Capital Blue Cross is the Blue Cross plan for the 21 counties of central Pennsylvania and the Lehigh Valley. Highmark Blue Shield covers the same central counties, so check the card carefully. For ABA, Capital is mostly a preauthorization and benefits question. Every ABA code needs preauthorization for Commercial and CHIP members. Its Provider Manual publishes the decision deadlines. The clinical criteria are not public: in 2023 Capital removed ABA from its autism medical policy.
The Provider Manual says “Applied Behavior Analysis treatment services require a preauthorization prior to beginning treatment.” Requests go through the Preauthorization application in the Provider Portal with the plan of care, clinical notes and other clinical documents. The same package supports concurrent (continued-stay) review. Capital also offers a standard ABA Progress Report under Provider forms.[1][2]
The Single Source Preauthorization List marks 97151–97158 as “Select Outpatient Behavioral Health Services — Applied Behavior Analysis (ABA)”. It lists 0362T and 0373T under “Investigational And Experimental Procedures”, also typed ABA. All require preauthorization for Commercial/CHIP and none for Medicare Advantage. Capital tells providers to bill ABA with these CPT codes and no longer with H0032, H2014, H2019, H2020, H2021 or H2022. The manual’s ASD claim-form section still mentions “Level II HCPCS” codes and modifiers. The preauthorization list is the newer instruction, but confirm the billing codes with Provider Services (866.688.2242).[1][2]
Capital’s autism medical policy, MP 2.304 “Medical Treatments of Autism Spectrum Disorder” (effective 8/1/2026), no longer covers ABA. Its history notes that in 2023 “ABA and Behavior therapy removed from policy”, and in 2024 it removed “statements related to behavioral health services”. What remains covers diagnostic evaluation and investigational treatments. Its product variations say that for fully insured groups, CHIP, and “self-funded groups that have opted to be subject to Act 62”, the policy applies to the extent Act 62 allows.[3][1]
For behavioral health, the Provider Manual says Capital uses “industry standard clinical management criteria”, reviewed yearly. Specific criteria are available by calling the clinical management team at 1.800.471.2242. So supervision ratios, hour ranges and setting rules for ABA are not published. They come with the authorization.[3][1]
The manual’s utilization-management table names ABA in its outpatient rows. Standard outpatient requests: for Commercial, FEP, Exchange and Managed Care, a missing-information notice within 48 hours and a decision within 15 calendar days. For CHIP, a decision within two business days. Expedited outpatient requests: Commercial, Exchange and Managed Care decide “ASAP but within seventy-two (72) hours”, and CHIP within two business days. Urgent requests on weekends or holidays go to the clinical management line (1.800.471.2242), with a response within 24 hours of the call.[1][10]
The manual also cites Act 146. If you cannot give electronic access to records, that cannot be the reason a prior-auth request is denied.[1][10]
Act 62 requires fully insured group policies for employers with 51 or more employees, and CHIP, to cover diagnostic assessment and treatment of ASD, including ABA, for members under 21. The treatment plan must come from a licensed physician or psychologist. The insurer may review it once every six months. A diagnostic assessment is valid for 12 months. Capital’s manual states Act 62 in one line, noting that copays, deductibles and coinsurance still apply. The Insurance Department’s 2026 notice sets the statutory cap at $51,908 for 2026 renewals ($53,310 for 2027). It expects the cap to have no impact on coverage, because autism is treated as a mental health condition under federal parity. Self-funded groups are outside Act 62 unless they opt in, and MP 2.304 explicitly allows for that.[6][7][9][1]
Capital manages behavioral health preauthorization itself. The manual names no outside behavioral health vendor for ABA. However, “some employer groups have made alternative arrangements for behavioral health services”, and in that case the member’s ID card shows where behavioral health benefits sit. Read the card before you request authorization.[1][5]
Telehealth is governed by Network Reimbursement Policy NR-30.026. The manual says it lets any state-licensed provider with telehealth capability deliver covered services billed under Capital’s telehealth code set, and requires written member consent specific to telehealth. NR-30.026 itself was not retrieved (it was last revised effective May 1, 2026), so which ABA codes are payable remotely is unconfirmed.[1][5]
Rates: Capital publishes no commercial ABA fee schedule. Rates are negotiated in the Provider Agreement.[1][5]
Pennsylvania has no behavior-analyst license, and the BACB licensure table has no Pennsylvania entry. Under Act 62 § 635.2(g), the State Board of Medicine licenses Behavior Specialists (49 Pa. Code §§ 18.521–18.527). Act 62 defines an “autism service provider” as one licensed or certified in Pennsylvania. Capital’s manual requires every rendering practitioner to be credentialed and active in your group before seeing Capital members.[11][14][12][1]
Pennsylvania’s prompt-pay rule, 31 Pa. Code § 154.18, requires licensed insurers and managed care plans to pay clean claims "within 45 days of the licensed insurer’s or managed care plan’s receipt of the claim," with interest on late clean claims paid within 30 days of the claim payment. It applies to claims under health insurance policies.[15][1]
Capital’s provider manual sets the filing clock for professional claims: “CMS 1500 claims must be submitted to Us no later than 180 days after the date of service,” and CMS-1500 adjustments “must be submitted within 180 days of the original date of service” (some groups’ agreements set shorter limits). When Capital is secondary, the claim is due no later than 180 or 365 days, depending on provider type, from the other carrier’s notice. Administrative claim reviews and medical-necessity appeals must be filed in writing “within 180 calendar days following the date the Provider is given notice via a Statement of Remittance,” and Capital reviews a complete dispute within 60 calendar days. The billing provider NPI and, when applicable, taxonomy code “must match what is registered with Capital Blue Cross”; the taxonomy field is required for an institution with more than one billing subpart. The manual says nothing about EVV.[15][1]
Capital’s provider manual (Chapter 2, Unit 6, The BlueCard program) covers members of other Blue plans who live in or travel to its 21-county Central Pennsylvania and Lehigh Valley area: "members from other Blue Plans are responsible for obtaining precertification/preauthorization for their services from their Blue Plan." Participating providers must notify the member’s plan within 48 hours of a change to a preservice review. Check eligibility through Capital’s provider portal, a HIPAA 270, or BlueCard Eligibility at 1.800.676.BLUE (2583), which handles "eligibility, benefit, and precertification/referral authorizations only." Claims go to Capital, which pays under your Capital fee schedule. The BlueCard Provider Service Unit is 1.877.892.6298.[1]
Out-of-area HMO and POS members of other Blue plans "receive the indemnity level of benefits offered through BlueCard Traditional" outside their home plan’s area, and HMO products "may have limited benefits out-of-area" (the back of the card says so). Check benefits before starting an ABA program for such a child. Capital’s CMS-1500 instructions for autism spectrum disorder claims require the full prefix in Block 1a. If a BlueCard member’s card has no prefix, file directly with the member’s Blue plan.[1]
Only with preauthorization on HMO and POS products. In its standing-referral rules for HMO and POS members, Capital Blue Cross's 2026 provider manual says “All treatments by non-Participating Providers require preauthorization.” Out-of-network benefits on PPO products depend on the plan, and Capital publishes no ABA single-case-agreement process or rate.[1]
The questions that decide whether a family can start with Capital Blue Cross in Pennsylvania, and what they have to bring. Each maps onto something intake should ask on the first call.
No instrument is required. MP 2.304 says a comprehensive diagnostic evaluation may include “validated diagnostic instruments (e.g., ADOS-2, ADI-R)”, plus developmental and behavioral history with direct observation, speech-language evaluation, and an audiological assessment to rule out hearing deficits. These are listed as options, not requirements.[3]
No PCP referral is needed. The manual states that “a referral is not needed for … Behavioral Health Care” from a network provider, even on POS, HMO and CHIP products that otherwise require PCP coordination. The Single Source Preauthorization List classes ABA as a behavioral health service. The gate is preauthorization before treatment starts. On Act 62 plans, treatment follows a plan developed by a licensed physician or psychologist.[1][2][6]
Capital’s manual publishes the deadlines, and ABA appears by name in the outpatient rows. Standard (non-urgent) outpatient PA for Commercial, FEP, Exchange and Managed Care: a missing-information notice “no later than forty-eight (48) hours”, and a decision and written notice within 15 calendar days. CHIP: within two business days. Expedited outpatient PA for Commercial, Exchange and Managed Care: “ASAP but within seventy-two (72) hours”. CHIP expedited: two business days. Urgent requests on weekends or holidays: call 1.800.471.2242, response within 24 hours of the call. Self-funded ERISA groups are also bound by 29 CFR 2560.503-1 (15 days + 15, urgent 72 hours).[1][10][16]
Capital publishes no ABA age limit. On plans Act 62 reaches (fully insured groups of 51 or more, CHIP, and self-funded groups that opted in, per MP 2.304), coverage is required for members under 21. For older members and for non-mandate plans, the benefit booklet decides.[6][3]
Ask the plan: Provider Portal eligibility, or Provider Services 866.688.2242. Ask whether the group is fully insured, CHIP, or self-funded, whether it opted into Act 62, and whether it has an ABA age term.
Capital publishes no recency rule of its own. On Act 62 plans, a diagnostic assessment of ASD is “valid for a period of twelve (12) months, unless a licensed physician or licensed psychologist determines an earlier assessment is necessary.”[6]
Ask the plan: Capital clinical management (1.800.471.2242): ask what diagnostic documentation, and how recent, it expects with the initial ABA preauthorization on this plan.
MP 2.304 describes a comprehensive diagnostic evaluation that may include “clinical assessment by a qualified professional (e.g., developmental pediatrician, child psychologist, pediatric neurologist)”. These are examples, not a closed list. On Act 62 plans, the diagnostic assessment is performed by a licensed physician, licensed physician assistant, licensed psychologist or certified registered nurse practitioner. LCSW: no published rule. The plan names no diagnosing-provider list, so ask it whether an LCSW's diagnosis is accepted.[3][6]
Ask the plan: Capital clinical management (1.800.471.2242) for non-mandate plans: ask which diagnosing credentials it accepts for an ABA preauthorization.
Two parents’ plans: Capital’s manual applies the birthday rule to children under 18 when the parents are married or living together. The plan of the parent whose birthday falls earlier in the year pays first; on the same birthday, the plan that has covered the parent longer pays first. If the other plan does not use the birthday rule, the father’s plan is primary (the “Gender Rule”). Joint custody without a court-assigned coverage duty follows the same order. Medicaid: Capital pays before Medical Assistance. PA requires other insurance to be used first (55 Pa. Code § 1101.64), providers must bill private insurance before MA for ASD services, and MA pays IBHS only when no third party pays. Get Capital’s preauthorization even when MA will be secondary. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)). CHAMPVA is the last payer (38 CFR 17.270).[1][17][18][19][20][21][22]
Ask the plan: Capital Provider Services (866.688.2242) when unsure which plan is primary, as the manual directs. Record every other coverage the child has.
Unconfirmed for ABA. The manual says Capital pays eligible telehealth when “a licensed qualified health care professional is furnishing the remote service” by interactive audio and/or video. NR-30.026 lets any state-licensed provider bill the codes in Capital’s telehealth code set. The provider must get written member consent specific to telehealth and keep it on file. Whether 97151–97158 are in that code set, and which POS and modifiers apply, is in NR-30.026, which was not retrieved.[1][5]
Blocked on: Capital Blue Cross Network Reimbursement Policy NR-30.026 Telehealth Services (Provider Portal / provider library): check its code list for 97151–97158, plus the POS and modifier rules.
Coverage decides whether Capital Blue Cross in Pennsylvania 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.
The manual’s ASD claim instructions (CMS-1500): put the rendering provider’s NPI in Block 24j, and leave it blank “if the Provider is contracted as a facility”. Put the billing provider’s NPI in Block 33a, with a street address rather than a PO Box in Block 33. Every rendering practitioner must be credentialed and active in your group on the date of service.[1]
No ABA-specific rule. The manual’s general medical-record standard requires every entry to carry “legible author identification, date of service” and credentials, handwritten or authenticated electronic signature. Physician assistants and residents need a supervising physician’s cosignature. Capital does not say whether a caregiver signature or supervisor co-signature is required on ABA session notes.[1]
Ask the plan: Capital Provider Services or your Provider Agreement. Ask what an ABA session note must carry to survive a records request.
Not published. Capital has no public ABA policy: MP 2.304 dropped ABA in 2023. Behavioral health reviews use unnamed “industry standard clinical management criteria”, so no supervision ratio or credential ladder for technicians is published.[1][3]
In licensed criteria: Capital clinical management team (1.800.471.2242), which the manual names as the source of the specific criteria, plus your Provider Agreement.
Not addressed in any Capital document read (Provider Manual, MP 2.304, Single Source Preauthorization List).[1]
Ask the plan: Capital Provider Services (866.688.2242): get a written answer on concurrent 97153/97155 billing.
Capital publishes no ABA unit ceiling. The manual requires claims to report “total units (time-based) for each service”. The authorized units on each preauthorization are the working limit.[1]
Ask the plan: The approved units on the Capital preauthorization, and Provider Services for any code-level edits.
Not published for ABA. The ASD claim instructions require the service location in Block 32 but no document states which settings (home, clinic, school, community) are payable.[1]
Ask the plan: Capital clinical management at preauthorization. Name the setting in the request and confirm it on the approval.
On HMO and POS plans, only with preauthorization: “All treatments by non-Participating Providers require preauthorization.” No ABA single-case-agreement process or rate is published.
CMS-1500 claims are due within 180 days of the date of service, and adjustments within 180 days of the original date of service, unless your agreement sets a shorter limit.
180 calendar days from the Statement of Remittance; Capital reviews a complete dispute within 60 calendar days.
Yes. ABA is a preauthorized service for Commercial and CHIP members. Fully insured large groups, CHIP and self-funded groups that opted in must cover it under Act 62 for members under 21. Other plans follow the benefit booklet.
Yes, before treatment starts. 97151–97158, 0362T and 0373T are on the Single Source Preauthorization List for Commercial/CHIP. Submit through the Provider Portal with the plan of care and clinical notes.
For commercial members, the manual allows up to 15 calendar days for a standard request and 72 hours for an expedited one, with a missing-information notice within 48 hours. CHIP requests are decided within two business days.
Capital publishes no ABA fee schedule. Commercial ABA rates are negotiated in the Provider Agreement.
Within 45 days of receipt of a clean claim (31 Pa. Code § 154.18), for insured plans.
The member’s own Blue plan. Capital’s manual says members from other Blue plans are responsible for precertification from their plan, which you can request through BlueCard Eligibility at 1.800.676.BLUE. Out-of-area HMO members may have limited benefits, so check before starting. File the claim with Capital, with the prefix in Block 1a.
Not according to its autism claim instructions. The 2026 provider manual’s CMS-1500 instructions for autism spectrum disorder cover Blocks 1a (ID with prefix), 2, 11c, 21, 24d (codes, autism diagnosis, modifiers and total time-based units), 24j (rendering NPI), 32, 33 and 33a (billing NPI), and do not call for Block 17. Preauthorization, not a referral, is the gate for ABA.
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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