CareFirst BlueCross BlueShield is the Blue plan for Maryland, Washington, D.C. and Northern Virginia, and the commercial card a Maryland ABA agency sees most. Two CareFirst documents govern ABA: Medical Policy 3.01.015 (Autism Spectrum Disorder), which sets the medical-necessity criteria and says ABA must be preauthorized, and Medical Policy Operating Procedure 8.01.011A (Habilitative Services, MD and DC Mandates), which carries Maryland's hour floors. A third, Payment Policy PP CO 020.01, answers the question agencies ask most: CareFirst does not contract with RBTs directly, but pays for their services when a licensed BCBA supervises and bills. As with every Maryland commercial plan, the funding type decides whether the state mandate applies at all.
Medical Policy 3.01.015 (last reviewed 12/01/2025, effective 3/1/2026) covers "Adaptive Behavioral Treatment (ABT), including Applied Behavioral Analysis (ABA) and Developmental Relationship Based Intervention (DRBI)," as medically necessary when all four criteria are met: a confirmed ASD diagnosis from a qualified healthcare provider; treatment "provided by an appropriately trained, certified or licensed health care professional" using a systematic approach based on ABA and/or DRBI principles; treatment that targets the core deficits of ASD as set out in the DSM-5; and services rendered appropriately in type, frequency, extent, site and duration and "expected to result in meaningful and measurable improvements." ABT is not medically necessary for any non-ASD indication. The services needed to make the ASD diagnosis are themselves medically necessary.[1][3][8]
The policy adds two benefit limits. ABA benefits "apply only to eligible members under a contract's habilitative benefit," so check the member's contract. And "Benefits are not provided for diagnostic or treatment services related to learning, curriculum planning, educational achievement or special education programs," which the policy assigns to the school system under IDEA or a 504 plan. The January 2026 policy update also added a pointer to Md. Insurance § 15-835 for Maryland members. CareFirst's own utilization management relies on MCG Health Behavioral Health Care Guidelines alongside the Medical Policy Reference Manual.[1][3][8]
Both CareFirst documents require ABA to be preauthorized. Operating Procedure 8.01.011A says "Applied behavioral analysis (ABA) services and habilitative diagnoses must be preauthorized," and Habilitative Services is on CareFirst's published list of services needing pre-service review for PPO members. Requests go through the CareFirst Provider Portal (Prior Auth/Notifications tab, where the PAL tool shows code-level requirements) or 1-866-773-2884 (1-866-PRE-AUTH). Neither policy separates the 97151 assessment from treatment, so check the assessment code in PAL.[1][1][4]
If CareFirst asks, you must make available for annual review: a brief medical history; a written evaluation establishing baseline data with objective tests and measurements where possible; a plan of treatment listing diagnosis, short- and long-term goals, procedures, visits per week, estimated duration and the "date of last certification by referring physician"; and progress notes documenting improvement or changes to the plan. Build intake to capture the referring physician and the date of that physician's last certification.[1][1][4]
CareFirst does not credential or contract with technicians at all. Payment Policy PP CO 020.01 (Limited Licensed Providers) states: "CareFirst currently does not contract directly with physician assistants, assistant behavior analysts, and registered behavior technicians." Their services are "eligible for reimbursement when rendered under the supervision of a physician or licensed board-certified behavior analyst as required by local licensing agencies and submitted under that supervising physician's or licensed board-certified behavior analyst's name and provider number." No extra modifier distinguishes the technician, and the allowance is based on the supervising BCBA's fee schedule.[2][6][11][1][14][15]
So CareFirst's own documents name the technician as a registered behavior technician and tie payment to supervision "as required by local licensing agencies." They do not separately require RBT certification for someone working under a licensed BCBA. The medical policy requires treatment by "an appropriately trained, certified or licensed health care professional," and COMAR 31.10.39.03E lets a Maryland carrier limit payment to people "licensed, certified, or otherwise authorized" under the Health Occupations Article. Maryland's licensing rules, which PP CO 020.01 points to, do not require the RBT credential either. COMAR 10.58.16 lets a licensed behavior analyst deliver services through supervisees under a tiered model, and its definition of a "paraprofessional" is someone who "practices behavior analysis under the supervision of a licensed behavior analyst in accordance with requirements set by the Behavior Analyst Certification Board," is not a BCaBA, and "may be a registered behavior technician." So state licensure permits an uncertified technician under a licensed BCBA. What no CareFirst document says is whether CareFirst will pay for one, since PP CO 020.01 names only assistant behavior analysts and registered behavior technicians. Treat RBT certification as the safe standard and confirm with CareFirst before billing uncertified staff.[2][6][11][1][14][15]
At the supervisor level, CareFirst credentials "Licensed Board-Certified Behavior Analyst (Maryland and Virginia only)" as an eligible professional provider type, and the practitioner "must be licensed in the state where the member receives the service" within CareFirst's service area (Maryland, Washington, D.C. and Northern Virginia). Credentialing runs through CAQH ProView plus the CareFirst questionnaire.[2][6][11][1][14][15]
Operating Procedure 8.01.011A carries the Maryland mandate into CareFirst's rules. For children "until the end of the month in which the insured or enrollee turns 19 years of age," habilitative benefits are provided "under all contracts that follow Maryland state mandates," do not count toward any therapy maximum, and include ABA "for at least the following hours": a minimum of 25 hours a week from 18 months to 6 years, and a minimum of 10 hours a week from 6 until the month the child turns 19. That matches COMAR 31.10.39.03D, which bars denial based solely on hours at or under those levels and allows more when medically necessary. COMAR 31.10.39.03 also lets a carrier require a comprehensive evaluation by the PCP or a specialty physician, a prescription with specific treatment goals, and an annual review by the prescriber. It bars denying ABA as experimental or investigational, and bars denying payment because a treatment goal places services in the child's educational setting.[1][9][11][3]
The statute reaches insurers, nonprofit health service plans and HMOs issuing or delivering contracts in Maryland (§ 15-835(b)). It does not require reimbursement for services delivered through early intervention or schools (§ 15-835(c)(2)). Self-funded employer plans administered by CareFirst are not bound by it, and CareFirst notes that non-local accounts such as NASCO and the Federal Employee Program "may differ from our local determinations." For Washington, D.C. contracts, 8.01.011A records a separate mandate covering habilitative services including ABA at all ages in non-grandfathered individual and small-group plans.[1][9][11][3]
Claims for technician and BCaBA services go out under the supervising licensed BCBA's name and provider number (PP CO 020.01). Operating Procedure 8.01.011A says habilitative services should be reported with the Category I CPT code plus modifier 96 (habilitative services), effective 1/1/2018. CareFirst applies CMS National Correct Coding Initiative edits, both procedure-to-procedure pairs and Medically Unlikely Edits, to professional claims (PP CO 090.01). Claims must be filed within 365 days of the date of service. On rates, CareFirst publishes no ABA fee schedule. PP CO 020.01 says a BCBA is paid 75% of CareFirst's base physician fee schedule, but the dollar amounts are in your contract. Maryland Medicaid's published fee schedule is the public benchmark to negotiate against.[2][2][1][7][6][13]
CareFirst's Provider Manual (Chapter 3, Reimbursement) describes the fee schedule as "a list of plan allowances that are reviewed regularly": when it changes, affected providers "will receive a list of the impacted codes and fees" (or a list of the most commonly billed codes for their specialty when the changes are many), and "Fee schedules for additional codes can also be obtained via CareFirst Direct." New HIPAA codes are added to the base fee schedule as AMA or CMS release them, and "Fee schedules for these changes can be released at the provider's request." So to learn your 97153 allowance, look the code up in CareFirst Direct or ask CareFirst Provider Service for your fee schedule; participating providers accept that plan allowance as payment in full.[2][2][1][7][6][13]
A family with CareFirst BlueCross BlueShield Community Health Plan Maryland is on a Medicaid HealthChoice MCO, and Maryland carves ABA out of every HealthChoice MCO. Authorizations and claims for those children go to Carelon Behavioral Health under the Maryland Medicaid rules, not to CareFirst. Use the Maryland Medicaid guide for them.[2][2][1][7][6][13]
Maryland licenses the practice: “an individual shall be licensed by the Board before the individual may practice behavior analysis in the State” (Health Occupations § 17-6A-10(a)). Section 17-6A-10 itself exempts only students in a qualifying unpaid clinical educational experience, so plan on a Maryland license before treating a child located in Maryland remotely.[19][6]
CareFirst’s rule is the strictest on paper. Its provider manual (Chapter 3, Credentialing) says the practitioner “must be licensed in the state where the member receives the service and must be within the CareFirst service area, which includes Maryland, Washington, D.C. and Northern Virginia,” and lists “Licensed Board-Certified Behavior Analyst (Maryland and Virginia only)” as an eligible provider type. A BCBA based outside that service area does not meet CareFirst’s credentialing criteria as written.[19][6]
File within 365 days. Provider Manual Chapter 5: “To be considered for payment, claims must be submitted within 365 days from the date of service,” and “A member cannot be billed by a provider for failure to submit a claim to CareFirst within the guidelines.” If a claim is rejected as late but you can prove timely submission, a timely-filing reconsideration “must be received within six months of the provider receiving the original rejection” notice. For electronic claims the proof is a clearinghouse confirmation that CareFirst accepted the claim, and “Error records are not acceptable documentation.”[7][20][22]
A denied claim takes one of three routes. A coding or data error gets a corrected claim: electronically in the 837P, or on paper with “Corrected Claim” written at the top. Allow 30 days for reprocessing, and do not send a corrected claim with a Provider Inquiry Resolution Form (PIRF). A payment question (why a claim processed the way it did) is an inquiry: file it through CareFirst Direct’s IASH function, or on the PIRF, “within 180 days or six months from the date of the EOB.” Denials for enrollment, copay or deductible, missing prior authorization and claims payment go to Provider Services at 800-842-5975. A denial on medical necessity, setting or level of care is an appeal: send a letter on your letterhead within 180 days of the EOB or denial notice, with the clinical rationale, the claim number, the dates of service and the supporting records (treatment plans and progress notes). Professional appeals go to Mail Administrator, P.O. Box 14114, Lexington, KY 40512-4114. Allow 30 days for a written decision; the Maryland appeals line is 800-854-5256. Before that, a pre-service medical-necessity denial can go to a peer-to-peer call with a CareFirst medical director at 410-528-7041. After five days from the denial, file an appeal instead.[7][20][22]
On a fully insured Maryland contract, state law sets the payment clock. Insurance § 15-1005 requires the carrier, within 30 days of receiving a claim, either to pay it or to send a notice saying what is denied, what is disputed, or what is missing to make it clean. Interest runs on a clean claim still unpaid after 30 days, at 1.5% a month for days 31–60, 2% for days 61–120 and 2.5% after that. The same section requires at least 180 days to file a claim and at least 90 working days after a denial to appeal it. CareFirst’s 365-day and 180-day windows meet both floors. When CareFirst acts as administrator of a self-funded plan, the section applies only “To the extent consistent with” ERISA.[7][20][22]
EVV: no CareFirst document we read (the medical policy, the habilitative-services procedure, the payment policies or the provider manual chapters) asks for electronic visit verification on ABA. EVV is a federal Medicaid requirement. CMS applies section 1903(l) of the Social Security Act to Maryland’s “home health care services,” not to commercial plans. For a child on CareFirst Community Health Plan Maryland (Medicaid), ABA goes through Carelon, and no Maryland Medicaid ABA document requires EVV either.[7][20][22]
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 Maryland.[5]
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).[5]
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.”[5]
CareFirst publishes no ABA-specific rule on whether an authorization belongs to the clinician or the group. What its own documents show is that authorizations and claims are keyed to NPIs, not to the tax ID. The Utilization Management Outpatient Authorization Request (form SUM7690-1E, October 2026 edition; the portal request in CareFirst Direct asks for the same) identifies a requesting provider by name and NPI and a rendering provider by name and NPI, with a box to tick when they are the same, and has no tax ID field. On the claim, "Your billing and rendering National Provider Identifier (NPI) are required on all claim submissions" (Provider Manual Chapter 5), with the federal tax ID in box 25.[24][7][2]
For ABA the rendering NPI is the supervising BCBA, not the technician: CareFirst does not contract with assistant behavior analysts or registered behavior technicians, and their services are submitted under the supervising licensed BCBA's name and provider number (PP CO 020.01). In practice, then, list the supervising BCBA (or the group, as requesting provider) on the authorization, and bill the claim with the same rendering NPI the authorization names. CareFirst does not say whether an approved authorization carries over when a different BCBA in the same group takes over the case. Before the change, ask CareFirst at 1-866-773-2884 (1-866-PRE-AUTH), or through CareFirst Direct, to update the rendering provider on the authorization.[24][7][2]
Maryland limits how far back a state-regulated carrier can take money back. Under Insurance § 15-1008 a carrier "may only retroactively deny reimbursement during the 6-month period after the date that the carrier paid the health care provider," or 18 months for services subject to coordination of benefits with another carrier, Medicaid or Medicare, and it must give "a written statement specifying the basis for the retroactive denial." A carrier that skips those steps "may not retroactively deny reimbursement or attempt in any manner to retroactively collect reimbursement already paid." The limits do not apply where "the information submitted to the carrier was fraudulent," where the claim was "improperly coded" and the carrier gave the provider its coding guidelines "at least 30 days prior to the date the services ... were rendered," or for duplicate claims. Self-funded employer plans are outside state insurance law; ask the administrator.[26]
The questions that decide whether a family can start with CareFirst BlueCross BlueShield (Maryland), and what they have to bring. Each maps onto something intake should ask on the first call.
A "qualified healthcare provider." Medical Policy 3.01.015 requires a "confirmed diagnosis of autism spectrum disorder (ASD) from a qualified healthcare provider" and does not list which credentials qualify. On a fully insured Maryland contract, COMAR 31.10.39.03 lets the carrier require a comprehensive evaluation by the child's primary care provider or a specialty physician. LCSW: not named. 3.01.015 asks only for a "qualified healthcare provider", and Maryland lets a licensed certified social worker–clinical (LCSW-C) do the "evaluation, diagnosis, and treatment" of biopsychosocial conditions and behavioral health disorders (Health Occ. § 19-101(n)(5)); an LMSW or LCSW-A may formulate a diagnosis only under an LCSW-C's supervision. Ask CareFirst at authorization whether it accepts an LCSW-C diagnosis.[25][1][11]
Medical Policy 3.01.015 sets no age limit. For contracts that follow Maryland mandates, Operating Procedure 8.01.011A covers habilitative services including ABA "for children until the end of the month in which the insured or enrollee turns 19 years of age," with the 25-hour (18 months to 6) and 10-hour (6 to 19) weekly floors. D.C. mandate contracts cover ABA at all ages. Self-funded plans follow their own plan document.[1][9]
Ask the plan: Benefits check (Provider Portal or the number on the card): confirm whether the plan follows Maryland mandates (fully insured Maryland contract) or is self-funded, and any age limit on the habilitative benefit.
Two separate things. First, the product: BlueChoice HMO members need a written PCP referral for office services not rendered by the PCP. A written referral lasts "a maximum of 120 days and limited to three visits," and members with long-term conditions can get a standing referral. BlueChoice Open Access, BlueChoice Advantage and PPO (BluePreferred) members need no specialist referral. Second, the mandate: on a fully insured Maryland contract, COMAR 31.10.39.03 lets the carrier require a prescription with specific treatment goals from the PCP or a specialty physician, plus annual review by that prescriber. CareFirst's documentation list asks for the date of the referring physician's last certification.[5][11][1]
Ask the plan: Read the product off the card (BlueChoice HMO vs. Open Access/Advantage vs. PPO). For BlueChoice HMO, confirm whether ABA falls under a standing referral.
CareFirst's telemedicine billing rules are published, but no ABA code list is. PP CO 200.02 requires modifier GT or 95 for synchronous audio-video, POS 02 (not in the patient's home) or 10 (in the patient's home), and says services by telemedicine "must meet all the coding components of a face-to-face visit." "CareFirst will only cover audio-only calls where mandated by law." For fully insured Maryland members that means E/M codes at in-person rates, not ABA codes. Neither PP CO 200.02 nor Medical Policy 2.01.072A says which of 97151–97158 may be delivered remotely. For a fully insured Maryland policy, Insurance § 15-139 requires coverage "for health care services appropriately delivered through telehealth regardless of the location of the patient," bars excluding a service "solely because it is provided through telehealth," requires reimbursement "on the same basis and at the same rate" as in person, and allows preauthorization only if appropriateness is judged "in the same manner" for both. Self-funded employer plans are outside the statute.[18][2][1]
Ask the plan: CareFirst prior authorization: ask which ABA codes (97151–97158) are approved for telehealth on this member's plan before requesting them with GT/95.
CareFirst's manual says "Request review timelines vary, and are based on applicable NCQA, state and federal requirements." For a fully insured Maryland contract, the state clock is Insurance § 15-10B-06. Initial non-emergency determinations are due "within 2 working days after receipt of the information necessary to make the determination." Requests for additional services within an existing treatment plan are due within 1 working day. If information is missing, CareFirst must say what is needed within 3 calendar days. A determination not made within the time limits "shall be deemed approved." The same section requires acceptance of Maryland's uniform treatment plan form for mental and emotional disorder services. Self-funded plans follow federal rules and the plan document instead.[10][8]
Ask the plan: Confirm funding type on the benefits check. For a self-funded plan, ask CareFirst for that plan's UM decision timeframes.
CareFirst applies COB "whenever a member covered under a CareFirst contract is also eligible for health insurance benefits through another insurance company or Medicare." As primary, it pays per the member's contract. As secondary, its standard method pays the lesser of the balance up to the provider's full charge, or what CareFirst would have paid as primary minus the other carrier's payment. "Claims for secondary benefits must be accompanied by the explanation of benefits from the primary carrier." Group contracts may coordinate differently. Which parent's plan is primary is not set out in the manual.[7]
Ask the plan: Eligibility response in the CareFirst Provider Portal for an other-insurance record. Collect both parents' plans and birth dates at intake and ask CareFirst which is primary.
CareFirst publishes no recency rule for the diagnostic evaluation. The currency requirements that exist sit on the prescription. COMAR 31.10.39.03 lets a carrier require an annual review by the prescribing PCP or specialty physician. CareFirst's treatment-plan documentation asks for the "date of last certification by referring physician." Capture both the evaluation date and the physician's most recent certification date.[1][11]
Ask the plan: CareFirst prior authorization (PAL tool or 1-866-PRE-AUTH): ask whether an evaluation of this age will be accepted, or whether an updated evaluation or physician re-certification is needed.
No instrument is named. Medical Policy 3.01.015 requires a confirmed ASD diagnosis but names no diagnostic tool or score. Its annual-review documentation asks for "a written evaluation that establishes the physical baseline data utilizing objective tests and measurements, where possible."[1]
Ask the plan: CareFirst prior authorization (1-866-PRE-AUTH): ask whether a specific instrument is expected behind the diagnosis before scheduling testing.
Coverage decides whether CareFirst BlueCross BlueShield (Maryland) 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 rule is about who supervises and bills, not a numeric ratio. PP CO 020.01: services by assistant behavior analysts or registered behavior technicians are "eligible for reimbursement when rendered under the supervision of a physician or licensed board-certified behavior analyst as required by local licensing agencies and submitted under that supervising physician's or licensed board-certified behavior analyst's name and provider number." CareFirst credentials the licensed BCBA (Maryland and Virginia) but not the technician. CareFirst publishes no supervision-hours ratio. The ratio you work to is the BACB's and Maryland licensure's, not a CareFirst figure: COMAR 10.58.16.14 requires a licensee to “comply with the Behavior Analyst Certification Board requirements regarding supervision of supervisees.” On the technician’s credential, Maryland licensure recognizes an uncertified “paraprofessional” working under a licensed behavior analyst (COMAR 10.58.16.02), but CareFirst’s payment policy names only assistant behavior analysts and registered behavior technicians. Confirm with CareFirst before billing a technician who is not an RBT.[2][6][14][16]
CareFirst’s code-pair rule is the CMS NCCI table. PP CO 090.01 applies NCCI procedure-to-procedure edits to professional claims: when both codes of an edit pair are billed for the same member on the same date, the column-two code is denied unless a clinically appropriate modifier is reported. In the current CMS practitioner PTP table (October 2026, v32.3), the only edit between two ABA codes is 0362T (column one) with 97152 (column two), and it allows a modifier. There is no NCCI edit between 97153 and 97155, or between 97153 and 97156. The pairs that do deny are ABA codes billed by the same provider on the same date as psychotherapy or evaluation codes: 90791, the 90832–90838 psychotherapy codes, 96112, the 96130–96139 testing codes and 96156–96159 are paired with the ABA codes at modifier indicator 0, so no modifier can unbundle them. E/M visits such as 99213 pair with the ABA codes too, but at indicator 1, so a modifier can override. Neither CareFirst’s medical policy nor its payment policies add a same-clock-time rule of their own for 97153 and 97155.[2][21]
CareFirst applies the CMS Medically Unlikely Edits to professional claims. PP CO 090.01 defines an MUE as "the maximum number of units to be reported for a code by the same provider/supplier for the same member on the same date of service," and says distinct-service modifiers "should not be included to bypass an MUE." CareFirst publishes no ABA-specific unit table of its own. The per-code daily ceilings are the CMS practitioner MUE values, and the authorization sets the hours.[2]
Under the supervising licensed BCBA. PP CO 020.01: technician and assistant-behavior-analyst services are "submitted under that supervising physician's or licensed board-certified behavior analyst's name and provider number"; "services rendered do not require additional modifiers to distinguish between provider types," and "allowances will be based on the fee schedule for the supervising physician or licensed board-certified behavior analyst." A BCBA's allowance is 75% of CareFirst's base physician fee schedule. Operating Procedure 8.01.011A asks that habilitative services carry CPT modifier 96 (effective 1/1/2018).[2][1]
Two rules pull against each other, and funding type decides between them. Medical Policy 3.01.015 excludes "diagnostic or treatment services related to learning, curriculum planning, educational achievement or special education programs" as the school system's responsibility under IDEA or a 504 plan. Operating Procedure 8.01.011A, in its D.C. mandate section, says benefits may not be provided to a child under an individualized education program or other IDEA obligation of a public school. For a fully insured Maryland contract, COMAR 31.10.39.03F says a carrier "may not deny payment for habilitative services if a treatment goal identifies the location of the habilitative services as the child's educational setting," though it need not cover services owed under an IEP. Telehealth is billed with POS 02 or 10.[1][1][11]
Ask the plan: Benefits check on the member's plan: confirm funding type, then ask which places of service are payable for ABA and whether a school-setting goal is covered.
No session-note signature rule is published. What CareFirst does publish is the record it can request for annual review: a brief medical history; a written evaluation establishing baseline data; a treatment plan listing diagnosis, short- and long-term goals, procedures, visits per week, estimated duration and the date of last certification by the referring physician; and progress notes documenting improvement or changes. Records requested for billing verification are due within 15 days.[1][2]
Ask the plan: CareFirst provider services: ask who must sign technician session notes (the RBT, the supervising BCBA, or both) and by when, since claims go out under the BCBA.
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 (Anthem), 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 Anthem benefits.
CareFirst’s Provider Manual (Chapter 2): members are responsible for pre-authorization of outpatient services from their own Blue plan, providers can request it on their behalf through 800-676-BLUE or Electronic Provider Access, and all claims go to CareFirst, which is "your sole contact for claims payment, adjustments and issue resolution." FEP is not part of BlueCard.
Yes, for autism spectrum disorder. Medical Policy 3.01.015 covers Adaptive Behavioral Treatment, including ABA, when the child has a confirmed ASD diagnosis from a qualified healthcare provider, treatment is by an appropriately trained, certified or licensed professional, it targets core ASD deficits, and it is expected to produce measurable improvement. On fully insured Maryland contracts the habilitative mandate adds floors of 25 hrs/week (18 months–5) and 10 hrs/week (6–18).
No CareFirst document requires it, but none promises to pay without it either. CareFirst does not credential technicians at all. Payment Policy PP CO 020.01 says it does not contract directly with assistant behavior analysts or registered behavior technicians, and pays for their services when rendered under the supervision of a licensed BCBA "as required by local licensing agencies" and billed under that BCBA's name and provider number. Maryland's licensing rules (COMAR 10.58.16.02) allow an uncertified "paraprofessional" to practice under a licensed behavior analyst, a person who "may be a registered behavior technician." CareFirst's policy names only RBTs and assistant behavior analysts, so RBT certification is the safe standard. Confirm with CareFirst before billing a technician who is not an RBT.
CareFirst's public documents do not say. Medical Policy 3.01.015, the habilitative-services procedure 8.01.011A and the provider manual chapters we searched (3, 5 and 7) have no rule on changing ABA providers, overlapping authorizations or a required discharge. Ask CareFirst prior authorization (1-866-773-2884) before the new agency submits: will it authorize a second agency's 97151 assessment while another agency holds an active ABA authorization, and does it need the first agency's discharge summary or end date? If the child's card is CareFirst BlueCross BlueShield Community Health Plan Maryland (Medicaid), CareFirst is not the decision-maker: ABA goes through Carelon, and Carelon allows the new agency's initial assessment while the child is still with the current provider, using a Continuity of Care Form plus a parent or guardian note (see the Maryland Medicaid guide).
Yes. Medical Policy 3.01.015 says ABT "must be preauthorized," and Operating Procedure 8.01.011A says ABA services and habilitative diagnoses must be preauthorized. Submit through the CareFirst Provider Portal or 1-866-773-2884, and check the 97151 assessment code in the PAL tool, since the policies do not treat it separately.
Medical Policy 3.01.015, Autism Spectrum Disorder (ASD), effective 3/1/2026, for medical necessity. Medical Policy Operating Procedure 8.01.011A, Habilitative Services (MD and DC Mandates), for the Maryland mandate and its hour floors. Payment Policy PP CO 020.01, Limited Licensed Providers, for how technician services are billed. The old policy 3.01.006 (Pervasive Developmental Disorders) is retired.
CareFirst publishes no ABA fee schedule. PP CO 020.01 says a BCBA is paid 75% of CareFirst's base physician fee schedule, and technician services are allowed at the supervising BCBA's rate. The dollar amounts are in your participating-provider agreement; CareFirst's provider manual says fee schedules for additional codes "can also be obtained via CareFirst Direct," so look up 97153 there or ask CareFirst Provider Service for your fee schedule. Use Maryland Medicaid's published fee schedule as the public benchmark.
No CareFirst document we read requires electronic visit verification for ABA: not the medical policy, the habilitative-services procedure, the payment policies or the provider manual. EVV is a federal Medicaid rule that CMS applies to Maryland’s home health services. Children on CareFirst Community Health Plan Maryland get ABA through Carelon, and Maryland Medicaid’s ABA documents do not require EVV either.
CareFirst uses the CMS NCCI edits (PP CO 090.01). In the October 2026 NCCI practitioner table the only pair between two ABA codes is 0362T with 97152, and a modifier is allowed on it. 97153 with 97155, and 97153 with 97156, are not NCCI pairs. ABA codes billed by the same provider on the same date as 90791, psychotherapy (90832–90838), 96112, psychological testing (96130–96139) or 96156–96159 are denied, and no modifier unbundles them. CareFirst publishes no separate same-clock-time rule.
Match the route to the reason. A coding or data error gets a corrected claim (837P, or “Corrected Claim” on paper; allow 30 days). A payment question is an inquiry through CareFirst Direct (IASH) or the PIRF, within 180 days of the EOB. Enrollment, cost-share, prior-authorization and payment denials go to Provider Services at 800-842-5975. A medical-necessity denial is an appeal: a letter on your letterhead within 180 days of the EOB or denial, with clinical records, mailed to P.O. Box 14114, Lexington, KY 40512-4114. Decisions come in about 30 days. For a pre-service denial, ask for a peer-to-peer at 410-528-7041 within five days. A claim rejected as late needs a timely-filing reconsideration within six months, with proof that CareFirst accepted the original.
365 days from the date of service (Provider Manual Chapter 5). Maryland law (Insurance § 15-1005) sets a 180-day minimum for fully insured plans, so CareFirst’s window is longer. The same statute requires payment, or a written notice of what is wrong, within 30 days of receipt, with interest on clean claims still unpaid after 30 days.
The supervising licensed BCBA. Payment Policy PP CO 020.01: technician and assistant-behavior-analyst services are “submitted under that supervising physician’s or licensed board-certified behavior analyst’s name and provider number,” with no extra modifier for the provider type, and are allowed at the supervising BCBA’s fee schedule. CareFirst does not contract with RBTs or BCaBAs directly.
Maryland requires a Maryland license to practice behavior analysis (Health Occupations § 17-6A-10). CareFirst credentials only practitioners “licensed in the state where the member receives the service” and within its Maryland, D.C. and Northern Virginia service area.
To NPIs. CareFirst's outpatient authorization request names a requesting provider NPI and a rendering provider NPI and has no tax ID field, and every claim must carry the billing and rendering NPI. For ABA the rendering NPI is the supervising licensed BCBA, because technician and BCaBA services bill under that BCBA's name and provider number (PP CO 020.01). CareFirst publishes no rule on moving an authorization to another BCBA in the same group, so call 1-866-773-2884 to update the rendering provider before a change in supervisor.
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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