Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc., one of the five health plans NVHA lists for Nevada Medicaid and Nevada Check Up since statewide managed care began on January 1, 2026. Its provider manual lists Applied Behavioral Analysis as a covered service “rendered to Medicaid-eligible individuals of any age who meet medical necessity criteria,” and Anthem’s 2024 provider notice confirmed that all PT 85 codes were opened to every age. This is the Medicaid plan; Anthem’s commercial Nevada plans have their own guide.
The manual’s covered-services table describes ABA as “a behavior intervention model to treat members, usually children, with autism spectrum disorder (ASD) as well as other developmental diagnoses as clinically appropriate,” rendered at any age to members who meet medical necessity, with children “supported in accordance with” EPSDT. Its listed components include assessment, re-evaluation, a treatment plan with measurable goals, functional communication, adaptive living and social skills. Anthem’s November 2024 notice on SB 191 lists all ten PT 85 codes (97151–97158, 0362T, 0373T) and says the age change “does not change the procedure for obtaining authorization for ABA services”; providers submit through Availity Essentials (Patient Registration, then Authorizations and Referrals), and behavioral health authorizations and inquiries may still route to Interactive Care Reviewer. Anthem’s precertification page says to submit all behavioral health precertification requests through Availity. The same notice names Carelon Behavioral Health as the company providing utilization management on behalf of the plan and the route for joining the behavioral health network.[1][2][3][11][6]
Standard authorization decisions, per the July 2025 manual, come “within the State’s established timelines that will not exceed 14 calendar days,” with up to 14 more, and expedited decisions within 72 hours. Federal rules have since tightened the standard limit to 7 calendar days for rating periods starting on or after January 1, 2026, which covers Nevada’s 2026 contracts. Nevada’s managed-care rules give members (or a provider acting with the member’s written permission) 60 calendar days from the notice of adverse benefit determination to appeal to the plan, allow one level of internal appeal, and require a standard appeal decision within 30 calendar days (expedited within 72 hours); after the plan’s appeal, the member may request a State Fair Hearing (MSM 3604).[1][2][3][11][6]
Network providers “must submit claims within 180 days from the date of service”; out-of-state providers have 365 days, and when other insurance exists the 180 days run from the primary carrier’s payment notice. “Clean claims are adjudicated to a paid or denied status within 30 calendar days of receipt,” with interest if payment is late. Anthem and its providers agree “the Medicaid program will be the payer of last resort,” so a claim is redirected to the other carrier when Anthem knows of it. For ABA billing rules (rendering NPI, UD modifier, ordering-provider NPI), Anthem publishes nothing of its own; the state PT 85 rules are the floor.[1][7]
Not without a Nevada license. NRS 641D.900 bars anyone from engaging “in the practice of applied behavior analysis unless he or she is licensed or registered as required by the provisions of this chapter.” Telehealth does not get around that: NRS 629.031 counts “A behavior analyst, assistant behavior analyst or registered behavior technician” as a provider of health care, and NRS 629.515 says that before a provider at a distant site “may use telehealth to direct or manage the care or render a diagnosis of a patient who is located at an originating site in this State,” the provider “must hold a valid license or certificate to practice his or her profession in this State.” A BCBA directing a Nevada child’s program from another state is therefore treated as practicing in Nevada and is “subject to the laws and jurisdiction of the State of Nevada.” The fast path is licensure by endorsement under NRS 641D.340: a behavior analyst who holds “a corresponding valid and unrestricted license as a behavior analyst” in another state or D.C. may apply, and unless the Board denies for good cause it must issue the license within 45 days of the application or 10 days after the fingerprint background report, whichever is later. Payers add their own layer: credential the clinician with each plan before billing.[13][14][5]
The questions that decide whether a family can start with Anthem Blue Cross and Blue Shield Healthcare Solutions (Nevada Medicaid), and what they have to bring. Each maps onto something intake should ask on the first call.
None: the manual covers ABA for “Medicaid-eligible individuals of any age who meet medical necessity criteria,” consistent with MSM 3704.1.[1][2][5]
Anthem publishes nothing of its own. The state rule: the diagnosis is “completed only one time” and repeat testing “should not be performed when full criteria were previously met” (MSM 3704.2A(6)(b)).[5][1]
Anthem publishes nothing of its own. The state’s FA-11F must be signed by a physician, physician assistant, APRN or psychologist acting within scope.[8][5]
Anthem publishes nothing of its own. Nevada Medicaid’s list (MSM 3704.2A(5)(f), FA-11F): ADOS-2, CARS-2, GARS-3 or an FASD diagnostic category, with the score on FA-11F; if DSM-5 criteria alone are used, the specific criteria met must be documented.[5][8]
Anthem publishes nothing different. Nevada Medicaid’s rule (MSM 3704.1, FA-11F): ABA “must be rendered according to the written orders of” a physician, physician assistant, psychologist or APRN/NP, who certifies the diagnosis on FA-11F with the first request.[5][8]
Anthem publishes no ABA telehealth rule of its own. Nevada Medicaid’s rule: MSM 3403 gives telehealth “parity with in-person health care services,” requires the originating site to be in Nevada and lists only personal care, home health and private duty nursing as in-person-only; NRS 422.2721 bars extra prior authorization for telehealth. Bill POS 02 or 10 with modifier 95 (audio-video) or 93 (audio-only). The clinician needs a Nevada license (NRS 629.515). No Nevada ABA document lists which ABA codes may be delivered remotely.[9][10][16][14]
“Anthem and our providers agree the Medicaid program will be the payer of last resort when third-party resources are available”; Anthem rejects a claim and redirects you to the other carrier when it knows of the coverage, or recovers after payment. With other insurance, file within 180 days of the primary carrier’s payment notice (365 for out-of-state providers).[1][12]
The July 2025 manual promises standard decisions “within the State’s established timelines that will not exceed 14 calendar days following receipt,” extendable by 14, and expedited decisions “no later than 72 hours after receipt.” For rating periods starting on or after January 1, 2026, 42 CFR 438.210(d) caps standard decisions at 7 calendar days.[1][11]
Ask the plan: Anthem Nevada Medicaid Provider Services, 844-396-2330: confirm the standard decision timeframe now applied to ABA requests.
Coverage decides whether Anthem Blue Cross and Blue Shield Healthcare Solutions (Nevada 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.
Anthem publishes no ABA supervision rule of its own. Nevada Medicaid’s rule (MSM 3704.3A, MSM 3704.2A(1)(j)): supervision follows NRS 641D.610, “must be overseen by a Licensed Psychologist, BCBA-D or BCBA who has experience in the treatment of autism,” may be delivered by a BCaBA at their direction, and is capped at 20% of direct therapy hours unless clinical documentation supports more. MSM 3600 requires MCOs to provide services with the same amount, duration and scope as fee-for-service.[5][6][1]
Anthem publishes no ABA unit limits of its own. Nevada Medicaid’s limits (MSM 3704.2A(4); PT 85 billing guide): 12 hours of ABA per provider per day, 40 hours per recipient per week; focused 15–25 and comprehensive 25–40 hours a week counting 97153, 97155 and 0373T together; 97151 one 16-unit and 97152/0362T one 4-unit session per 180 days; 97156 4 units a week. Limits may be exceeded with prior authorization and documented medical necessity.[5][7][6]
Anthem publishes no ABA note rule of its own. Nevada Medicaid’s rule (MSM 3704.4G): a progress note for each day of service with the recipient’s name, place of service, date, actual start and end times, the name and credentials of the provider who delivered the service, and “The signature of the provider who delivered the service.”[5][6]
Anthem publishes no ABA setting rule of its own. Nevada Medicaid’s rule (MSM 3704.1, 3704.2A(8)): ABA may be delivered in a clinic or office, the community or the home, and in “the natural setting (i.e. home, school and community-based settings, including clinics)”; resorts, spas, camps, education services, respite and child care are not covered. Telehealth is billed POS 02 or 10.[5][16]
Not addressed by Anthem, and the state publishes no same-time rule for 97153 and 97155.[1][7]
Ask the plan: Anthem Nevada Medicaid Provider Services, 844-396-2330, or your provider agreement.
Not stated by Anthem. The fee-for-service rule is to bill the NPI “of the actual provider of the service, not the supervising clinician,” with modifier UD for BCaBA and RBT lines; whether Anthem uses the same rendering rule is set in the provider agreement.[7][1]
Ask the plan: Anthem Nevada Medicaid Provider Services, 844-396-2330: ask whether RBT lines go out under the RBT’s own NPI with UD, as in fee-for-service.
Yes. Anthem’s manual covers ABA for Medicaid members of any age who meet medical necessity, following Nevada’s 2024 removal of age limits.
Through Availity Essentials (Authorizations and Referrals); behavioral health requests may route to Interactive Care Reviewer. Use the state FA-11E/FA-11F content, and confirm assessment-code rules in the lookup or with Provider Services at 844-396-2330.
180 days from the date of service for network providers, 365 for out-of-state providers; clean claims are adjudicated within 30 calendar days.
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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