CareFirst BlueCross BlueShield is the Blue plan for Washington, D.C., Maryland and Northern Virginia; in the District its business name covers Group Hospitalization and Medical Services, Inc. (GHMSI) and CareFirst BlueChoice. Two CareFirst documents govern ABA: Medical Policy 3.01.015 (Autism Spectrum Disorder), updated for March 1, 2026 with a pointer to D.C. Code § 31-3272 for DC members, and Operating Procedure 8.01.011A (Habilitative Services, MD and DC Mandates). CareFirst also administers the Federal Employee Program, which matters in Washington: FEP plans are outside the DC statute but list ABA among services needing prior authorization.
We could read CareFirst’s update notices, prior-authorization lists and provider-manual chapters, but not the full text of the two policies, which sit behind CareFirst’s SAI360 policy portal. Where a rule depends on that text, this guide says so and points to where to confirm it.
CareFirst’s in-network precertification page lists, for BlueChoice HMO members, "Behavioral Health and Substance Use Disorder (Milliman Care Guidelines)" and "Applied Behavioral Analysis (ABA) (3.01.015)" among services requiring authorization; for PPO members, "Habilitative Services (8.01.011A)" is on the pre-service review list. Its provider manual lists ABA as requiring prior authorization under FEP Standard and Basic Option and FEP Blue Focus. CareFirst warns the lists "may vary based on account contracts and should be verified by contacting 1-866-773-2884," and code-level answers are in the Prior Authorization Lookup (PAL) tool inside the provider portal. CareFirst’s care-management chapter lists MCG Behavioral Health Care Guidelines among its review criteria.[1][2][5][6][7]
The January 2026 policy update to 3.01.015 (effective March 1, 2026) made no change in coverage but added that member contracts take precedence over clinical criteria, that coverage "may be subject to state specific mandates," and that for the District "please refer to § 31–3272." It also added the PAL tool and 1-866-PRE-AUTH as the route for prior-authorization requirements. Operating Procedure 8.01.011A was revised in December 2024.[1][2][5][6][7]
CareFirst contracts with "independently practicing licensed healthcare practitioners," who must be "licensed in the state where the member receives the service" and practice within its Maryland, DC and Northern Virginia service area. Its list of eligible professionals names "Licensed Board-Certified Behavior Analyst (Maryland and Virginia only)," so a BCBA practicing in the District should ask CareFirst how it credentials DC behavior analysts now that the District licenses them. CareFirst’s payment-policy index lists PP CO 020.01, "Limited Licensed Providers," as covering "Assistant Behavior Analysts and Registered Behavior Technicians"; we could not open the policy text. Claims "must be submitted within 365 days from the date of service," and billing and rendering NPIs are required on every claim.[3][4][12]
For District-regulated plans, D.C. Code § 31-3132 requires a health insurer to reimburse "within 30 days after the receipt of a clean claim," with interest at 1.5% a month from the 31st day, 2% from the 61st and 2.5% after the 120th, and to allow "a minimum of 180 days from the date a covered service is rendered" to file; an electronic claim is presumed received within 24 hours. CareFirst’s 365-day limit is longer than that floor. CareFirst publishes no check-run schedule in the documents we read.[3][4][12]
The District’s autism coverage rule is a habilitative-services statute, not a stand-alone ABA law. D.C. Code § 31-3272 (D.C. Law 16-198, 2007) requires a health insurer to "Provide coverage of habilitative services for children under the age of 21 years and may do so through a managed care system." Section 31-3271 defines habilitative services as "services, including occupational therapy, physical therapy, and speech therapy, for the treatment of a child with a congenital or genetic birth defect to enhance the child’s ability to function," and says a congenital or genetic birth defect "includes: (A) Autism or an autism spectrum disorder." Denying a habilitative request because the condition is not a birth defect is, by statute, an adverse decision. The coverage "shall not be more restrictive than coverage provided for any other illness, condition, or disorder" for deductibles, durational or dollar limits, visit or treatment limits, and cost sharing. An insurer does not have to pay for habilitative services "actually delivered through early intervention or school services." The statute itself never names applied behavior analysis. ABA is named in the District’s essential-health-benefit standard: the DC Health Benefit Exchange Authority’s March 22, 2013 resolution defines the habilitative category as services that help a person "keep, learn or improve skills and functioning for daily living, including, but not limited, to applied behavioral analysis (ABA) for the treatment of autism spectrum disorder." CareFirst’s own ASD policy (3.01.015, updated for March 1, 2026) points DC members to § 31-3272 for mandated coverage. Two exclusions matter in Washington especially: the statute’s definition of a health benefit plan excludes "federal employee health plans, pursuant to contracts with the United States government" and Medicare coverage, and self-funded employer plans answer to ERISA rather than District insurance law.[9][10][11][6][20]
The District now licenses behavior analysts, but recently. D.C. Law 25-191 (effective July 19, 2024) gave the Board of Psychology the job of regulating "the practice of behavior analysis" and added a licensed behavior analyst seat to the Board (D.C. Code § 3-1202.11). Under § 3-1207.71 the Board licenses a person who completes a criminal background check, holds "a current certification issued by the Behavior Analyst Certification Board," and has a master’s or higher from a BACB-accredited program, with the education requirement waived for anyone certified by the BACB on or before July 19, 2024. The Mayor was to issue licensure rules (ethics code, education and clinical training, exam, continuing education) within one year. The BACB’s licensure table lists the District (2024, DC Board of Psychology). As of October 2026, though, DC Health’s Board of Psychology page links regulations for psychologists and psychology associates only and shows no behavior-analyst rule or application, so confirm with DC Health whether licenses are being issued before you tell a BCBA they need one. Carriers have not caught up either: CareFirst’s credentialing list still names "Licensed Board-Certified Behavior Analyst (Maryland and Virginia only)" and requires a practitioner to be "licensed in the state where the member receives the service." For telehealth or a BCBA based outside the District, plan on meeting the licensure rule of the place where the child is: DHCF’s telemedicine guidance applies that rule to Medicaid, and ask each commercial plan how it applies it. On rates: commercial ABA rates are negotiated and unpublished. DC Medicaid publishes its ASD fees on the dc-medicaid.com portal, which we could not open.[17][18][19][22][3][23]
Yes, through BlueCard. CareFirst’s Provider Manual (Chapter 2, BlueCard Program) defines BlueCard as “a national program that enables members of one BCBS Plan to obtain healthcare service benefits while traveling or living in another BCBS Plan’s service area,” and tells participating providers “The program lets you submit claims for patients from other BCBS Plans, domestic and international, to CareFirst.” Its own example is a member with employer coverage through another Blue plan who lives in, or travels to, CareFirst’s area. Traditional, PPO, EPO, POS and HMO products can run through BlueCard; the Federal Employee Program (FEP), standalone dental and vendor-delivered vision and drug programs are excluded, and “EPO products may have limited benefits out-of-area.” The member gets in-network PPO benefits by seeing a BlueCard PPO provider — a CareFirst participating provider in its Maryland, District and Northern Virginia area.[2]
Prior authorization and medical policy belong to the member’s home plan, not CareFirst. The manual: “You should remind patients that they are responsible for obtaining pre-authorization/pre-certification for outpatient services from their Blue Plan.” To find out what the home plan requires for ABA, use the Out-of-Area Medical Policy and Pre-Authorization/Pre-Certification Router at carefirst.com/preauth with the three-character prefix on the card; call BlueCard Eligibility at 800-676-BLUE (2583), which is “for eligibility, benefit and pre-authorization inquiries only” and transfers you to the home plan’s Behavioral Health review area; or use Electronic Provider Access in CareFirst Direct, which routes you into the home plan’s own portal to submit the request. So for an Anthem member from Ohio or any other state, the ABA authorization follows that Anthem plan’s rules and goes to that plan (or the vendor it names).[2]
Claims go to CareFirst. “After the member of another Blue Plan receives services from you, file the claim with CareFirst. We will work with the member’s plan to process the claim,” and “CareFirst is your sole contact for claims payment, adjustments and issue resolution.” Bill the full member ID with its prefix — “claims with incorrect or missing prefixes and member ID numbers cannot be processed” — follow CareFirst billing guidelines, and do not collect more than the member’s cost share up front. CareFirst pays you “under the terms of our contract and based on the members benefits and coverage.”[2]
The questions that decide whether a family can start with CareFirst BlueCross BlueShield (District of Columbia), and what they have to bring. Each maps onto something intake should ask on the first call.
Not stated in the CareFirst documents we could read; 3.01.015 points DC members to § 31-3272. For fully insured District plans, D.C. Code § 31-3272 requires habilitative coverage (autism included) for children under 21, with no dollar or visit cap allowed beyond what applies to other conditions. Federal employee plans and self-funded ERISA plans are outside the statute, so funding type decides whether that binds.[6][10][9]
Ask the plan: Live benefits verification: establish product and funding type, then the contract’s habilitative and ABA terms.
CareFirst requires authorization (HMO) or pre-service review (PPO) rather than a referral rule in the documents we read. For a fully insured District plan, D.C. Code § 31-3272 sets no referral or treatment-plan requirement of its own; it lets the insurer deliver habilitative coverage "through a managed care system," which § 31-3271 defines as review and preauthorization of the treatment plan. Federal employee plans and self-funded ERISA plans sit outside the statute.[1][10][9]
Ask the plan: CareFirst, 1-866-773-2884: ask whether the member’s product needs a PCP referral for ABA.
CareFirst’s ABA telehealth rules sit in its payment policies, which we could not open. For a District-regulated plan, D.C. Code § 31-3862 says an insurer "may not deny coverage for a healthcare service on the basis that the service is provided through telehealth if the same service would be covered when delivered in person," must reimburse it, and may review telehealth appropriateness only "in the same manner" as in-person care; cost sharing cannot exceed the in-person amount. The statute names no ABA codes, POS or modifiers, and self-funded and federal employee plans are outside it.[14][3]
Ask the plan: CareFirst Provider Service: ask which ABA codes, POS and modifier it pays by telehealth.
Depends on how the plan is funded. Plans regulated by the District fall under the Prior Authorization Reform Amendment Act of 2023 (D.C. Code ch. 38F). Once it has all required information, a utilization review entity must decide and notify "within … 3 business days of receiving the request via electronic portal or 5 business days of receiving the request via mail, telephone, or facsimile" (24 hours for urgent services), and a request not answered in time "shall be deemed approved." Before an adverse determination it must tell the provider that medical necessity is being questioned and offer a chance to add information. An approval is valid "for at least one year," an approval for a chronic condition stays valid "for as long as medically reasonable and necessary," and it may not be revoked if care is provided within 45 business days. The family gets at least 15 calendar days to appeal. Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1 instead: pre-service decisions "not later than 15 days after receipt of the claim," with one 15-day extension. CareFirst publishes no District-specific ABA turnaround or reauthorization lead time.[15][24][25][20]
Ask the plan: At benefits verification ask whether the plan is regulated by the District, FEP or self-funded, and what reauthorization lead time CareFirst expects.
For a child on two plans, the order of benefits comes from the plans’ coordination-of-benefits provisions; we did not read a District COB regulation, so ask CareFirst which plan is primary. When a child changes plans mid-treatment, D.C. Code § 31-3875.07 makes a District-regulated plan "honor an approval granted by a previous utilization review entity for at least the initial 60 days" of new coverage. If the child also has DC Medicaid, CareFirst pays first: Medicaid pays after other coverage (42 CFR 433.139), and DC’s Medicaid plans require the primary’s EOB with the claim. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270). If a payer later retracts payment because another carrier was primary, § 31-3133 limits that clawback to 18 months and gives you 180 days to bill the right carrier.[16][13][26][27][28]
Ask the plan: Ask CareFirst at benefits verification for the coordination-of-benefits order and record every other coverage the child has.
Not stated in the documents we could read; behavioral health review uses MCG guidelines, which are licensed.[1][5]
In licensed criteria: CareFirst, 1-866-773-2884: ask what diagnostic documentation and dates it expects.
Not stated in the documents we could read; set in policy 3.01.015 and MCG.[6][5]
Blocked on: CareFirst Medical Policy 3.01.015 or 1-866-773-2884.
Not stated in the documents we could read; MCG criteria are licensed.[5]
In licensed criteria: CareFirst, 1-866-773-2884.
Coverage decides whether CareFirst BlueCross BlueShield (District of Columbia) 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.
CareFirst’s supervision terms for technicians sit in Payment Policy PP CO 020.01 (Limited Licensed Providers, covering assistant behavior analysts and RBTs), whose text we could not open.[3]
Blocked on: CareFirst Payment Policy Reference Manual (provider.carefirst.com → Payment Policy), PP CO 020.01, or CareFirst Provider Service.
Not stated in the CareFirst documents we could read.[4]
Blocked on: CareFirst Payment Policy Reference Manual or Provider Service.
Not stated in the CareFirst documents we could read; hours are set per authorization.[1]
Blocked on: Medical Policy 3.01.015 / Operating Procedure 8.01.011A, or 1-866-773-2884.
Not stated in the CareFirst documents we could read.[4]
Blocked on: Your CareFirst agreement and the Medical Policy Reference Manual.
Not stated in the CareFirst documents we could read. D.C. Code § 31-3272 does not require payment for habilitative services delivered through early intervention or school.[1][10]
Blocked on: Medical Policy 3.01.015 or CareFirst Provider Service: ask which POS codes it pays for ABA.
Billing and rendering NPIs are required on all claims (provider manual ch. 5). How RBT and BCaBA services are billed is set by PP CO 020.01, which we could not open.[4][3]
Blocked on: CareFirst Payment Policy PP CO 020.01, or CareFirst Provider Service: ask whose NPI goes in the rendering field for RBT services in the District.
For District-regulated plans, within 30 days of a clean claim under D.C. Code § 31-3132, with interest after that (1.5% a month, rising to 2% and 2.5%). Self-funded plans are not bound by the statute.
Yes, through the BlueCard program, unless it is an FEP card or an EPO with no out-of-area benefits. Get the ABA prior authorization from the member’s home plan, using carefirst.com/preauth with the card prefix, BlueCard Eligibility at 800-676-BLUE, or Electronic Provider Access in CareFirst Direct. Then file the claim with CareFirst with the full ID and prefix; CareFirst pays you under your CareFirst contract based on the member’s home-plan benefits.
Yes. ABA (policy 3.01.015) is on the BlueChoice HMO authorization list, habilitative services (8.01.011A) need pre-service review on PPO, and FEP plans require prior authorization for ABA. Check codes in the PAL tool or at 1-866-773-2884.
No. D.C. Code § 31-3271 excludes federal employee health plans. FEP plans still list ABA as needing prior authorization, so follow the FEP rules.
CareFirst requires practitioners to be licensed where the member receives care, and its credentialing list names licensed BCBAs in Maryland and Virginia only. The District began licensing behavior analysts in 2024, so ask CareFirst credentialing how it handles DC BCBAs.
365 days from the date of service, per CareFirst’s provider manual.
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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