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]
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. Whether a claim for an uncertified technician would be paid is not stated anywhere. Treat RBT certification as the safe standard and confirm with CareFirst before billing uncertified staff.[2][6][11][1]
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]
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][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][13]
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.[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.[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.[2][6]
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.
Not published for ABA. CareFirst applies CMS NCCI procedure-to-procedure edits to professional claims (PP CO 090.01). 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. Neither the medical policy nor the payment policies say whether 97155 may be billed alongside 97153 for the same clock time.[2]
Ask the plan: CareFirst provider services or the Provider Portal: ask whether 97155 pays when billed for the same clock time as 97153 on this member's plan, and whether an NCCI edit applies to the pair.
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, 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).
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. Their services are paid 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. CareFirst's documents do not state a separate certification rule for technicians, so RBT certification is the safe standard. Confirm with CareFirst before billing uncertified staff.
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. Use Maryland Medicaid's published fee schedule as the public benchmark.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 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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