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 August 24, 2026, effective September 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.[1][2]
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." Some Anthem plans carve mental health out to another company — the ID card says so.[1][2]
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."[3][4][10][5][11][12]
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.[3][4][10][5][11][12]
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.[13][14][9][1]
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.
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.[1][3]
Ask the plan: Benefits verification on the member ID — fully insured vs. self-funded, then the employer plan’s own terms for ASO groups.
Anthem publishes no California recency rule of its own. 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)); utilization review is still allowed. Self-funded plans run on licensed MCG criteria.[3][4]
Ask the plan: Anthem UM (800-274-7767) at the ICR request; for self-funded plans the answer sits in MCG B-806-T.
No Anthem referral or order requirement for PPO ABA was found; the statute’s requirement that BHT be prescribed by a physician or developed by a psychologist works as the order. HMO members may route through their medical group — confirm on the card.[3][15]
Ask the plan: The behavioral health number on the member ID card — for HMO members, whether BH is retained by Anthem or delegated to a medical group.
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.[16][17]
Blocked on: Anthem California commercial reimbursement policy "Telehealth" 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.[6][7][18]
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.[19][20][21][22]
Ask the plan: Ask Anthem at benefits verification for the member’s COB order, and record every other coverage the child has.
Anthem California names no diagnosing-provider list. The statutory floor for fully insured plans: BHT must be "prescribed by a physician and surgeon" or "developed by a psychologist" (§ 1374.73(d)(1)(A)).[3]
Ask the plan: Anthem UM 800-274-7767 — how the AACAP-based review treats the diagnosing clinician; self-funded plans apply licensed MCG B-806-T.
No Anthem California requirement for a specific instrument (ADOS-2 etc.) was found in any published document.[2]
In licensed criteria: Self-funded plans: MCG B-806-T (licensed, not publishable); fully insured: the Adaptive Behavioral Treatment Request checklist in Availity or Anthem UM 800-274-7767.
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 California publishes no supervision ratio. 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."[1][14]
Blocked on: Anthem California Facility and Professional Provider Manual (Availity-gated) or the ABA group agreement.
No per-day cap published; units are limited to what is authorized per CPT code, and "billings with units that include fractions or decimals cannot be processed."[2]
Ask the plan: The ICR authorization (units per code) and Anthem’s reimbursement policy on MUEs in Availity.
Nothing published by Anthem California on ABA settings. 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)).[3][10]
Ask the plan: Anthem UM at the ICR request — whether school-setting hours are approvable for this member.
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." Whether technicians appear as rendering on ABA claims is not stated.[2]
Ask the plan: Anthem provider services or the ABA group agreement — whether RBT/paraprofessional time is billed under the BCBA or the group.
Not addressed in any public Anthem California document.[2]
Blocked on: Anthem California commercial reimbursement policies (Availity) and the group agreement’s fee schedule exhibit.
Nothing published by Anthem California on who signs ABA session notes or when.[2]
Blocked on: Anthem California provider manual (Availity-gated) or the ABA group agreement.
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.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 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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