Blue Cross Blue Shield of Michigan and its HMO, Blue Care Network (BCN), are Michigan’s Blue plan. Behavioral health prior authorizations for their commercial members, autism included, run through Blue Cross Behavioral Health. Blue Cross publishes an unusually complete set of autism documents, and three of its rules go beyond the state mandate: no age limit on ABA since 2022, no required re-evaluation, and no billable-unit limits beyond the authorization. This guide stacks Blue Cross’s own rules on top of Michigan’s mandate and the plan’s funding type.
Before an ABA provider can ask Blue Cross Behavioral Health for prior authorization, the member needs a comprehensive diagnostic evaluation showing the DSM criteria for autism, completed by a licensed physician, licensed psychologist or other licensed clinician qualified to diagnose autism. Michigan members have two routes: an approved autism evaluation center (AAEC), which arranges each discipline’s evaluation and hands the family the results, or a primary care provider and/or independent autism evaluation providers. Prior authorization is not required for the behavioral health components of the evaluation, but some BCN commercial members need a PCP referral for each medical specialist involved. AAECs and independent teams must field medical, behavioral and speech-language specialists and use standardized testing with interviews and observation (ADOS, ADI-R, CARS, SCQ, ASRS, SRS are named examples).[1][2][3][4]
Blue Cross does not require a comprehensive re-evaluation later: "It’s optional, based on clinical need." Blue Cross accepts only current-DSM autism codes; Asperger’s and PDD now fall under the ASD diagnosis.[1][2][3][4]
Blue Cross Behavioral Health manages autism prior authorizations for Blue Cross commercial, Medicare Plus Blue, BCN commercial and BCN Advantage. The procedure-code list (v.2026.3) marks 97151 through 97158 as requiring prior authorization for BCN HMO, Medicare Plus Blue PPO, and Blue Cross commercial "fully insured groups and … select self-funded groups," and the member page confirms "All Blue Care Network HMO plans require prior authorization" while "Some Blue Cross Blue Shield of Michigan PPO plans require prior authorization, but not all." Out-of-network providers submit through online ABA assessment and treatment request forms. Blue Cross also notes that its autism benefits comply with the Michigan mandate but "The mandate doesn’t apply to some self-funded employer groups," Medicare Advantage or Medigap plans, or Blue Cross Complete (Medicaid).[5][6][4][7][8][9]
Billing: the supervising LBA bills all ABA, technician time included; behavior analysts must be Michigan-licensed to be paid (since Jan. 7, 2020); "There are no limits for billable ABA services" beyond the authorized units; each date of service goes on its own line with the authorization number. Blue Cross publishes no commercial ABA rates — they are contract terms.[5][6][4][7][8][9]
Blue Cross’s July 2026 documentation standards spell out each note: patient identification, place of service and any telemedicine, technician and supervising LBA with credentials, date with start and stop times (narratives in no more than four-hour blocks), interventions, data and progress, and the signatures and credentials of the RBT and supervising LBA (97153/97154) or the LBA (97155–97158). Where the LBA supervises live, the note must separate 97153 technician care from 97155 supervision. Caregivers are expected to participate in at least two hours a month of caregiver training and attend at least 80% of scheduled sessions.[10]
Michigan’s autism mandate has two parallel statutes: MCL 500.3406s for insurers (added by 2012 PA 100, amended by 2016 PA 276, applying to policies delivered, issued or renewed beginning 180 days after its April 18, 2012 enactment) and MCL 550.1416e for health care corporation group and nongroup certificates. Both require coverage "for the diagnosis of autism spectrum disorders and treatment of autism spectrum disorders," including behavioral health treatment such as applied behavior analysis, and bar the carrier from limiting the number of visits, from denying coverage because treatment "is educational or habilitative in nature," and from applying dollar limits, copays, deductibles or coinsurance that do not apply to physical illness generally.[11][12]
Unlike newer mandates, Michigan’s still carries age and dollar ceilings the carrier may choose to apply: coverage for treatment may be limited "through 18 years of age" and to a maximum annual benefit of $50,000 through age 6, $40,000 from 7 through 12, and $30,000 from 13 through 18. Treatment must be "prescribed or ordered" by a licensed physician or licensed psychologist who finds it medically necessary, behavioral health treatment must be "provided or supervised by a board certified behavior analyst or a licensed psychologist," and the diagnosis means assessments "including the autism diagnostic observation schedule, performed by a licensed physician or a licensed psychologist." While a member is in treatment the carrier may require a treatment plan and treatment review, request the ADOS results, request that the ADOS be repeated no more than once every three years, and request an annual development evaluation. Utilization review, medical-necessity review, network requirements and coordination of benefits still apply. Exempt: self-funded ERISA employer plans (outside state insurance law), exchange qualified health plans to the extent the coverage exceeds essential health benefits, and, under 500.3406s, short-term policies of six months or less.[11][12]
Michigan licenses behavior analysts through LARA’s Board of Behavior Analysts under Part 182A of the Public Health Code (Michigan’s licensure law dates from 2016). A license requires current BACB certification in good standing sent directly from the BACB, a criminal background check, human-trafficking and implicit-bias training, and renews every four years; assistant behavior analysts have their own LARA license and supervision verification. Technicians are not licensed by the state. Blue Cross ties payment to it: behavior analysts "must be licensed by the state of Michigan to be reimbursed by Blue Cross or BCN," and psychologists who want to provide ABA file an attestation form.[13][14][15][7]
The questions that decide whether a family can start with Blue Cross Blue Shield of Michigan, and what they have to bring. Each maps onto something intake should ask on the first call.
No age cap on Blue Cross commercial or BCN commercial ABA since 2022: "For dates of service on or after Jan. 1, 2022, the above services are benefits for members with an ASD diagnosis regardless of age"; before that, ABA ran "only through the age of 18." This is more generous than the state mandate, which would allow an age-18 limit. Employer groups can customize autism benefits, so check the member’s coverage.[3][4][11]
No expiry: "A comprehensive diagnostic re-evaluation is not required by Blue Cross Behavioral Health. It’s optional, based on clinical need," separate from the reassessments the licensed behavior analyst completes during treatment (typically semi-annual). Under the mandate a fully insured plan may still request that the ADOS be repeated no more than once every three years.[1][7][11]
The comprehensive diagnostic evaluation must be "completed by a licensed physician, a licensed psychologist or another licensed clinician who is qualified to diagnose autism by state licensure and related training," either at an approved autism evaluation center (AAEC) in Michigan or through a primary care provider and/or independent evaluation providers (pediatrician, developmental pediatrician, pediatric neurologist, neurologist, child psychologist, child or adult psychiatrist, neuropsychologist, psychologist, speech-language therapist). AAECs and independent evaluation teams must have medical, behavioral and speech-language disciplines on the core team.[1][4][2]
The evaluation must contain DSM diagnostic criteria (current edition). For AAECs and independent evaluation teams Blue Cross requires standardized, age-appropriate testing that includes both interviews and observation — examples: ADOS, ADI-R, CARS, SCQ, ASRS, SRS — plus cognitive, adaptive, language and sensory assessments, an in-depth medical history and developmental and behavioral observations.[1][2]
Blue Cross needs a comprehensive diagnostic evaluation before an ABA provider may request prior authorization, and the evaluation’s treatment plan should recommend ABA. For some BCN (HMO) commercial members "a referral from the primary care provider is required for each medical specialist who will see the member during the evaluation process." For a fully insured Michigan policy the mandate adds an order requirement: covered treatment is care "prescribed or ordered for an individual diagnosed with 1 of the autism spectrum disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary," and the treatment plan is developed "when the treatment of an autism spectrum disorder is first prescribed or ordered." Self-funded ERISA plans sit outside the statute.[1][11]
Turns on how the plan is funded. Fully insured Michigan insurance and HMO plans follow MCL 500.2212e: after May 31, 2024 a non-urgent prior authorization request "is considered granted" if the insurer does not grant it, deny it, or ask for more information "within 7 calendar days after the date and time of submission," and again within 7 calendar days after additional information is submitted; a request the provider certifies as urgent is considered granted if not acted on within 72 hours. An approved authorization "is valid for not less than 60 calendar days or for a duration that is clinically appropriate, whichever is later." The statute’s "health benefit plan" covers individual and group insurance, HMO contracts, and self-funded plans of the state or local governments, not private self-funded employer plans, which follow ERISA: pre-service decisions "not later than 15 days after receipt of the claim," one 15-day extension, urgent claims within 72 hours.[16][17]
Ask the plan: At benefits verification ask whether the plan is fully insured (Michigan-regulated) or self-funded (ERISA), then confirm the Blue Cross Behavioral Health turnaround and reauthorization lead time (the Blue Cross Behavioral Health number on the member ID card (Blue Cross 1-800-762-2382; BCN 1-800-482-5982)).
Which plan pays first is set by Michigan’s Coordination of Benefits Act for state-regulated plans: for a dependent child whose parents are married or living together, "The plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (same birthday: the plan covering the parent longer); for divorced or separated parents a court order assigning health coverage controls, then the order in MCL 550.253. The autism mandate adds that a member with two policies covering autism gets benefits "subject to the limits of this section when coordinating benefits." If the child also has Michigan Medicaid, Blue Cross pays first: Medicaid is payer of last resort and "is not liable for payment of services denied because coverage rules of the primary health insurance were not followed," so get Blue Cross’s authorization even when Medicaid (the PIHP) will pay secondary. TRICARE pays after other coverage except Medicaid (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[18][11][19][20][21]
Ask the plan: Ask Blue Cross at benefits verification for the member’s coordination-of-benefits order (the Blue Cross Behavioral Health number on the member ID card (Blue Cross 1-800-762-2382; BCN 1-800-482-5982)); self-funded plans set their own COB terms in the plan document. Record every other coverage the child has.
Blue Cross points providers to a separate "Telehealth for behavioral health providers" document on its secure Provider Resources site (via Availity) to determine which ABA services are allowed via telemedicine; progress notes must record when telemedicine was used. The telehealth document itself is portal-gated.[7][10]
Blocked on: Telehealth for behavioral health providers (Availity > Payer Spaces > BCBSM and BCN > Resources > Secure Provider Resources), or Blue Cross Behavioral Health.
Coverage decides whether Blue Cross Blue Shield of Michigan 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.
Blue Cross requires ABA to be delivered or supervised by a Michigan-licensed behavior analyst: "Effective Jan. 7, 2020, behavior analysts must be licensed by the state of Michigan to be reimbursed by Blue Cross or BCN." Technician line therapy is administered "under the direction of an LBA," and LBA supervision of line therapy and skills training is billed as protocol modification (97155). Blue Cross publishes no minimum supervision ratio. Its documentation standards add a caregiver requirement: parents or guardians should participate in at least two hours a month of direct caregiver training with the LBA/BCBA and bring the child to at least 80% of scheduled sessions.[7][10]
Allowed for 97153 and 97155. The billing guide describes 97155 as protocol modification that "may simultaneously direct a technician in administering the modified protocol while the member is present," and the documentation standards require that "If live supervision with technician and LBA, documentation must clearly show *97153 is for direct technician care and *97155 is for the LBA’s supervision." Direction of a technician without the client present "is not reported separately," and 97155 may not be used to bill training a technician to perform line therapy.[7][10]
"There are no limits for billable ABA services. The services billed must be based on the units authorized." Units billed may not exceed the number on the authorization letter for each code, each date of service goes on its own claim line within the authorized dates, and progress-note narratives must be documented in no more than four-hour (16-unit) increments.[7][10]
Each ABA progress note must carry the "Signature and credentials of the RBT and supervising LBA" for technician services (97153, 97154) and the "Signature and credentials of the LBA" for 97155, 97156, 97157 and 97158, along with the date, start and stop times, the place of service and whether telemedicine was used, and the names and credentials of the technician and supervising LBA.[10]
The supervising LBA bills. "Line therapy is billable only by an LBA. A technician’s services are billed by the supervising LBA," and skills-training groups likewise. Behavior analysts must be licensed by the State of Michigan (since Jan. 7, 2020) to be reimbursed; H-codes and S-codes are payable only to non-Michigan providers who cannot use the AMA category I codes. Bill each date of service on its own line with the autism diagnosis from the authorization and the 10-digit authorization number.[7]
Blue Cross’s published autism documents do not list covered or excluded settings; they require each progress note to record the "Location / place of service and if telemedicine delivered technology is utilized." Setting limits (including school) are in the member’s certificate and the Blue Cross Commercial Provider Manual, which sits behind the Availity portal.[10][7]
Blocked on: Blue Cross Commercial Provider Manual, Psychiatric Care Services chapter, "Autism spectrum disorder" section (Availity > Payer Spaces > BCBSM and BCN > Resources), or Blue Cross Behavioral Health.
For Blue Cross commercial and BCN commercial members, ABA and the other autism services are benefits regardless of age for dates of service on or after Jan. 1, 2022 — subject to the member’s own group benefits.
No. Michigan members can use an AAEC or a primary care provider and/or independent evaluators, as long as the comprehensive evaluation meets Blue Cross’s requirements and shows the DSM criteria.
For all BCN HMO plans, yes. For Blue Cross PPO it depends on the group: fully insured groups and select self-funded groups require it. Check the member’s autism coverage.
Blue Cross says there are no limits for billable ABA services beyond the units authorized. A fully insured plan may still apply the mandate’s annual dollar maximums for members through age 18 if its certificate does.
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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