Anthem HP, LLC — the Elevance plan formerly branded Empire BlueCross BlueShield HealthPlus — carries the NY Medicaid ABA carve-in with an Anthem-specific authorization layer on the state's eligibility baseline. The center of gravity is its Treatment Plan Request Form for Autism Spectrum Disorders (June 2026 revision — proof the plan is an active NY ABA payer), submitted through Availity. Like other Elevance plans, it sorts requests into Comprehensive versus Focused ABA, and it returns incomplete forms rather than pending them.
Treatment authorization runs on Anthem's Treatment Plan Request Form for Autism Spectrum Disorders — New York Medicaid (form NY-BCBS-CD-008303-26-GRP2461, June 2026 revision), submitted via Availity.com as the preferred channel. The form requires the treating BCBA/QHCP's information, captures the member's age at first ABA treatment, and classifies the request as Comprehensive or Focused ABA — the standard Elevance intensity-review framework, so expect requested hours to be weighed against that model. The operational rule that costs the most time: incomplete forms are returned, not worked — so treat every field as required and package the clinical documentation with the first submission.[1]
What a re-authorization should carry. The June 2026 form’s treatment section says the treatment plan “should be dated within 30 days of the start date” and lists what Anthem recommends including: previous interventions and outcomes, the current behavioral support and treatment plan, “Cumulative graphs/charts of baseline data and current progress,” a description of progress on goals since the last review, “baseline and updated assessments (for example, Vineland, VB Mapp, ABLLS-R) to show progress toward goals is occurring,” other services and care coordination, the treatment setting, the weekly schedule, caregiver changes with measurable parent-training goals, and generalization plans. Graphs are recommended content rather than a stated condition of approval, but sending them avoids a pend.[1]
Several operational facts have no published answer we could verify: whether the assessment code 97151 itself requires PA (the plan's published process is a treatment-plan-request workflow), whether Carelon Behavioral Health plays a UM role for ABA, and any hour caps or rates. Anthem also maintains an ABA Services FAQ for NY providers (provider news article 13424) that wasn't retrievable at review time. Until the plan confirms otherwise in Availity or through provider services, run assessments on the assumption a request may be needed, and get the answer in writing per case.[2]
Anthem HealthPlus sets its own filing limit in its provider agreement and manual; New York law sets the floor. Ins. Law § 3224-a, which covers New York insurers, Article 43 corporations and Article 44 HMOs, requires claims to be submitted within 120 days of the date of service unless the contract is more favorable to the provider — and for Medicaid managed care contracts lets the parties agree on a different period "but in no event less than ninety days." Undisputed claims must be paid within 30 days of receipt when submitted electronically and 45 days on paper, with interest at the greater of the corporate-tax rate or 12% per annum when paid late.[11][12][4][5][1][6][2]
Electronic Visit Verification does not reach ABA: the Department of Health’s EVV list for fee-for-service and managed care Medicaid covers personal care and home health care codes (CDPAP, home care, HCBS habilitation and respite) and no ABA code (97151–97158).[11][12][4][5][1][6][2]
Anthem’s own rules, from its New York Medicaid provider manual: “Timely filing is within 90 days from the date of service, or per the terms of the Provider Agreement”; “In the case of other insurance, submit the claim within 90 days of receiving a response from the third-party payer”; and, “Provided the claim was originally received timely, a corrected claim must be received within 60 days of notification.” “We adjudicate all clean electronic claims within 30 days and all clean paper claims within 45 calendar days of receipt of a clean claim,” with interest if late. Remittance runs on a cycle: Anthem tells providers to “review the weekly Explanation of Payment (EOP)” and that “biweekly, we produce and mail to you an EOP” covering claims adjudicated in the previous check-week cycle; check claim status if a claim has not appeared on an EOP within 30 business days. No weekly submission cut-off is published.[11][12][4][5][1][6][2]
For Medicaid managed care specifically, the state’s model contract adds a payment rule: the plan “shall make payments to Participating Providers and to Non-Participating Providers, as applicable, for items and services covered under this Agreement on a timely basis, consistent with the claims payment procedures described in SIL § 3224-a,” and must comply with 42 CFR 447.45(d)(5) and (6).[11][12][4][5][1][6][2]
Code set: Anthem’s New York ABA Services FAQ lists “the following… allowable CPT® codes for MMC” — 97151 through 97158, each with authorization required — and states: “Medicaid does not cover CPT codes 0362T and 0373T and schools as a place of service.” No HCPCS H-code appears; the June 2026 Treatment Plan Request Form likewise requests units by 97151–97158 (its assessment instructions mention 0362T, which the FAQ says Medicaid does not cover). For a Medicaid member, the state baseline is narrower still: New York Medicaid’s ABA fee schedule (effective October 1, 2026) and the eMedNY manual’s billing table carry only CPT 97151–97158 — no 0362T or 0373T and no HCPCS H-code (H0031, H0032, H2019, H2014).[11][12][4][5][1][6][2]
The questions that decide whether a family can start with Anthem Blue Cross and Blue Shield HP (NY Medicaid), and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the New York Medicaid rule: ABA is covered for members “under 21 years of age with a diagnosis of Autism Spectrum Disorder (ASD) as defined by… (DSM-5) and/or Rett Syndrome.” No minimum age and no adult pathway — the 21st birthday is a hard cliff. Anthem publishes no age rule of its own for the New York Medicaid line; its Treatment Plan Request Form captures the member’s age at first ABA treatment rather than gating on current age.[3][1]
Follows the New York Medicaid rule — the 2-year referral is the clock, and no maximum age is set on the diagnostic evaluation. Anthem publishes no recency rule of its own for the Medicaid line; what its form does capture is treatment history, including the age at which ABA was first received.[3][1]
Follows the New York Medicaid rule: the diagnosis and referral must come from a NYS-licensed, NYS Medicaid-enrolled physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner or physician assistant, following DSM-5 criteria and NYSDOH’s Clinical Practice Guideline on ASD. LBAs and CBAAs sit outside that list — they may not diagnose and may not self-refer. Anthem’s Treatment Plan Request Form requires the treating BCBA/QHCP’s information but names no diagnosing credential of its own for the Medicaid line.[3][1]
Follows the New York Medicaid rule: no instrument is mandated. What the state requires with the referral is the “DSM-5 Diagnostic Checklist for ASD diagnoses” plus the severity level when the referral comes from an ASD-diagnosing provider; the treatment plan need only record the assessment methodology used and, “as appropriate, identify standardized assessment used (e.g., adaptive behavior scales, symptom inventories, aggression ratings) and results.” Anthem’s New York Medicaid form asks for the Comprehensive-versus-Focused classification and clinical documentation rather than a named instrument battery.[3][1]
Follows the New York Medicaid rule: the member “must be referred for ABA services by a NYS-licensed and NYS Medicaid-enrolled physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner, or physician assistant,” the referral is “valid for no more than two years,” and it must carry age, the ASD/Rett diagnosis, date of initial diagnosis, co-morbid diagnoses, symptom severity level, a statement the patient needs ABA, and the DSM-5 Diagnostic Checklist. Anthem’s own gate sits on top: treatment authorization runs on the Treatment Plan Request Form for Autism Spectrum Disorders — New York Medicaid (form NY-BCBS-CD-008303-26-GRP2461, June 2026 revision), submitted through Availity.com as the preferred channel, with incomplete forms returned rather than pended. Whether assessment code 97151 needs its own prior authorization is not published.[3][1]
The NYS Medicaid Telehealth Policy Manual (Version 2026-V2, July 2026) applies to services delivered “under contracted Medicaid Managed Care (MMC) Plans,” lists “Providers licensed or certified by the New York State Education Department (NYSED) to provide Applied Behavioral Analysis (ABA) therapy” among telehealth providers, and requires that “Providers must meet all elements of the procedure code via telehealth.” Its managed-care section says plans “are required to cover, at a minimum, services that are covered by NYS Medicaid FFS and included in the MMC benefit package… and must provide telehealth coverage as described in this guidance,” must “ensure claims allow the use of the telehealth modifiers in this guidance” and “may establish additional claiming requirements.” Billing baseline: modifier 95 or GT for audio-video; place of service 02 (not the home), 10 (the member’s home) or 11 where the in-person visit would be POS 11; payment parity with in-person until April 1, 2028. A code defined as face-to-face with the patient (97152, 97153) qualifies only if every element can be met by video. The state ABA manual separately allows LBA supervision of technicians by synchronous audio-video, but the two monthly supervision contacts must be real time and never by phone, email or text. Anthem publishes no ABA telehealth rule of its own for the New York Medicaid line: the June 2026 Treatment Plan Request Form names no remote code, modifier or place of service, and the New York Medicaid provider manual mentions telehealth only for home-care agencies and CDPAS assessments. So the state rule above is the Anthem rule. One thing the form does settle: its place-of-service block includes a “Telehealth (if allowed)” box alongside Home, Clinic and School, so mark telehealth on the treatment-plan request when any remote delivery is planned. Neither the state manuals nor the plan say whether the authorization itself must flag telehealth — state the delivery mode in the treatment plan and ask at authorization.[7][3][1][4]
Anthem’s NY Medicaid manual runs the 7-day ceiling: a standard precertification is decided “within three business days of receipt of the necessary information, but no later than 7 days after the receipt of the request,” an urgent one “no later than 72 hours after receipt of the request,” and a continuing-care (concurrent) request “within one business day of receipt of the necessary information, but no more than 7 days after receipt of the request” (urgent concurrent: one business day, 72 hours at most). “In accordance with the New York State Medicaid contract,” any of these may be extended up to 14 days. ABA goes in through Availity on Anthem’s ASD Treatment Plan Request Form, and the plan should be dated within 30 days of the requested start date. No reauth submission lead time is published.[4][1]
“We and our providers agree the Medicaid program will be the payer of last resort when third-party resources are available.” If Anthem knows of other coverage it rejects the claim and redirects you “to bill the appropriate insurance carrier”; if it learns later, it recovers after payment. So bill the other plan first, then submit to Anthem with the COB/other-insurance information — “In the case of other insurance, submit the claim within 90 days of receiving a response from the third-party payer.” The manual does not say whether Anthem’s own ABA precertification is still required when it is secondary — confirm with Provider Services (800-450-8753) before starting on the primary plan’s approval alone.[4]
Coverage decides whether Anthem Blue Cross and Blue Shield HP (NY Medicaid) 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.
Follows the New York Medicaid rule, which the state applies to FFS and managed care alike: “an LBA can supervise no more than six CBAAs/unlicensed individuals at a time,” “LBAs are required to supervise unlicensed individuals for a minimum of five percent of the hours the unlicensed individual spends providing behavior analysis services each calendar month,” and “supervision must include at least two face-to-face, real-time contacts per month” with the LBA observing service delivery in at least one. Supervision may run over synchronous audio-and-video where on-site is impractical. 97155 counts toward the 5% “only when the LBA joins the patient and the unlicensed individual during a treatment session to direct the unlicensed individual/technician in implementing a new or modified treatment protocol.” CBAAs need direct supervision, and the supervisor “should assess each patient’s/client’s progress at least every 6 months… and review and sign treatment notes and reports prepared by the CBAA supervisee.” Anthem’s own New York Medicaid Treatment Plan Request Form (June 2026) adds a dosage on top of the state’s 5% floor: it describes 97153 as treatment by a technician “receiving two hours of supervision for every 10 hours of direct treatment.” Anthem sets no technician caseload cap of its own beyond the state’s six. The form requires the treating BCBA/QHCP’s information, which in New York must be an NYSED-licensed LBA (a BCBA credential alone does not qualify), Anthem’s New York ABA Services FAQ restates the cap in its own words — “CBAAs must be supervised by an LBA. LBAs bill for services of CBAAs under their supervision and can supervise up to six CBAAs” — and the signer of the form confirms “that any paraprofessional under my supervision has the appropriate education and training.”[3][1][2]
Follows the New York Medicaid rule: the LBA supervisor must “review and sign treatment notes and reports prepared by the CBAA supervisee,” and documentation of supervision itself “should be recorded in the patient file.” Clinical documentation must carry the treatment plan with assessment and goals, the goal data, total hours of service per week by who delivered them, and the location(s) of services. Records are kept “for a minimum of six years and, for minors, until the patient turns 22 years of age.” Anthem publishes no additional session-note signature rule for its New York Medicaid line.[3]
Ask the plan: Anthem NY Medicaid provider services for any plan-specific documentation standard beyond the state rule.
Follows the New York Medicaid rule: “LBAs and CBAAs may work in any legally authorized setting. Examples of such settings include private practice, settings where patients/clients reside full-time or part-time, clinics, hospitals, residences, and community settings” — but “NYS Medicaid does not reimburse for ABA services in a school setting.” The treatment plan must record the location(s) of services. Anthem publishes no separate place-of-service rule for the New York Medicaid line; the state’s school bar is the operative constraint.[3]
Ask the plan: Availity or Anthem NY Medicaid provider services for any plan-specific setting restriction.
Not published for the New York Medicaid line. Anthem’s Medicaid Treatment Plan Request Form is an authorization instrument, not a reimbursement policy, and the state manual is silent on 97153 with 97155.[1][3]
Ask the plan: Availity or Anthem NY Medicaid provider services, and Anthem’s reimbursement policies for the New York Medicaid line.
No published hour cap for the New York Medicaid line, but the June 2026 form sets the unit clock per code: assessment codes (97151, 97152) and family-guidance codes (97156, 97157) are requested “per authorization period,” and treatment codes (97153, 97154, 97155, 97158) “per week,” so the approved weekly units are the operative 97153 limit. The form sorts requests into Comprehensive versus Focused ABA — the standard Elevance intensity-review framework — so expect requested hours to be weighed against that model rather than against a stated ceiling. Authorization periods, unit limits and rates are not published. Per-day claim edits: the federal Medicaid NCCI medically unlikely edits (October–December 2026: 97153 – 32 units a day, 97155 – 24, 97151 – 32, 97152/97156/97157/97158 – 16, 97154 – 18) are mandatory for fee-for-service claims, but CMS calls applying them to managed-care claims “desirable but optional,” and Anthem does not say whether it applies them — treat the authorized units as the ceiling and ask the plan about any per-day edit.[8][9][1]
Ask the plan: Availity or Anthem NY Medicaid provider services — confirm authorization period, unit limits and any hour-cap logic per case in writing.
Not published for the New York Medicaid line — Anthem’s form collects the treating BCBA/QHCP’s information but states no rendering-versus-supervising NPI convention. At the fee-for-service layer New York is explicit: LBAs bill “using the LBA’s National Provider Identification (NPI) number for the ‘Billing’ provider and/or ‘Supervising’ provider,” with “the NPI number of the CBAA that provided the ABA service… reported as the ‘Rendering’ provider on each claim”; for unlicensed aides and LBA limited-permit holders the supervising LBA’s NPI fills all three roles. CBAAs cannot bill directly and enroll as OPRA providers. Anthem’s ABA Services FAQ adds the technician rule in its own words: “Unlicensed aides cannot enroll as a provider” (it names no RBT requirement), and “LBAs bill for services of CBAAs under their supervision.” Because the state manual directs managed-care providers to their plan for billing guidance, confirm the Anthem claim format in Availity before billing CBAA- or technician-delivered units.[1][2][3]
Ask the plan: Availity or Anthem NY Medicaid provider services — confirm the rendering/supervising NPI convention and any modifier requirement in writing.
Yes — it carries the NY Medicaid ABA carve-in for members under 21 with ASD/Rett, with treatment authorized via its Treatment Plan Request Form submitted through Availity. The June 2026 form revision confirms it remains an active NY ABA payer.
Yes. Anthem’s ABA Services FAQ for New York providers says authorizations are required and marks 97151 and 97152, like every other ABA code, “Authorization required: Yes.”
Anthem names no RBT requirement. Its NY ABA FAQ says services come from LBAs, CBAAs or other individuals allowed under Education Law Article 167, that “unlicensed aides cannot enroll as a provider,” and that LBAs bill for the staff they supervise.
Anthem returns incomplete Treatment Plan Request Forms rather than pending them. Complete every field — including BCBA/QHCP information and the Comprehensive/Focused classification — and attach clinical documentation up front.
Six at a time. New York Medicaid, which applies the rule to fee-for-service and managed care alike, says an LBA "can supervise no more than six CBAAs/unlicensed individuals at a time," must supervise each for at least 5% of their monthly service hours, and must hold at least two face-to-face real-time contacts a month, observing service delivery in one. In New York the supervisor must be a NYSED-licensed behavior analyst; BCBA certification alone is not a license.
Your contract sets it, but New York Ins. Law § 3224-a bars a Medicaid managed care contract from setting less than 90 days from the date of service (120 days is the default without a contract term). Clean electronic claims must be paid within 30 days, paper within 45.
No. Anthem’s New York ABA FAQ lists CPT 97151–97158 as the allowable Medicaid managed care codes and says Medicaid does not cover 0362T or 0373T; no H-code is listed, and the state ABA fee schedule carries only 97151–97158.
Yes, as recommended content: the treatment plan request form lists cumulative graphs or charts of baseline data and current progress, a description of progress since the last review, and baseline and updated assessments such as the Vineland, VB-MAPP or ABLLS-R. The treatment plan should be dated within 30 days of the start date.
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.
Carelu collects all of this automatically.
Every ID, document, and detail this payer requires — gathered conversationally the moment a family reaches out, with insurance verified before your team touches the file.
Get a Demo