Buckeye Health Plan (Centene) runs Ohio Medicaid ABA under Centene's corporate clinical policy CP.BH.104 — and offers the most intake-friendly front door of Ohio's stricter plans: in-network assessment codes 97151 and 97152 require no prior authorization (PA applies out-of-network only). The treatment side is where Centene's structure bites, with explicit hour parameters and a documentation package that rewards preparation.
Treatment PA (97153–97158) runs through Buckeye's Autism Services Prior Authorization Request Form, which wants the individual diagnostic interview or FBA, objective testing results, a description of coordination with other services, the proposed schedule with rendering provider type per session, a parent-training plan, and a copy of the IEP or IFSP. The form also requires an HSPP-or-physician attestation of active participation in the treatment plan. Requests fax to (866) 694-3649 (UM phone (800) 224-1991); retrospective dates aren't processed on the standard form and route to a separate fax. The pre-auth check tool on buckeyehealthplan.com answers code-level questions.[2]
CP.BH.104 sets the numbers: treatment should not exceed 6 hours/day and 30 hours/week without detailed clinical justification (severity or escalation criteria, with BCBA and guardian signatures), and the policy expects under 20 hours/week for children attending school full-time — comprehensive ABA is framed as 30–40 hours/week for the cases that warrant it. Protocol modification (97155) should run at least 2 hours/week or 10% of direct hours (whichever is greater), capped at 20% unless justified. The comprehensive diagnostic evaluation is accepted if conducted within the past five years.[1]
Filing deadline: “Providers will have 365 days to timely file a claim, including any timely filing exceptions, in accordance with Ohio Administrative Code (OAC) rule 5160-1-19”; unless the provider agreement says otherwise, clean claims (initial, corrected and voided) must be submitted within 365 days of the date of service. Claim disputes (any provider disagreement with a claim decision): “within 12 months from the date of service or 60 calendar days after the payment, denial or partial denial of a timely claim submission, whichever is later.” Pre-service provider appeals are due within 60 calendar days of the notice of adverse action.[8][7][9]
EVV does not apply to ABA in Ohio. OAC 5160-32-01 lists the services subject to Ohio’s EVV program — named waiver services in the home care, MyCare, PASSPORT and developmental-disability waivers, plus state-plan home health, private duty nursing and RN assessment and consultation — and makes managed care entities responsible for applying it; ABA is not on the list, and services delivered by telehealth are exempt.[8][7][9]
Payment clock: Buckeye’s 2026 provider manual defines a clean claim but prints no payment timeframe or check-run schedule, so the state contract standard governs: ODM’s managed care provider agreement (Rev. 12/2025, App. L §10) requires every Ohio MCO — unless the MCO and the provider agreed an alternative payment schedule in the provider contract — to pay or deny 90% of clean claims within 21 calendar days of receipt, 99% within 60 calendar days and 100% of all claims within 90 calendar days; behavioral health claims are measured as their own category, and the standard applies to network and out-of-network providers alike. The same agreement requires the MCO to accept claims for 365 calendar days from the date of service under OAC 5160-1-19 (App. K §5a).[8][7][9]
CP.BH.104 (last revised 02/26) continues ABA when behavior concerns are not worsened by treatment and all of the following are documented: an updated behavior assessment at least every six months that meets the initial-assessment standard — including results “to include visual representations [graphs, tables, grids] as appropriate”; the percentage of scheduled sessions completed and caregiver participation, with justification when attendance falls below 80% of authorized hours; two to four performance-based caregiver training goals with baseline data and mastery criteria and documented family participation (ideally at least two hours a month); documented coordination of care with schools and other therapists; and an updated treatment plan at least every six months whose behavior-reduction goals include “baseline data, operational definition/topography of behavior, treatment strategies and graphs,” plus a titration plan with progress over the prior authorization period. So Buckeye expects graphs on behavior-reduction goals and graphs, tables or grids in the assessment results.[1]
The questions that decide whether a family can start with Buckeye Health Plan (OH), and what they have to bring. Each maps onto something intake should ask on the first call.
Buckeye accepts the comprehensive diagnostic evaluation if it was conducted within the past five years — the most generous window of the Ohio plans, and worth knowing against CareSource’s 24-month letter trigger.[4][1][2][1]
Follows the Ohio Medicaid framework: the ASD diagnosis comes from a documented comprehensive diagnostic evaluation by a licensed physician, psychologist, or other clinician qualified to diagnose autism, demonstrating DSM-5-TR criteria.[4][1][2]
No referral or service order is required, but the treatment package is prescriptive: treatment PA (97153–97158) runs through Buckeye’s Autism Services Prior Authorization Request Form, which wants the individual diagnostic interview or FBA, objective testing results, a description of coordination with other services, the proposed schedule with the rendering provider type per session, a parent-training plan, and a copy of the IEP or IFSP — plus an HSPP-or-physician attestation of active participation in the treatment plan. In-network assessment codes 97151 and 97152 need no prior authorization at all; PA applies out-of-network only.[4][1][2][2][1]
Buckeye’s ABA policy (CP.BH.104, last revised 02/26) allows telehealth as a modality: services “may be provided in various settings (e.g., home, clinic, school, community) and modalities (e.g., in-person, telehealth).” It quotes the CASP telehealth parameters that telehealth “is not intended to replace in person service” but to supplement it, says modality should be chosen on the member’s needs, caregiver availability and environmental support, and tells providers to “refer to respective state allowances for telehealth services.” It names no ABA codes. ODM’s 2026 Telehealth Billing Guidelines list no ABA code as telehealth-eligible, and say the MCOs “cover the same telehealth services as in fee-for-service but may have different billing requirements.” Before billing a remote 97151 or 97155, confirm with Buckeye which codes, modifier and place of service it accepts.[1][6]
Buckeye’s 2026 Medicaid manual: standard (non-urgent pre-service) determinations are made “no later than 7 calendar days after Buckeye receives the request for service.” Expedited determinations: “no later than 48 hours after Buckeye receives the request,” with provider attestation of urgency. Lead time: “Standard prior authorization requests should be submitted for medical necessity review at least five (5) business days before the scheduled service delivery date or as soon as the need for service is identified.” No separate ABA reauthorization lead time is published. Ohio’s MCO rule sets the clock. For a standard request the MCO “must provide notice to the provider and member as expeditiously as the member’s health condition requires but no later than seven calendar days following receipt of the request for service,” extendable by up to fourteen calendar days (an MCO-requested extension needs ODM’s prior approval). An expedited decision is due “no later than forty-eight hours after receipt of the request for service” (OAC 5160-26-03.1, effective 1/1/2026). The 48 hours is stricter than the federal 72-hour managed-care cap.[8][11]
Buckeye’s 2026 manual publishes no COB procedure of its own beyond asking providers to “obtain and report to Buckeye information regarding other insurance coverage,” so the state MCO rule governs. Ohio’s MCO rule: “The MCE is the payer of last resort when a member has third party resources available.” Providers must “take reasonable measures to obtain all third party payments and file claims with all TPPs prior to billing the MCE.” That means a remittance from the other payer showing a valid non-payment reason (service not covered, applied to the deductible or copay, benefit maximum reached), a partial payment with its remittance, or no response within ninety days of submitting to the other payer. The MCO pays at most its allowed amount minus the other payments, and must allow at least ninety days from the other payer’s remittance to file. Exception: “The MCE, except SPBM, pays first for preventive pediatric services before seeking reimbursement from any liable third party.” Children in the custody of a county children’s services agency are exempt from TPL cooperation (OAC 5160-26-09.1).[12][8]
Ask the plan: Buckeye Provider Services: whether a Buckeye ABA authorization is required when a commercial plan pays first.
Follows the Ohio Medicaid framework, which publishes no verifiable age bound for ABA; under-21 members carry EPSDT protections through the MCO. codes.ohio.gov now returns “No Ohio Administrative Code rule number corresponds to ‘5160-34’” (re-confirmed 10/1/2026) rather than refusing the connection, and the chapter remains absent from the Title 5160 index, so no in-force rule text exists to read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Per ODM’s 7/30/2026 provider stakeholder presentation, the rewrite was paused in 2025 for reevaluation (budget pressure, national ABA-spend scrutiny, other-state audit findings) and the draft (ERF188422B) still carries a “DRAFT — NOT FOR FILING” header and no JCARR filing, so draft content does not govern.[4][1][2]
Blocked on: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
No plan-specific instrument list found, and the state framework names none. Other Ohio MCOs do publish lists (CareSource: ADOS, ADI-R or CARS-2; Optum for UHC Community Plan: one validated screener plus one formal tool), so confirm in this plan’s portal rather than assuming. codes.ohio.gov now returns “No Ohio Administrative Code rule number corresponds to ‘5160-34’” (re-confirmed 10/1/2026) rather than refusing the connection, and the chapter remains absent from the Title 5160 index, so no in-force rule text exists to read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Per ODM’s 7/30/2026 provider stakeholder presentation, the rewrite was paused in 2025 for reevaluation (budget pressure, national ABA-spend scrutiny, other-state audit findings) and the draft (ERF188422B) still carries a “DRAFT — NOT FOR FILING” header and no JCARR filing, so draft content does not govern.[4][1][2]
Blocked on: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
Coverage decides whether Buckeye Health Plan (OH) 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.
Buckeye publishes a numeric floor the state rule does not: protocol modification (97155) should run at least 2 hours a week or 10% of direct hours, whichever is greater, capped at 20% unless justified. The OAC 4783-6-02 COBA supervision-plan requirements still apply underneath.[4][1][2][1][5]
CP.BH.104 sets the numbers: treatment should not exceed 6 hours a day and 30 hours a week without detailed clinical justification — severity or escalation criteria, with BCBA and guardian signatures — and the policy expects under 20 hours a week for children attending school full time, with comprehensive ABA framed as 30–40 hours a week for the cases that warrant it.[4][1][2][1]
CP.BH.104 ties intensity to school attendance rather than naming payable settings: under 20 hours a week is expected for children attending school full time, and the treatment package requires a copy of the IEP or IFSP. The Ohio Medicaid School Program boundary still applies — the MCO is not responsible for services provided through MSP.[4][1][2][1][2]
Follows the Ohio Medicaid framework: independent practitioners are Certified Ohio Behavior Analysts (ORC Chapter 4783) or BACB BCBAs and BCBA-Ds enrolled with ODM as Provider Type 19, Specialty 190, with BCaBAs and RBTs delivering under supervision. The routing rule holds everywhere in Ohio: OhioRISE does not pay for ABA — ODM’s Mixed Services Protocol assigns ABA claims to the member’s MCO or fee-for-service even for OhioRISE-enrolled youth.[4][1][2]
Not resolved. No state-level rule on billing 97153 and 97155 for the same clock time could be verified, and this plan publishes none. codes.ohio.gov now returns “No Ohio Administrative Code rule number corresponds to ‘5160-34’” (re-confirmed 10/1/2026) rather than refusing the connection, and the chapter remains absent from the Title 5160 index, so no in-force rule text exists to read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Per ODM’s 7/30/2026 provider stakeholder presentation, the rewrite was paused in 2025 for reevaluation (budget pressure, national ABA-spend scrutiny, other-state audit findings) and the draft (ERF188422B) still carries a “DRAFT — NOT FOR FILING” header and no JCARR filing, so draft content does not govern.[4][1][2]
Blocked on: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
No plan-specific session-note signature standard found, and none could be verified at state level. codes.ohio.gov now returns “No Ohio Administrative Code rule number corresponds to ‘5160-34’” (re-confirmed 10/1/2026) rather than refusing the connection, and the chapter remains absent from the Title 5160 index, so no in-force rule text exists to read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Per ODM’s 7/30/2026 provider stakeholder presentation, the rewrite was paused in 2025 for reevaluation (budget pressure, national ABA-spend scrutiny, other-state audit findings) and the draft (ERF188422B) still carries a “DRAFT — NOT FOR FILING” header and no JCARR filing, so draft content does not govern.[4][1][2]
Blocked on: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
Yes — under Centene's CP.BH.104 policy. In-network assessments (97151, 97152) need no prior authorization; treatment codes require PA via the Autism Services form.
No more than 6 hours/day and 30 hours/week without detailed clinical justification, and under 20 hours/week expected for full-time students. Protocol modification runs 2 hrs/week or 10% of direct hours, capped at 20% unless justified.
The comprehensive diagnostic evaluation is accepted if conducted within the past 5 years.
365 days from the date of service, per OAC 5160-1-19; claim disputes within 12 months of the date of service or 60 days after the payment or denial, whichever is later (Buckeye provider manual 2026).
Buckeye’s manual prints no payment timeframe, so ODM’s MCO contract standard applies unless your provider contract sets another schedule: 90% of clean claims paid or denied within 21 calendar days of receipt, 99% within 60 and all claims within 90. No weekly submission cutoff is published.
Yes for behavior-reduction goals: CP.BH.104 requires the updated treatment plan’s behavior-reduction goals to include baseline data, definitions, strategies and graphs, and the six-monthly behavior assessment to present results with graphs, tables or grids as appropriate. Attendance below 80% of authorized hours must be justified.
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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