagnosis and the mandate needs a physician prescription or psychologist-developed plan. Anthem's April 2026 California commercial Treatment Plan Request Form for Autism Spectrum Disorders sets the diagnostic packet: for the initial assessment request (or new coverage), a diagnostic evaluation "completed by a doctorate-level clinician or allowable qualified healthcare provider per state regulations," showing DSM-5-TR criteria and standardized tools such as the ADI-R, ADOS-2 or CARS-2; the form asks who made the diagnosis. It sets no recency window, and for fully insured contracts renewed from 2026 Anthem may not demand a rediagnosis to keep coverage. The treatment plan should be dated within 30 days of the start date. Submit on ICR in Availity or fax 866-582-2287.
The rendering NPI should be the provider named on the authorization, and Anthem’s California ABA Provider Resource Guide says technician-delivered ABA "must show the supervising BCBA or other QHP in box 31," with HM/HN/HO modifiers for the technician’s education level.
Anthem’s behavioral health group guide says to submit original claims within 90 days of the service. For the DMHC-licensed plan, state regulation bars deadlines shorter than 90 days for contracted providers (180 for non-contracted) and, since January 1, 2026, payment of a complete claim within 30 calendar days of receipt (H&S § 1371 as amended by AB 3275).
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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