Blue Cross and Blue Shield of Illinois, a division of Health Care Service Corporation, is the dominant commercial carrier in Illinois. For ABA its rules sit in three places: a commercial behavioral health PA code list, a clinical payment and coding policy (CPCP011, effective March 20, 2026) that reads like an audit checklist, and a January 2026 change that moved preservice requests to the phone. BCBSIL’s Medicaid plan, Blue Cross Community Health Plans, has its own guide.
BCBSIL’s 2026 Commercial Outpatient Behavioral Health Prior Authorization Codes (effective January 1, 2026, updated August 2026) cover “some of our commercial non-HMO members, such as” PPO, Blue Choice Preferred PPO, Blue Choice PPO, Blue Options/Blue Choice Options and Blue High Performance Network. The ABA lines are 97153, 97154, 97155, 97156, 97157, 97158, 0362T and 0373T, all “Managed By BCBSIL”; 97151 and 97152 are not on it. ABA is defined as therapy “to improve or change specific behaviors of members who have a diagnosis within the Pervasive and specific developmental disorders category of ICD-10.” From April 2026, “to initiate a preservice request for behavioral health applied behavior analysis, you must call our customer service number on the member’s ID card. Forms will no longer be the primary method,” and “A clinician will follow up with you for telephonic clinical review.” BCBSIL still tells providers to check eligibility and benefits on Availity first.[2][5][9][10][13][11][14]
How Public Act 104-0028 applies to commercial ABA is unsettled. BCBSIL’s January 2026 notice lists the commercial “no review” windows (72 hours for inpatient and residential, 48 hours for IOP and partial hospitalization, two business days for TMS and psychological testing); ABA is not on that list, and only for its Medicaid plan did BCBSIL add a 24-hour notification rule for applied behavior analysis. The statute is broader: 215 ILCS 5/370c(w)(1) says “No policy shall require prior authorization for outpatient or partial hospitalization services for treatment of mental, emotional, or nervous disorders or conditions” by any “licensed, certified, or legally authorized provider,” permits concurrent and retrospective review after a notification deadline of up to 2 business days, and the autism mandate’s treatment-plan clause (356z.14(f)) says it does not supersede that prohibition. The statute does not name ABA. For a fully insured member, ask BCBSIL in writing whether the ABA preservice review is still required; self-funded plans are outside the statute.[2][5][9][10][13][11][14]
CPCP011 (version 1.0, plan effective March 20, 2026) says ABA is not reimbursable unless provided by a professional “certified by the Behavior Analyst Certification Board as a Behavior Analyst and/or licensed in their state as a Licensed Behavior Analyst or Licensed Psychologist”; not reimbursable for “more than one Board Certified Behavior Analyst (BCBA) or qualified healthcare professional providing same/similar services on the same dates of service” (technicians excepted); and not for “educational, vocational, respite or custodial purposes.” Services outside POS 10, 11 and 12 need documented rationale. Assessments over eight hours (32 units of 97151) may not be reimbursed. Parent education is authorized at one hour a week (26 hours per typical 26-week period). Billable supervision “must be face to face and involves only one technician,” indirect supervision is bundled, and direct supervision may be authorized “at a minimum of 1 hour per week when less than 10 hours of direct services are authorized.” Groups (97154/97158) need 2 to 8 members, and 97153 carries a single HM, HN or HO modifier. The 8-minute rule applies to every timed unit.[6][8][1]
Reauthorization and payment. CPCP011 does not list what a reauthorization must contain beyond the documentation rules below; since January 1, 2026 BCBSIL reviews ABA against licensed MCG criteria (CPCP011 update history: Medical Policy PSY301.021 “is moving to MCG Criteria, see Medical Policy ADM1001.036”), and the review happens on the preservice call, so ask the BCBSIL clinician what progress data and graphs to send. Timely filing: BCBSIL’s October 28, 2024 provider notice says commercial non-HMO participating providers (PPO, Blue Choice PPO, Blue High Performance Network) “must submit claims within the 180-day period following” the date of service (discharge for inpatient care), or, when BCBSIL is the secondary payer, the provider’s receipt of the primary payer’s explanation of benefits; claims received after the deadline are denied and may not be billed to the member. HMO filing rules are in BCBSIL’s HMO manual. For fully insured Illinois policies the Insurance Code sets the payment clock: “All claims and indemnities payable under the terms of a policy of accident and health insurance shall be paid within 30 days following receipt by the insurer of due proof of loss,” with 9% annual interest after the 30th day, and the insurer must tell the insured or assignee within 30 days if documentation is missing (215 ILCS 5/357.9). Self-funded ERISA plans are outside it. No weekly submission cutoff or check-run day is published.[6][8][1]
Documentation must include “a parent or caregiver’s signature for each rendered service that also includes the service/code provided, rendering provider’s name/signature, certification and credentials, place of service, the date of service, and the beginning/end times of the service,” a note, and data that “may be required immediately after the service occurred and for the purposes of audit.” And on whose NPI: “The provider who renders treatment week to week to the member is considered the ‘rendering provider’ and should bill for the services provided,” and “An unlicensed, non-network-credentialed, or otherwise non-qualified provider cannot provide services and bill through another person’s NPI number.”[6][8][1]
Illinois’s autism mandate is Section 356z.14 of the Illinois Insurance Code (215 ILCS 5/356z.14). Group and individual policies and managed care plans issued or renewed after December 12, 2008 “must provide individuals under 21 years of age coverage for the diagnosis of autism spectrum disorders and for the treatment of autism spectrum disorders.” Coverage “shall be subject to a maximum benefit of $36,000 per year but shall not be subject to any limits on the number of visits to a service provider,” and “The Director of Insurance shall, on an annual basis, adjust the maximum benefit for inflation” using the medical care CPI; we did not find the Department’s current adjusted figure, so get it from the plan. Cost sharing may apply only as it does to other medical services, and benefits “may not be subject to dollar limits, deductibles, copayments, or coinsurance provisions that are less favorable to the insured” than for physical illness. Treatment explicitly includes “applied behavior analysis,” prescribed, provided or ordered by a physician “or (B) a certified, registered, or licensed health care professional with expertise in treating effects of autism spectrum disorders when the care is determined to be medically necessary and ordered by a physician licensed to practice medicine in all its branches.” The diagnosis must be prescribed, performed or ordered by a physician licensed in all branches or “a licensed clinical psychologist with expertise in diagnosing autism spectrum disorders”; P.A. 104-561 adds a licensed speech-language pathologist with that expertise for children under 3, effective January 1, 2028. The insurer may ask for records showing medical necessity and progress, and a treatment plan (diagnosis, treatment by type, frequency, duration, goals, update schedule), but subsection (f) adds: “Nothing in this subsection supersedes the prohibition on prior authorization for mental health treatment under subsection (w) of Section 370c.” Medical-necessity decisions must be made the same way as for other illnesses, and an appeal challenge is reasonable only if the review includes a physician with current ASD treatment expertise. Subsection (e-5) bars denial “solely because of the location wherein the clinically appropriate services are provided.” The Department of Insurance has enforced that last point: Company Bulletin 2024-17 (December 4, 2024) reminds every company writing accident and health insurance and managed care plans that Public Act 102-0322, in effect since January 1, 2022, bars an insurer from denying “otherwise covered services … solely because of the location wherein the clinically appropriate services are provided,” and that for autism services “such as applied behavior analysis” sites “include non-school, non-home, or non-provider locations,” private or public. It adds that “An issuer cannot apply medical necessity criteria that contradict a statutory requirement,” that criteria for mental health conditions “including autism spectrum disorder, must be consistent with generally accepted standards of care, including with respect to setting or site of care” (215 ILCS 5/370c(h)-(i), (k)), and that members denied for medical necessity keep appeal rights under the Managed Care Reform and Patient Rights Act and the Health Carrier External Review Act. Separately, 370c(w), added by Public Act 104-0028 from January 1, 2026, says “No policy shall require prior authorization for outpatient or partial hospitalization services for treatment of mental, emotional, or nervous disorders or conditions” by licensed, certified or legally authorized providers; concurrent and retrospective review remain allowed, and a commercial insurer may require notice within “2 business days after the initiation of the covered person’s treatment,” with no concurrent review of services before that deadline. 370c(w) does not name ABA, and carriers still list ABA codes for authorization, so whether a fully insured plan may prior-authorize ABA in 2026 is a question to put to the plan and, if needed, the Department of Insurance. Like every state mandate, it reaches fully insured plans; self-funded employer plans answer to ERISA, and Evernorth’s Illinois addendum, for example, says it does “not apply with regard to Covered Services rendered to Participants covered under self-funded plans.”[11][12][13][14][15][27]
Illinois licenses behavior analysts. IDFPR lists two professions under the Behavior Analyst Licensing Act (225 ILCS 6), the Licensed Behavior Analyst and the Licensed Assistant Behavior Analyst, and says the Department “commenced licensing behavior analysts and assistant behavior analysts on January 15, 2025.” It gave applicants a grace period: IDFPR “will not begin enforcement actions for unlicensed practices provided by Behavior Analysts and Assistant Behavior Analysts until Monday, April 21, 2025,” so that date has passed and a BCBA practicing in Illinois now needs the Illinois license. A second deadline is still ahead. IDFPR quotes Section 150 of the Act: beginning 24 months after licensing began, no business may offer behavior analysis services “unless every member, partner, shareholder, director, officer, holder of any other ownership interest, agent, and employee who renders applied behavior analysis services holds a currently valid license,” and it reads that as: “By or before January 15, 2027 anyone who is not licensed as a behavior analyst or assistant behavior analyst … and who currently owns a business providing applied behavior analysis services must divest from the business.” The statute is blunter than IDFPR’s notice: Section 150 covers “every member, partner, shareholder, director, officer, holder of any other ownership interest, agent, and employee who renders applied behavior analysis services,” “Notwithstanding” the Section 20 exclusion for people implementing a plan under a licensed behavior analyst’s supervision, so ask IDFPR how it applies to RBT employees after January 15, 2027. The BACB’s licensure table lists Illinois (law enacted 2022) with IDFPR as the board. Out-of-state BCBAs and telehealth: no. Section 20 of the Act says an individual “shall not engage in the practice of applied behavior analysis unless licensed under this Act or covered by an exemption,” and its exemption list (family caregivers, staff implementing a plan under a licensed behavior analyst, listed licensed professions such as clinical psychologists, LCSWs, LCPCs, SLPs and OTs acting within their training, students and fellows, school-endorsed staff, QIDPs, DHS-designated providers, and people practicing on Medicaid when the Act took effect while working toward licensure) contains nothing for a behavior analyst licensed in another state. The Telehealth Act closes the remote route: “A health care professional treating a patient located in this State through telehealth services must be licensed or authorized to practice in Illinois” (225 ILCS 150/10). So a BCBA licensed elsewhere needs the Illinois license to treat or supervise a client located in Illinois, in person or by telehealth. For commercial credentialing this means the carrier will expect the Illinois license number as well as BACB certification. CPCP011 itself accepts BACB certification “and/or” a state Licensed Behavior Analyst credential, but that does not excuse Illinois licensure for practice in Illinois.[16][17][28][18][19][6]
The questions that decide whether a family can start with Blue Cross and Blue Shield of Illinois (HCSC), and what they have to bring. Each maps onto something intake should ask on the first call.
No referral rule appears in the commercial PA list or CPCP011; what is required is preservice review of the listed treatment codes, started by phone. For fully insured Illinois plans, 215 ILCS 5/356z.14 covers ABA as treatment “ordered by a physician licensed to practice medicine in all its branches” when delivered by a certified, registered or licensed professional, so keep a physician order on file; the Department of Insurance has also told carriers they may not deny covered ABA “solely because of the location” of care (Company Bulletin 2024-17). Self-funded ERISA plans sit outside state insurance law.[2][5][15]
BCBSIL’s ABA documents read set no age limit; the member’s benefit booklet governs. For fully insured Illinois plans, 215 ILCS 5/356z.14 mandates autism coverage for “individuals under 21 years of age,” subject to a $36,000-a-year maximum that the Director of Insurance adjusts annually for medical inflation, with no visit limits; the plan may cover older members, and the current adjusted dollar figure should be confirmed with the plan. Self-funded ERISA plans are outside the statute.[2][11]
Ask the plan: Availity eligibility and benefits, or the number on the card: confirm ABA benefit age terms and whether the plan is fully insured.
How to bill it is published; which ABA codes the member’s plan pays by telehealth is not. BCBSIL’s telehealth reimbursement policy RP033 (effective March 27, 2026) says modifiers “FQ, FR, G0, GT, 93 and 95 are telemedicine service or telehealth service modifiers and must be appended to the HCPCS or CPT code(s), in conjunction with a place of service-POS code,” and professional telehealth claims “must be submitted with Place of Service (POS) Code ‘02’ or ‘10’” (10 when the patient is at home). “The Plan will not accept asynchronous telecommunication services”: lines with modifier GQ are not reimbursed. Records must show start and end times and the method of communication, and the provider must be licensed to treat members in Illinois. Neither RP033 nor CPCP011 (ABA) lists which of 97151–97158 may be delivered remotely, and CPCP011 treats POS 10, 11 and 12 as the usual settings.[7][6]
Ask the plan: Availity eligibility and benefits, or the number on the member’s card: ask whether the plan covers 97153, 97155 and 97156 by telehealth and whether the authorization must say so.
Depends on how the plan is funded. Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1: pre-service decisions “not later than 15 days after receipt of the claim,” one 15-day extension, urgent care within 72 hours. For fully insured Illinois plans, 215 ILCS 5/370c(w) (Public Act 104-0028, from January 1, 2026) bars prior authorization of outpatient mental health treatment and lets the insurer set a notification deadline of up to 2 business days after treatment starts, with no concurrent review of services before that deadline; Illinois’s general prior-authorization decision deadlines were not read this run. BCBSIL publishes no Illinois-specific ABA turnaround or reauthorization lead time in the documents read.[20][14][13][9]
Ask the plan: Ask during the preservice call how long the telephonic clinical review takes and what reauthorization lead time BCBSIL expects.
Illinois’s group coordination-of-benefits rule could not be retrieved this run, so the order between two parents’ plans is not stated here; ask the plan. What is certain is the order against public coverage: if the child also has Illinois Medicaid, BCBSIL pays first. HFS is “by federal and State Law, the payer of last resort,” and claims must be adjudicated by all liable third parties before HFS considers them (42 CFR 433.139). TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[22][23][24][25]
Ask the plan: Ask BCBSIL at benefits verification for the coordination-of-benefits order, and record every other coverage the child has.
Not stated in BCBSIL’s published ABA documents. BCBSIL no longer has its own ABA medical policy: CPCP011’s update history (12/12/2025) says Medical Policy PSY301.021 was removed and “Effective January 1, 2026, this policy is moving to MCG Criteria, see Medical Policy ADM1001.036.” MCG criteria are licensed and not public, so any diagnosis-recency requirement is applied in the telephonic preservice review.[6][2]
In licensed criteria: The BCBSIL clinician on the preservice phone review (number on the member’s card): ask how recent the diagnostic evaluation must be under the MCG criteria BCBSIL applies.
Not stated in BCBSIL’s published ABA documents; since January 1, 2026 its ABA medical-necessity criteria are MCG (CPCP011 update history), which are licensed and not public. For fully insured Illinois plans, 356z.14 defines the diagnosis as tests or evaluations “prescribed, performed, or ordered by (A) a physician licensed to practice medicine in all its branches or (B) a licensed clinical psychologist with expertise in diagnosing autism spectrum disorders” (a licensed speech-language pathologist with that expertise for children under 3 is added from January 1, 2028 by P.A. 104-561).[6][11][2]
In licensed criteria: Ask during the telephonic preservice review which diagnosing credentials BCBSIL accepts; for fully insured plans the 356z.14 definition applies.
Not stated in BCBSIL’s published ABA documents; since January 1, 2026 its ABA medical-necessity criteria are MCG (CPCP011 update history), which are licensed and not public.[6][2]
In licensed criteria: Ask during the telephonic preservice review whether a specific instrument (for example ADOS-2) must be in the diagnostic report.
Coverage decides whether Blue Cross and Blue Shield of Illinois (HCSC) 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.
CPCP011: billable supervision is face to face with one technician; indirect supervision is bundled and not separately paid; CASP’s 10–20% of direct hours for case supervision is cited, and direct supervision “may be authorized … at a minimum of 1 hour per week when less than 10 hours of direct services are authorized.”[6]
CPCP011: ABA “not reimbursable for more than one Board Certified Behavior Analyst (BCBA) or qualified healthcare professional providing same/similar services on the same dates of service. This does not refer to the technician(s) or direct service provider simultaneously rendering service with the BCBA.” A QHP directing a technician during 97154 bills 97155.[6]
CPCP011 points to the CMS MUE table for maximum units per day and notes MUEs “indicate that direct services are typically requested for up to 40 hours per week”; assessment over 32 units of 97151 may not be reimbursed; parent education typically one hour a week. Units above coding guidelines must be justified.[6]
CPCP011: “a parent or caregiver’s signature for each rendered service” that includes the code, the rendering provider’s name, signature and credentials, POS, date and start/end times, plus a note and data points, which may be required immediately after the service.[6]
CPCP011: services in “anything other than Place of Service/POS codes 10, 11, and 12” need supporting documentation and a rationale on file. For fully insured Illinois plans, the Department of Insurance bars denial “solely because of the location” of care (Company Bulletin 2024-17).[6][15]
CPCP011: the provider who renders week to week is the rendering provider and bills; a non-credentialed or non-qualified provider “cannot provide services and bill through another person’s NPI number”; services “performed by a supervisee and billed through a supervisor should follow any applicable state laws, Board requirements, and/or CMS conventions,” with direct personal supervision in the immediate vicinity.[6]
For commercial non-HMO plans (PPO, Blue Choice PPO, Blue High Performance Network), 180 days from the date of service, or 180 days from receiving the primary payer’s EOB when BCBSIL is secondary. Late claims are denied and cannot be billed to the family.
BCBSIL’s telehealth policy RP033 (effective March 27, 2026) requires a telehealth modifier (GT, 95, 93 and others) with POS 02 or 10, and does not pay asynchronous services (modifier GQ). It does not say which ABA codes a plan covers remotely, so confirm that on the member’s benefits.
For an Illinois provider treating a member of another Blue plan, BCBSIL says "The program allows you to submit claims for members from other BCBS Plans to the Illinois Plan," and BCBSIL is "your sole contact for claims payment, problem resolution and adjustments." Identify the member by the suitcase logo and three-character prefix, and verify benefits at BlueCard Eligibility, 800-676-BLUE (2583). Pre-certification follows the member’s own plan: call the same line and "ask to be transferred to the Medical Management Department," or use the out-of-area Pre-Cert/Pre-auth Router to see that plan’s medical policy and requirements; the BlueCard manual (June 2026) tells providers to remind patients they "are responsible for obtaining pre-certification/preauthorization for out-patient services from their BCBS Plan." BCBSIL’s own ABA rules (phone preservice review, CPCP011) apply to BCBSIL members. FEP is not processed through BlueCard.
For the non-HMO commercial plans on its 2026 list (PPO, Blue Options and others), yes for 97153–97158, 0362T and 0373T. The assessment codes 97151 and 97152 are not on that list; check Availity for the member’s plan.
Since April 2026, call the customer service number on the member’s ID card; a BCBSIL clinician follows up with a telephonic clinical review. Forms are no longer the primary method.
Yes. CPCP011 asks for a parent or caregiver signature for each rendered service, with the code, the rendering provider’s name, signature and credentials, POS, date and start/end times.
BCBSIL still lists ABA codes for preservice review, and its commercial “no review” list under Public Act 104-0028 does not mention ABA. But the law it implements, 215 ILCS 5/370c(w), bars prior authorization of outpatient mental health treatment under fully insured policies (concurrent review after a notice of up to 2 business days is allowed), and the autism mandate cross-references that ban. The statute does not name ABA, so for a fully insured member ask BCBSIL in writing. Its Medicaid plan uses a 24-hour ABA notification rule.
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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