Carelon Health of Pennsylvania (formerly Beacon Health Options / Value Behavioral Health of PA) is the HealthChoices behavioral health managed care organization for Medicaid members in Armstrong, Beaver, Butler, Crawford, Fayette, Indiana, Lawrence, Mercer, Venango, Washington and Westmoreland counties. As everywhere in Pennsylvania Medicaid, ABA is the ABA category of Intensive Behavioral Health Services (IBHS): for anyone under 21 with a behavioral health diagnosis, started by a written order.
Carelon’s IBHS policy CN.48 (DHS-approved 9/26/2024) is explicit on the funnel question: "The assessment does not require a prior authorization process however treatment does require a prior authorization process." Treatment is requested through ProviderConnect with a full IBHS packet — including Carelon’s Act 62 cover sheet whenever the child has an autism diagnosis — and approved for up to 180 days.
From a licensed practitioner with an active PROMISe ID, face-to-face, within 12 months of initiation, naming a DSM/ICD behavioral health diagnosis, clinical support, maximum hours of each service per month, settings and measurable discharge markers. In-network order writers submit the order to Carelon and the county through ProviderConnect within 7 business days.[1][3][2]
Up to 92 units (23 hours); ABA assessments completed within 30 calendar days of initiation, face-to-face and across settings, with a signed Service Delivery Schedule.[1][3][2]
Within 45 calendar days of initiation for ABA; exact hours per setting; signed by the youth or parent and a clinical-director-qualified reviewer; updated every 180 days.[1][3][2]
Through ProviderConnect within 45 days of the first assessment day for ABA: written order, assessment, tool results (e.g., CANS), signed Service Delivery Schedule, ITP, Act 62 cover sheet if ASD, and the Family Choice/Confirmation Form. An abbreviated packet (order, initial treatment plan, Act 62 sheet, family choice form) is allowed when treatment must start during the assessment.[1][3][2]
Carelon’s HealthChoices Covered Services Grid (PV 07/22/2026) is the claims source of truth: IBHS ABA codes are billed by PROMISe provider type 11, specialty 592 with "Auth Req? Y" for 97151 (BC-ABA; U7 for behavior analytic), 97152/97153 (BHT-ABA; U8 for assistant BC-ABA), 97155 and 97156 — while the assessment service class billed as 97151 AO or AP carries "Auth Req? N". Permitted places of service for 97151/97153/97155 are 02, 03, 10, 11, 12 and 99 (97156 omits 03), with FQ audio-only variants on POS 02/10.[5][12]
Carelon’s March 2026 IBHS summit reminded providers that BHT-ABA is not a stand-alone service — it must be overseen by BC-ABA or BA — that services requested must be on the written order, and that the requested start date for an initial cannot precede the family’s ITP signature.[5][12]
Carelon’s Act 62 FAQ: a child is Act 62 eligible with an ASD diagnosis and primary insurance; the Act 62 cover sheet goes with every new authorization request (only the top portion if there is no primary). When the primary covers autism services, Carelon issues an acknowledgement letter that services are covered under Act 62 and "will be reviewed for Medical Necessity once the primary insurance benefit has been met"; no Carelon authorization is needed when only copays, coinsurance or deductibles are billed. If the primary has no Act 62 coverage, send proof (EOB, determination letter, or an employer letter that the group has fewer than 50 employees or excludes autism) to the Claims Liaison Team; Navinet printouts are not accepted.[6][7][8][5]
Carelon "is not permitted to pay for services if the provider is not participating with that member’s primary insurance". Timely filing for secondary claims runs 90 days from the primary EOB. One inconsistency to watch: the covered-services grid flags IBHS ABA codes "TPL Exempt: Y", yet the Act 62 FAQ says that for a child with ASD and primary insurance "Carelon will deny the claim and request the primary insurance EOB" — follow the Act 62 process.[6][7][8][5]
Carelon pays under provider agreements; the covered-services grid lists codes, modifiers and places of service but not rates, and no public Carelon PA IBHS fee schedule was found. Confirm rates with your Carelon Provider Field Coordinator.[5]
The questions that decide whether a family can start with Carelon Health of Pennsylvania (HealthChoices BH-MCO; formerly Beacon / Value Behavioral Health), and what they have to bring. Each maps onto something intake should ask on the first call.
Under 21 — CN.48 defines the IBHS population as children (under 14), youth (14–17) and young adults (18 to under 21). No minimum age.[1][20]
What must be current is the written order: written within 12 months of initiation (the first day of assessment at the provider) and valid for twelve months "from the date that it was written and signed by the order writer" (CN.48).[1]
The written order must come from a licensed practitioner with an active PROMISe ID in Pennsylvania (CN.48); Carelon’s packet checklist lists MD, CRNP, PA, licensed psychologist, LPC, LCSW and LMFT as order writers.[1][3]
No named instrument is required behind the diagnosis. CN.48 asks for "Any contractually required or appropriate assessment tool results" in the packet, giving CANS, Child Behavior Checklist, BASC and CAFAS as examples.[1]
A written order is required. In-network order writers submit it to Carelon and the county through ProviderConnect within 7 business days of the face-to-face; Carelon and the county contact the family within 7 business days to link them with a provider, and the order goes to the family’s chosen provider within 2 business days. A provider that cannot fulfil the order must tell the family within 2 business days.[1]
Allowed under OMHSAS-22-02. Carelon discontinued the GT modifier; telehealth is identified "only by Place of Service": POS 10 in the patient’s home, POS 02 elsewhere (Alert 03.26.01, Jan. 2026). The covered-services grid lists 97151, 97153, 97155 and 97156 on POS 02/10, including FQ-modified lines for audio-only.[11][5]
Carelon’s own documents vary: CN.48 says care managers review IBHS requests "within five (5) business days of receipt", and its provider manual says Carelon has "seven (7) calendar days to enter a provider’s authorization". The DHS HealthChoices Appendix AA that binds every BH-MCO is tighter — verbal decision within 2 business days (prospective) or 1 business day (concurrent) of complete information, additional information requested within 48 hours with 14 days to respond, and automatic approval if the member has no written decision within 21 days. Federal floor: 7 calendar days standard / 72 hours expedited (42 CFR 438.210(d)). Continued-stay requests are due at least 10 business days before expiry; retro requests within 45 calendar days of service.[1][10][13][21]
Carelon is the payer of last resort: exhaust other coverage, attach the primary’s EOB with denial reason, file within 90 days of the EOB, and obtain the primary’s own authorization when required. Carelon "is not permitted to pay" if the provider does not participate with the primary. The authorization request (with the Act 62 cover sheet) still goes to Carelon when commercial is primary: for Act 62 cases Carelon issues an acknowledgement that services are covered under Act 62 and reviews medical necessity once the primary benefit is met, and no Carelon authorization is needed when billing only copays, coinsurance or deductibles. Proof of no autism coverage goes to the Claims Liaison Team (EOB, determination letter, or employer letter). TRICARE pays ahead of Medicaid (10 U.S.C. 1079(i)(1)).[6][8][9][7][22]
Coverage decides whether Carelon Health of Pennsylvania (HealthChoices BH-MCO; formerly Beacon / Value Behavioral Health) 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.
Follows the state IBHS rule (CN.48 defers to the IBHS regulations and publishes no separate ratio): 55 Pa. Code § 5240.82 requires 1 hour a month of individual face-to-face supervision for BA/BC-ABA staff (plus a second hour if they supervise assistant BC-ABA or BHT-ABA) and 30 minutes of observation every 6 months; BHT-ABA staff get 1 hour weekly at 37.5+ hours a week, otherwise twice a month, with 1 hour individual face-to-face monthly. Carelon’s March 2026 summit adds that BHT-ABA must be overseen by BC-ABA or BA and "MT shouldn’t be overseeing ABA cases".[15][1][12]
State rule plus Carelon’s standards: 55 Pa. Code § 5240.41 requires each service note to carry the signature of the staff person providing it. Carelon’s treatment-record standards require every entry to include the responsible clinician’s name, professional degree and identification number, dated; CN.48 requires the ITP and every update to be signed and dated by the youth or a parent/guardian and by the staff person who wrote it, and reviewed and signed by a clinical-director-qualified individual. Carelon’s September 2026 alert stresses that documentation must show who participated, when, where and for how long.[15][17][1][18]
Home, school and community. Carelon’s grid permits 97151, 97153 and 97155 at POS 02, 03 (school), 10, 11, 12 and 99, and 97156 at POS 02, 10, 11, 12 and 99 (no 03). The ITP must state exact hours per setting (home, community, school, center), and BHT school hours "should not switch to home setting over breaks from school".[5][12]
The IBHS agency bills — the grid ties every ABA code to PROMISe provider type 11, specialty 592 — with the rendering credential shown by modifier: 97151/97155 U7 for behavior analytic, unmodified for BC-ABA; 97152/97153 U8 for assistant BC-ABA, unmodified for BHT-ABA. All providers must register their NPI with DHS.[5][19]
No per-day unit ceiling is published. Carelon authorizes hours per month per service for up to 180 days; the grid gives each ABA code a 15-minute unit without a daily maximum, and its Billing Guide only bars date-span billing for services valued at more than one unit per day. The state FFS per-day ranges (OMHSAS-21-03) are fee-for-service only.[5][16]
Ask the plan: Your Carelon Health of PA provider agreement or Provider Field Coordinator — confirm whether any per-day unit edit applies to 97153/97155 beyond the authorized monthly hours.
Not published. CN.48, the covered-services grid and the Carelon Billing Guide state no rule on billing 97153 and 97155 for the same clock time.[5][1]
Blocked on: Carelon Health of PA IBHS team (PAIBHS@carelon.com) or your Provider Field Coordinator — ask whether 97155 may be billed for the same minutes as 97153 when the analyst directs the technician, and keep the written answer.
No. Policy CN.48: "The assessment does not require a prior authorization process however treatment does require a prior authorization process." Providers can use up to 92 units (23 hours) for the assessment; the covered-services grid lists the assessment as 97151 with modifier AO or AP and "Auth Req? N".
Up to 180 days. Submit continued-stay requests through ProviderConnect at least 10 business days before the current authorization expires.
No — IBHS ABA is available with any DSM/ICD behavioral health diagnosis on the written order. An autism diagnosis triggers Carelon’s Act 62 cover sheet and primary-insurance process.
Use a provider in the private plan’s network and bill it first. Carelon generates an acknowledgement letter that services are covered under Act 62 and reviews medical necessity once the primary benefit is met; if the provider bills Carelon only for copays, coinsurance or deductibles, no Carelon authorization is required.
Identify telehealth by place of service only — POS 10 in the member’s home, POS 02 elsewhere; Carelon discontinued the GT modifier (Alert 03.26.01, Jan. 2026). The grid lists FQ variants of the ABA codes on POS 02/10 for audio-only.
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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