BlueCross BlueShield of South Carolina is the state’s dominant commercial carrier. Its behavioral health benefits, autism included, are administered by its subsidiary Companion Benefit Alternatives (CBA). ABA criteria live in medical policy CAM 387, which had an interim review with "substantial updates to entire policy" on August 7, 2026. The rewrite borrows heavily from South Carolina Medicaid’s ASD manual: a required 97153/97155/97156 mix, home and school restrictions, and the BT grace period.
Layered on top is South Carolina’s autism mandate for group plans (S.C. Code § 38-71-280); CAM 387 itself reminds plans to check their contract language on autism services against the policy. BlueChoice HealthPlan, a BlueCross company, also runs Healthy Blue, one of the state’s Medicaid MCOs; that is a separate guide.
CAM 387 calls ABA medically necessary when the child has a confirmed ASD diagnosis "from a psychiatrist, psychologist, neurologist, developmental pediatrician, or other licensed physician experienced in the diagnosis and treatment of autism," and treatment targets ASD’s core deficits without duplicating therapies or school services. To start care, BlueCross wants: DSM-5-TR criteria with severity; completed psychological testing by a licensed clinical psychologist, LPES, psychiatrist, pediatric neurologist or developmental pediatrician (school-psychologist testing counts once one of them reviews it); at least one autism-specific instrument (ADOS-2, ADI-R, DISCO, CARS-2 or CARS-2-HF) plus one more evidence-based measure (MIGDAS-2, SRS-2, SCQ, ASRS, GARS-3 or similar); impairment at least one standard deviation below the mean, or skills needed to participate, or a risk of harm; and a BCBA assessment (VB-MAPP, ESDM checklist, ABLLS-R or AFLS) with graphs, goals and caregiver commitment, submitted on a signed ABA Service Provider Request form. "Assessment and observation are dated within 45 days prior to service request."[1]
Continued care needs six months of graphed data for behavior reduction, skills and parent training, progress statements and a fading plan. CAM 387 also adopts several Medicaid-style exclusions: no ABA "without routine delivery of 97156," no 97153 without 97155 and 97156, no 97155 without 97153, no two providers billing at once, nothing delivered by the child’s own family, and no ABA from a clinic related to the entity that made the diagnosis.[1]
BlueCross’s standard prior-authorization list includes "ABA for Autism" with 97151–97158, 0362T and 0373T (it notes PT/OT/ST with an autism diagnosis is covered under the medical plan). Most medical and behavioral requests now route through My Insurance Manager to Cohere Health, but "Autism services are excluded from this process. Continue to submit CBA autism PA requests to autismsupport@companiongroup.com." CBA also takes requests through its Form Resource Center, by fax (803-714-6456) or phone (800-868-1032), and says a member’s benefits decide whether preauthorization is needed. On claims, CBA asks that behavioral health claims "always include the rendering provider’s NPI in the rendering field." CBA’s general network page lists only independently licensed clinicians, so ask CBA how BCBAs, who hold no South Carolina license, are contracted.[2][3][4][5][6][9]
CBA’s Claims 101 page says its "health plan partners process and distribute payments for claims. They distribute payments once a week by electronic funds transfer or by hard copy check." CBA’s public pages do not state the filing deadline for initial, corrected or secondary claims (those answers sit in the login-only provider FAQ). For insured South Carolina plans, S.C. Code § 38-59-230 sets the clean-claim payment clock: 20 business days electronic, 40 on paper, for claims received within 120 business days of the service.[2][3][4][5][6][9]
South Carolina’s autism mandate, S.C. Code § 38-71-280 (2007 Act No. 65, known as Ryan’s Law), requires a "health insurance plan" to "provide coverage for the treatment of autism spectrum disorder." The definition is narrow in three ways. It reaches group policies and group benefit plans plus the State Health Plan, and it expressly excludes the individual market, individually underwritten plans and plans sold to small employers; self-funded employer plans answer to ERISA instead. It defines autism spectrum disorder by three older DSM labels (autistic disorder, Asperger’s syndrome, PDD-NOS). And the child must be "diagnosed with autistic spectrum disorder at age eight or younger," with benefits provided to "any eligible person under sixteen years of age." Coverage "is limited to treatment that is prescribed by the insured’s treating medical doctor in accordance with a treatment plan," which must state the diagnosis, treatment by type, frequency and duration, goals, the update schedule and the doctor’s signature; the plan "may only request an updated treatment plan once every six months." Dollar limits, deductibles and coinsurance may not be less favorable than for physical illness, but "Coverage for behavioral therapy is subject to a fifty thousand dollar maximum benefit per year," adjusted each January 1 by CPI. The Department of Insurance set that cap at $73,400 for calendar year 2026 (Bulletin 2025-09). The statute lets plans keep coordination of benefits, participating-provider rules, utilization review and "restrictions on services provided by family or household members."[7][8]
South Carolina has no behavior-analyst license to obtain, so the limits come from the payer. CAM 387 says "The BCBA-D, BCBA, or BCaBA completing the assessment must be located in the same state as the member or in a contiguous county," "No more than 50% of the assessment units can be conducted via telehealth," and assessments "must be completed by the same ABA provider who will be administering the ABA treatment." A BCBA in another state can therefore assess only from a county bordering the child’s state. South Carolina does not license behavior analysts. Title 40, Chapter 75 of the Code (the LLR board for counselors, marriage and family therapists, addiction counselors and psycho-educational specialists) has no behavior-analyst article, the 2021 licensure bill (H. 3731) never left committee, and the BACB’s licensure table does not list the state. Practically, BACB certification is the credential every payer checks. Two payer-level location rules matter more than any license. SC Medicaid requires ASD providers, including those working by telehealth, to be located within the South Carolina Medical Service Area (SCMSA; SCDHHS describes it as within 25 miles of the state border). BlueCross BlueShield of South Carolina’s ABA policy says the BCBA completing the assessment "must be located in the same state as the member or in a contiguous county." On claims, the state prompt-pay law (S.C. Code § 38-59-230) makes insurers pay a clean claim within 20 business days if filed electronically and 40 business days on paper, with interest after that; a "clean claim" must be received "within one hundred twenty business days" of the service. Overpayment recovery may not start more than 18 months after payment, except for fraud, self-insured plans or government programs. Commercial ABA rates are negotiated and unpublished; the public benchmark is the SC Medicaid ASD fee schedule (97153 $14.88 per 15-minute unit).[1][12][19][13][20][21][9][16]
The questions that decide whether a family can start with BlueCross BlueShield of South Carolina, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the diagnosis, but the BCBA assessment and observation must be "dated within 45 days prior to service request," for initial and continued care. For a mandated plan, the child must have been diagnosed at age eight or younger.[1][7]
Diagnosis by "a psychiatrist, psychologist, neurologist, developmental pediatrician, or other licensed physician experienced in the diagnosis and treatment of autism"; testing by a licensed clinical psychologist, LPES, psychiatrist, pediatric neurologist or developmental pediatrician.[1]
At least one autism-specific instrument (ADOS-2, ADI-R, DISCO, CARS-2 or CARS-2-HF) plus one more evidence-based measure (MIGDAS-2, SRS-2, SCQ, ASRS, GARS-3 or similar); the BCBA assessment uses VB-MAPP, ESDM checklist, ABLLS-R or AFLS.[1]
CAM 387 requires no separate referral; it requires prior authorization with the signed ABA Service Provider Request form. For a group plan subject to S.C. Code § 38-71-280, covered treatment must be "prescribed by the insured’s treating medical doctor in accordance with a treatment plan" signed by that doctor; the plan may ask for an updated plan only once every six months. Individual, small-employer and self-funded plans are outside the statute.[1][3][7]
CAM 387 sets no age limit. For a South Carolina group plan subject to S.C. Code § 38-71-280, coverage runs to "any eligible person under sixteen years of age" who was diagnosed at age eight or younger, with behavioral therapy capped at $73,400 for 2026 (DOI Bulletin 2025-09). Individual, small-employer and self-funded plans are outside the statute.[1][7][8]
Ask the plan: My Insurance Manager benefits check or CBA, 800-868-1032: establish plan type (insured group, State Health Plan, individual, small group or self-funded) and its autism terms.
For the assessment, "No more than 50% of the assessment units can be conducted via telehealth," and the assessing BCBA must be in the member’s state or a contiguous county. CAM 387 sets no telehealth rule for treatment codes.[1]
Ask the plan: Companion Benefit Alternatives, 800-868-1032: ask which ABA treatment codes the member’s plan pays by telehealth.
No South Carolina statute read sets a prior-authorization decision deadline for commercial plans. Title 38, Chapter 70 (utilization review) sets minimum standards for review programs, including notice of an adverse decision "within five business days" and a reconsideration or appeal procedure, but no clock for deciding a request. Federal claims rules therefore set the outer limit: ERISA plans must decide a pre-service claim "not later than 15 days after receipt of the claim" (one 15-day extension; urgent care within 72 hours), and insured group coverage must follow the same rule under 45 CFR 147.136. BlueCross and CBA publish no ABA-specific turnaround.[10][14][15][4]
Ask the plan: Companion Benefit Alternatives, 800-868-1032: ask the expected turnaround for initial and continued ABA requests.
For a child on two group plans, South Carolina Regulation 69-43 sets the birthday rule: when parents are not separated or divorced, "the benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later" (month and day only); for separated or divorced parents the custodial parent’s plan pays first unless a court decree assigns health costs to the other parent. The regulation binds insured group plans; a self-funded plan sets its own order. If the child also has SC Medicaid, the commercial plan pays first: Medicaid is payer of last resort (42 CFR 433.139), and SCDHHS asks for its own ASD authorization only "if Medicare or the primary carrier denied the service or the service is considered not covered." TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[11][22][20][23][24]
Ask the plan: Ask BlueCross (My Insurance Manager) for the member’s coordination-of-benefits order, and record every other coverage the child has.
Coverage decides whether BlueCross BlueShield of South Carolina 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.
CAM 387 requires delivery "by qualified providers who possess appropriate education, training, and supervision" and defines the tiers: BCaBAs practice under a BCBA, RBTs "under the close, ongoing supervision of a BCBA-D, BCBA or BCaBA," and an uncredentialed behavior technician gets one 90-day grace period, during which they may work only in a practice-based location with a BCaBA/BCBA/BCBA-D physically on site. It sets no numeric supervision ratio, and BACB supervision hours are not billable treatment.[1]
CAM 387 publishes no unit caps; hours are requested on the ABA Service Provider Request form and must match medical necessity. A mandated South Carolina group plan may apply the $73,400 annual behavioral-therapy cap for 2026.[1][7][8]
Home, clinic, office or school only: services "outside of the physical space of the home, clinic, office, or school" (sporting events, camps) are excluded unless approved. School ABA needs a current IEP, FBA and BIP and a school-based goal; in-home ABA requires an adult caregiver physically present, and both must be delivered by an RBT, BCaBA, BCBA or BCBA-D.[1]
"Two ABA providers billing at the same time" is not medically necessary under CAM 387. The policy does not carve out an exception for 97155 with 97153. ABA alongside other therapies: CAM 387 makes non-duplication a coverage condition — "The ABA services recommended do not duplicate services provided or available to the member by other medical or behavioral health professionals," naming "occupational, physical, and speech therapies" among the examples — but sets no explicit same-clock-time billing rule.[1][1]
Ask the plan: Companion Benefit Alternatives, 800-868-1032: ask whether 97155 and 97153 may be billed for the same clock time.
CBA asks that behavioral health claims "always include the rendering provider’s NPI in the rendering field." Neither CBA nor CAM 387 says whether RBT time bills under the supervising BCBA.[5][1]
Ask the plan: Companion Benefit Alternatives, 800-868-1032: ask which NPI goes in the rendering field for RBT services.
CAM 387 requires the assessment and program plan to carry the "Signature, title, and date by the multidisciplinary team members including the parent and/or caregiver," but sets no session-note signature rule.[1]
Ask the plan: Companion Benefit Alternatives provider portal FAQ or 800-868-1032: ask who must sign each session note.
Once a week, by EFT or paper check, per Companion Benefit Alternatives. The filing deadline is not on CBA’s public pages; ask CBA or check the login-only provider FAQ.
Yes, for ASD under medical policy CAM 387, with prior authorization through Companion Benefit Alternatives. Insured large-group plans and the State Health Plan also carry Ryan’s Law.
Yes. 97151 is on BlueCross’s standard prior-authorization list with the other ABA codes.
To Companion Benefit Alternatives at autismsupport@companiongroup.com; autism requests are excluded from the Cohere Health route other behavioral requests use.
Psychological testing with at least one autism-specific instrument (ADOS-2, ADI-R, DISCO or CARS-2) and one more measure such as SRS-2 or SCQ, plus a BCBA assessment dated within 45 days of the request.
Only partly: the BCBA completing the assessment must be in the member’s state or a contiguous county, and at most half the assessment units may be done by telehealth. South Carolina itself issues no behavior-analyst license.
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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