Blue Cross Blue Shield of Massachusetts (BCBSMA) is the state's largest commercial carrier, and it writes its ABA rules down in one public document: Medical Policy 091. It covers ABA for autism spectrum disorder and, since its October 2025 revision, for Down syndrome. Every ABA code needs prior authorization on HMO, POS, PPO and Indemnity plans, and the policy states typical hours for each code.
Underneath that policy sits ARICA, the Massachusetts autism mandate. It applies to fully insured BCBSMA plans and bars age caps and dollar or visit limits. Self-funded employer plans that BCBSMA only administers are outside it. This guide covers the policy, the request form, how BCBSMA handles out-of-state Blue members, and what intake should collect.
BCBSMA "covers medically necessary ABA services for the treatment of autism spectrum disorders (ASD) and/or Down Syndrome when diagnosed by a psychiatrist, psychologist, neurologist, developmental pediatrician, or other licensed physician experienced in the diagnosis and treatment of autism/Down Syndrome and when clinical direction is provided by an appropriately trained licensed psychologist or a licensed applied behavior analyst (LABA)/ board certified behavior analyst (BCBA)." ICD-10 codes listed are F84.0 and Q90.0–Q90.9. ABA for any other diagnosis is not covered.[1]
The policy gives typical amounts for each service. Assessment (97151) takes 12 hours and the analyst must do both the face-to-face and non-face-to-face parts. Supporting assessment (97152) and multi-technician assessment (0362T) are 12 hours each. Comprehensive treatment is 30 to 40 hours a week, counting technician and analyst face-to-face time together. Social-skills groups (97158) are two hours a week. Protocol modification (97155) is one to two hours for every ten technician hours. Groups may have two to eight patients.[1]
The policy also lists what is not covered: supervision or training of staff as a separate service; two analysts with the member at the same time; respite, chores, transport, or outings that are not in the treatment plan; nap or rest time; IEP services or educational-aide work during the school day; camp or program tuition; and ABA "provided simultaneously with other medical services such as occupational therapy, speech and language therapy, physical therapy, and psychotherapy."[1]
Prior authorization is required for outpatient ABA on Commercial HMO/POS and on Commercial PPO and Indemnity, and BCBSMA's Outpatient Prior Authorization Code List shows all ten ABA codes as "Prior authorization is required, in effect." Policy 091 tells providers to submit the request in Authorization Manager and to list the clinician's NPI as the servicing provider, "not the billing group." The request form is BCBSMA's Applied Behavior Analysis Service Request Form (144). Out-of-network providers fax to 888-641-5199.[1][2][3][4][10]
Form 144 has two paths. An initial assessment request completes sections A and B: member and agency details, the LABA name and license number, the 97151 hours and units, and the signed autism diagnosis. A treatment request completes sections A, C and D: CORI/SORI background checks, technician training hours, the child's other services (OT, PT, speech, mental health, pediatrician, IEP hours) and whether each coordinates with the LABA, ABA hours and location for each day of the week, weekly hours and units by code, and an updated treatment plan. The form's fax number is 1-617-246-4281 (BCBSMA employees: 1-888-608-3693). Behavioral health authorizations by phone are at 1-800-524-4010.[1][2][3][4][10]
BCBSMA also accepts the multi-payer Massachusetts Collaborative Standard Form for ABA Services Prior Authorization Requests. Its February 2024 Mental Health Brief said it would accept that form from April 16, 2024 under Division of Insurance Bulletin 2024-01, and the prior-authorization code list names the "Massachusetts Collaborative Prior Authorization Form" as a submission option.[1][2][3][4][10]
ARICA (Chapter 207 of the Acts of 2010) put autism coverage into each of the statutes BCBSMA operates under: M.G.L. c. 176A § 8DD (hospital service corporations), c. 176B § 4DD (medical service corporations) and c. 176G § 4V (HMOs, so HMO Blue). Covered treatment includes "applied behavior analysis supervised by a board certified behavior analyst" when "prescribed, provided or ordered" by a licensed physician or licensed psychologist who finds it medically necessary. A plan may not limit the number of visits to an autism services provider, and any dollar or unit-of-service limit may not be stricter than for physical conditions. IEP services provided by school staff are not reimbursable under the mandate.[11][17][18][12]
Chapter 388 of the Acts of 2024 added Down syndrome. From January 1, 2026, fully insured plans, including a new c. 176B § 4DD½, must cover "the treatment of Down syndrome through speech therapy, occupational therapy, physical therapy and applied behavior analysis services." BCBSMA added Down syndrome to Medical Policy 091 on October 1, 2025. Self-funded ERISA plans are not bound by either statute, so check the plan document for those members.[11][17][18][12]
A child with another state's Blue plan who gets ABA in Massachusetts is a BlueCard member. BCBSMA is the local (host) plan and the other plan is the home plan, and "The member's benefits are determined by their Home plan." BCBSMA tells Massachusetts providers to submit claims "the same way you do for Massachusetts members," with the member's three-character prefix and an ID of up to 17 characters entered exactly as on the card, and to contact BCBSMA for all claim questions.[7][19]
Prior authorization for these members goes to the home plan. Use BCBSMA's "Pre-service Review for BlueCard members" tool (the Blue plans' Electronic Provider Access router), which takes you to the home plan's own pre-service page from the prefix, or call BlueCard Eligibility at 1-800-676-BLUE (2583). Behavioral health is one of the four request types that route supports. Check eligibility the same ways. If your practice is outside Massachusetts and the child has a BCBSMA card, BCBSMA says to contact "your local, in-state Blue plan" for claim questions.[7][19]
Massachusetts licenses behavior analysts through the Board of Registration of Allied Mental Health and Human Services Professions. A licensed applied behavior analyst (LABA) needs a qualifying graduate degree with behavior-analysis coursework, supervised experience and a board-approved exam. A licensed assistant applied behavior analyst works under a LABA or under a physician or psychologist qualified in ABA. BCBSMA's policy accepts clinical direction by a LABA/BCBA or an appropriately trained licensed psychologist, and form 144 asks for the LABA's license number.[15][20]
Professional claims go on the 1500 form, preferably electronically (clearinghouse, Direct Connection, or ConnectCenter direct entry). Paper 1500s go to Blue Cross Blue Shield Data Capture, PO Box 986020, Boston, MA 02298. Enter the member's name exactly as on the ID card and the full ID with prefix. BCBSMA refers billers to the NUCC 1500 instruction manual for field-by-field rules. Its claim filing limit is published only to logged-in providers. BCBSMA posts its appeal queue dates, including a "Timely Filing Limit" queue.[21][9][14]
First-level provider appeals are due "within 180 days of the initial claim being denied or processed," through Appeals Manager or a Request for Claim Review Form. A second-level appeal is due within 60 days of the first-level decision. For HMO Blue, M.G.L. c. 176G § 6 requires the provider contract to commit the HMO to pay, deny with reasons, or ask for what is missing within 45 days of a completed claim, with interest of 1.5% a month (capped at 18% a year) after that.[21][9][14]
Medical Policy 091 defines ABA by CPT code. It describes each service by its code (97151 assessment, 97152 and 0362T supporting assessment, 97153/97154 treatment by protocol, 97155 and 97158 protocol modification, 97156/97157 caregiver guidance, 0373T), and its coding table lists 97151–97158, 0373T and 0362T. No HCPCS H-code is listed for ABA.[1]
Form 144, BCBSMA’s ABA service request form, asks for “an individualized, updated treatment plan” that includes “measurable goals,” “data related to progress within individual treatment goals,” “goal status (met, progressing, regressing),” and a “plan for supervision.” It does not ask for graphs. The fuller Treatment Plan Guidelines for Applied Behavior Analysis sit inside the Autism Payment Policy, behind the Provider Central login, so any graph or data-recency rule there could not be read. Medical Policy 091 itself sets no reauthorization content beyond its coverage criteria.[2][1]
The questions that decide whether a family can start with Blue Cross Blue Shield of Massachusetts, and what they have to bring. Each maps onto something intake should ask on the first call.
None in BCBSMA's policy. Medical Policy 091 says "ABA services may be provided across age and severity levels," and it sets no age bound in any of its code criteria. The state mandate sets none either: the ARICA sections for Blue Cross (M.G.L. c. 176A § 8DD, c. 176B § 4DD) and HMO Blue (c. 176G § 4V) define autism treatment without an age limit. A self-funded employer plan BCBSMA administers can write its own limits into the plan document.[1][11]
Medical Policy 091 covers ABA when the ASD or Down syndrome is "diagnosed by a psychiatrist, psychologist, neurologist, developmental pediatrician, or other licensed physician experienced in the diagnosis and treatment of autism/Down Syndrome." The request form asks for the diagnosis "signed by a licensed physician or licensed psychologist." A nurse practitioner or LABA diagnosis is not on either list.[1][2]
No PCP referral and no separate physician order form. BCBSMA's referral rules say "Behavioral health services, urgent care, and Emergency Department services (for emergency conditions) don't require a referral," even on the HMO plans (HMO Blue, Blue Choice in-network, Network Blue) that otherwise need one; prior authorization is still needed. What stands in for an order is the diagnosis document: the request form must attach "documentation of autism spectrum disorder signed by a licensed physician or licensed psychologist," and the state mandate defines covered autism treatment as care "prescribed, provided or ordered" by a licensed physician or licensed psychologist who finds it medically necessary. In practice the diagnosing physician's or psychologist's signed report goes in with the first request. BCBSMA publishes no validity period for it and no order template of its own.[5][2][11]
BCBSMA's own COB rules: for a child whose parents are married or living together, "the plan of parent whose birthday falls first in the calendar year is primary"; if the birthdays match, the plan in effect longer is primary. If the parents are not married or living together, the custodial parent's plan is primary, the custodial parent's spouse's plan secondary and the non-custodial parent's plan tertiary, unless a court decree assigns responsibility. As secondary payer BCBSMA pays "the balance up to the amount we would have paid if we had been the primary insurer," although some accounts use maintenance of benefits and pay less.[8]
For a fully insured plan, M.G.L. c. 176O § 12 sets the clock: an initial determination "within two working days of obtaining all necessary information," with an approval phoned to the provider within 24 hours and confirmed in writing within two working days; a concurrent review (reauthorization) within one working day of obtaining all necessary information, and the service "shall be continued without liability to the insured until the insured has been notified of the determination." A self-funded employer plan BCBSMA administers follows its own plan document and federal rules instead.[13]
Ask the plan: Benefits check (ConnectCenter or the number on the card): ask whether the plan is fully insured in Massachusetts or self-funded, and how long before an authorization ends BCBSMA wants the continued-services request.
Not set in BCBSMA's public documents. Medical Policy 091 and the ABA Service Request Form (144) ask for "documentation of autism spectrum disorder signed by a licensed physician or licensed psychologist" but state no maximum age for that evaluation. Form 144 points to "Treatment Plan Guidelines for Applied Behavior Analysis" inside the Autism Payment Policy, which is posted only behind the Provider Central login, so any recency rule there could not be read.[2]
Blocked on: BCBSMA Autism Payment Policy (Provider Central > Office Resources > Policies & Guidelines > Payment Policies, login required), or BCBSMA behavioral health authorizations at 1-800-524-4010 — ask whether an older diagnostic evaluation is accepted for an initial ABA request.
No named instrument. Medical Policy 091 describes the ABA assessment as interviews, "rating scales," standardized and non-standardized assessments and direct observation, and it says assessment is "not clinically indicated when multiple assessment tools are utilized to assess the same domain of functioning (e.g., multiple assessments of adaptive functioning)." It names no ADOS, Vineland or other required tool for the diagnosis or the assessment. The login-only Treatment Plan Guidelines could not be read.[1]
Blocked on: BCBSMA Autism Payment Policy / Treatment Plan Guidelines for ABA (Provider Central, login required).
Telehealth is a covered site of care on BCBSMA commercial plans: "We cover medically necessary services conducted via telehealth for suitable medical and mental health services," on the provider's own HIPAA-compliant platform, with no special credentialing, and "The same referral and authorization requirements apply for telehealth visits as in-person visits." Which ABA codes count as suitable is listed only in the Telehealth (Telemedicine) – Mental Health payment policy, which sits behind the Provider Central login. Medical Policy 091 itself requires every ABA code to be "administered face-to-face" and does not say whether video meets that.[6][1]
Blocked on: BCBSMA Telehealth (Telemedicine) – Mental Health payment policy (Provider Central login) — check whether 97151, 97155 and 97156 are on its covered-services list and which modifier and place of service it requires.
Coverage decides whether Blue Cross Blue Shield of Massachusetts 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.
Medical Policy 091 sets a typical supervision dose: protocol modification (97155, "clinical direction") runs "a minimum of 1 hour and maximum of 2 hours for every 10 direct hours provided by the behavior technician," that is 10–20% of technician time. Clinical direction must come from an appropriately trained licensed psychologist or a LABA/BCBA. "Supervision/training of behavior technician, LABA/BCBA, LAABA" is not separately covered. Every treatment request must attach a treatment plan that includes a "plan for supervision." The policy sets no caseload cap and no count of technicians per BCBA.[1][2]
Two overlap rules are written down. ABA "provided simultaneously with other medical services such as occupational therapy, speech and language therapy, physical therapy, and psychotherapy" is not covered, so 97153 cannot run during a speech or OT session. "More than one appropriately trained licensed psychologist or ... LABA/BCBA delivering services to a member during a specific time interval" is not covered either. 97155 may include "observation of the behavior technician implementing treatment protocols," and clinician-directed services are "provided in addition to direct treatment services." The policy does not say in so many words that 97153 and 97155 both pay for the same minutes. 97158 does not cover clinical direction of a technician.[1]
No per-day unit ceiling is published. Medical Policy 091 gives typical courses instead: 97151 assessment "completed in 12 hours," 97152 in 12 hours, 0362T in 12 hours; comprehensive treatment "between 30 to 40 hours of treatment per week," with "up to 40 hours per week" inclusive of technician and analyst face-to-face time; social-skills group (97158) typically two hours a week; and 97155 one to two hours per ten technician hours. Weekly hours and units are what gets authorized, on form 144's day-by-day schedule. For fully insured plans ARICA bars dollar or unit-of-service limits stricter than those on physical conditions, and visit limits.[1][11]
Medical Policy 091: coverage "may include medically necessary ABA services in certain community settings, such as the home, center (office), daycare, preschool, or camp." Not covered: services that are part of an IEP, working as an educational aide during the school day "in a public, private, or homeschool program," training school staff, and camp or program tuition. Form 144 records location per day as H (home), O (office) or C (community).[1][2]
Medical Policy 091 requires that "The medical record must include documentation of individual services provided, session notes, treatment plans, data collection, and assessment results," available to BCBSMA on request. It sets no rule on who signs a session note or by when.[1]
Blocked on: BCBSMA Autism Payment Policy (Provider Central login) and your provider agreement's documentation clause.
Partly published. The authorization goes in under the clinician: Medical Policy 091 says to "Enter the appropriate provider NPI or provider ID as the servicing provider, not the billing group," and form 144 names the LABA and the agency NPI. Form 144's code grid marks 97151, 97155, 97156, 97157 and 97158 "not reimbursed" for a behavior technician, so those are analyst lines. Whose NPI renders a technician's 97153 line is not stated publicly. BCBSMA's "Incident To Billing for Supervising Providers for Mental Health Services" payment policy covers billing for non-credentialed staff but is login-only.[1][2]
Blocked on: BCBSMA Autism Payment Policy and Incident To Billing for Supervising Providers for Mental Health Services payment policy (Provider Central login).
Yes. Medical Policy 091 covers medically necessary ABA for autism spectrum disorder and/or Down syndrome on HMO, POS, PPO and Indemnity plans, with prior authorization. Fully insured plans are also bound by ARICA, which bars visit limits and age caps. Self-funded employer plans follow their own plan document.
Yes. All ten ABA codes, 97151–97158, 0362T and 0373T, need prior authorization on commercial plans. Request the assessment alone using sections A and B of form 144: the 97151 hours and units, plus the autism diagnosis signed by a licensed physician or psychologist. A typical assessment course is 12 hours.
No PCP referral. BCBSMA says behavioral health services do not require a referral, even on HMO Blue. You do need prior authorization and a signed diagnosis from a licensed physician or licensed psychologist. That signed diagnosis is what the request form asks for, and the state mandate defines covered autism treatment as care prescribed, provided or ordered by one of them.
No. Medical Policy 091 lists as non-covered ABA "provided simultaneously with other medical services such as occupational therapy, speech and language therapy, physical therapy, and psychotherapy." Schedule ABA around those sessions. Form 144 also asks for the child's weekly OT, PT, speech and mental-health hours.
No daily unit cap is published. The policy calls comprehensive ABA 30 to 40 hours a week, counting technician and analyst time, and focused ABA is lower and individualized. Clinical direction (97155) typically runs 1–2 hours per 10 technician hours, and social-skills groups (97158) about 2 hours a week.
Policy 091 puts the typical dose of 97155 clinical direction at a minimum of 1 hour and a maximum of 2 hours for every 10 direct technician hours. The treatment plan must include a plan for supervision. Supervision or training of staff is not billable as a separate service, and the policy sets no technician-per-BCBA ratio.
BCBSMA covers telehealth as a site of care for suitable mental health services, with the same authorization rules as in person. Which ABA codes qualify is listed only in its login-only Telehealth (Telemedicine) – Mental Health payment policy, and Policy 091 says each ABA service is "administered face-to-face." Confirm before scheduling remote 97155 or 97156.
The home plan. Under BlueCard, benefits come from the member's home Blue plan, and pre-service review goes through BCBSMA's Pre-service Review for BlueCard members tool or 1-800-676-BLUE. You still submit the claim to BCBSMA with the full prefixed ID, the same way as for Massachusetts members.
Not for school-day educational support. Policy 091 excludes services that are part of an IEP, educational-aide work during the school day, and training school staff. It does allow medically necessary ABA in community settings such as the home, center, daycare, preschool or camp.
First-level provider appeals are due within 180 days of the claim being denied or processed. A second-level appeal is due within 60 days of the first-level decision. Use Appeals Manager or the Request for Claim Review Form.
Medical Policy 091 lists only CPT 97151–97158, 0362T and 0373T for ABA, with no H-codes.
Form 144 asks for an updated treatment plan with measurable goals, progress data for each goal, goal status and a supervision plan, but not graphs. The detailed Treatment Plan Guidelines are in the login-only Autism Payment Policy, so confirm there.
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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