CareSource is the dominant Ohio Medicaid plan in our data, and its ABA policy (MM-0028, current version effective 9/1/2026 — the prior 7/1/2025 version was archived 8/31/2026) is materially stricter than the state rule: it names which specialties may diagnose, which instruments count, and how many assessment hours are reasonable. As of the 9/1/2026 update, the MUE daily-unit table and the "no documentation, no payment" claims rule now live in a companion reimbursement policy, PY-1638 (same effective date) — the figures are unchanged, they just moved documents. If a family carries CareSource, these two policies are the gate.
Where the state rule accepts any licensed clinician qualified to diagnose autism, MM-0028 restricts the diagnosis to a child/adolescent psychiatrist, psychologist, child neurologist, or developmental pediatrician, using a standardized instrument — ADOS, ADI-R, or CARS-2. If the evaluation is more than 24 months old, a provider letter documenting DSM symptoms within the past year is required. Screening referral packets against these names and instruments at intake prevents the most common CareSource denial.[1]
All ABA services get medical-necessity review at baseline and every 6 months, with continuation requests documenting progress against baseline using the same measurement tools. Behavioral assessments should generally not exceed 6–10 hours per 6-month period without justification. The 9/1/2026 MM-0028 update adds two operational details: a continuation request filed after a temporary break in services (e.g., summer, vacation) must be filed as a continuation, not a new initial request; and progress notes now face more explicit anti-boilerplate requirements — generic, copy-pasted symptom language is no longer sufficient documentation.[1][2][3]
CareSource split its daily-unit and claims-documentation rules out of MM-0028 into a new companion reimbursement policy, PY-1638, effective the same day (9/1/2026) — the prior MM-0028 (eff. 7/1/2025) that carried these rules was archived 8/31/2026. The substance is unchanged, just relocated: daily units still follow the CMS MUE maxima — 97151 at 32, 97153 at 32, 97155 at 24, 97156 at 16 daily units, among others — and the operational standout survives verbatim: treatment records must be submitted to CareSource prior to claim submission — "claims will not be accepted without accompanying treatment documentation." UM runs at (800) 488-0134 via the CareSource Provider Portal.[1][2][3]
Other texture worth knowing: telehealth covers parent training and supervision, with 1:1 ABA via telehealth only when medically necessary under a documented service-delivery plan; and the discontinuation trigger is no meaningful progress across two successive 6-month authorization periods. One rule narrowed in PY-1638: CareSource will no longer reimburse H0036 for ABA whenever a designated ABA CPT code is usable — the older blanket acceptance of H0036 (CPST) billing from certified CBHCs in lieu of ABA CPT codes no longer holds.[1][2][3]
Filing deadline: claims and corrected claims “should be submitted within 365 days of the date of service or discharge.” Payment: unless the provider contract sets another schedule, CareSource must pay or deny 90% of clean claims within 21 calendar days of receipt, 99% within 60 calendar days and 100% of all claims within 90 calendar days.[9][7]
Claim disputes (any provider disagreement with a claim decision): “within 12 months from the date of service or 60 calendar days after the payment, denial or partial denial of a timely claim submission, whichever is later.” Appeals of medical-necessity decisions must be received within 60 calendar days of the denial.[9][7]
EVV does not apply to ABA in Ohio. OAC 5160-32-01 lists the services subject to Ohio’s EVV program — named waiver services in the home care, MyCare, PASSPORT and developmental-disability waivers, plus state-plan home health, private duty nursing and RN assessment and consultation — and makes managed care entities responsible for applying it; ABA is not on the list, and services delivered by telehealth are exempt.[9][7]
Continuation requests are due every six months, and a request after a temporary break (summer, vacation, a change in school hours) must be filed as a continuation, not a new initial request. MM-0028 (effective 9/1/2026) requires either (a) a persisting definitive ASD diagnosis with symptoms that will benefit from treatment in at least two settings, a treatment plan with “an updated progress report with assessment scores that note improvement and member response to treatment from baseline … using the same mode(s) of measurement utilized for baseline measurements” and a plan to step intensity down, and caregivers who are involved and progressing; or (b) where progress was inadequate within six months, the documented reasons and the changes made (techniques, caregiver training, time on targets, barriers, new co-existing disorders, revised goals). Discontinuation follows when there is no meaningful progress across two successive six-month periods on standardized assessments. Neither MM-0028 nor PY-1638 requires graphs — the requirement is comparable assessment scores against baseline — and PY-1638 pays telemedicine “in the same manner and subject to the same limits as in-person” delivery.[1][2]
The questions that decide whether a family can start with CareSource Ohio, and what they have to bring. Each maps onto something intake should ask on the first call.
CareSource sets the clearest recency rule in Ohio: where the diagnostic evaluation is more than 24 months old, a provider letter documenting DSM symptoms within the past year is required. Continuation requests must document progress against baseline using the same measurement tools, and a request filed after a temporary break in services (summer, vacation) must be filed as a continuation, not a new initial request.[4][1][2][1]
Narrower than the state framework: MM-0028 restricts the ASD diagnosis to a child or adolescent psychiatrist, psychologist, child neurologist, or developmental pediatrician — where the state rule accepts any licensed clinician qualified to diagnose autism. Screening referral packets against those four specialties at intake prevents the most common CareSource denial.[4][1][2][1]
MM-0028 requires the diagnosis to rest on a standardized instrument, and names three: ADOS, ADI-R, or CARS-2.[4][1][2][1]
Telehealth covers parent training and supervision. One-to-one ABA by telehealth is allowed only when medically necessary under a documented service-delivery plan.[4][1][2][1]
CareSource’s Ohio Medicaid manual matches the rule: “Standard Pre-Service — 7 calendar days from receipt of the request,” with one extension of up to 14 calendar days for lack of information if the member asks. Urgent pre-service decisions come in “48 hours from receipt of request.” No ABA reauthorization lead time is published in the manual. Ohio’s MCO rule sets the clock. For a standard request the MCO “must provide notice to the provider and member as expeditiously as the member’s health condition requires but no later than seven calendar days following receipt of the request for service,” extendable by up to fourteen calendar days (an MCO-requested extension needs ODM’s prior approval). An expedited decision is due “no later than forty-eight hours after receipt of the request for service” (OAC 5160-26-03.1, effective 1/1/2026). The 48 hours is stricter than the federal 72-hour managed-care cap.[9][10]
CareSource coordinates by subtracting “the primary payment from the lessor of the primary carrier allowable or the Medicaid allowable. If the member’s primary insurer pays a provider equal to or more than CareSource’s fee schedule for a covered service, CareSource will not pay the additional amount.” When CareSource is secondary, submit within 365 calendar days of the date of service. If a claim is denied for missing COB information, send the primary payer’s EOB within the rest of the timely-filing period, or within 90 calendar days of the primary EOB date if that period has passed. The manual does not say whether CareSource’s ABA authorization is still needed when a commercial plan pays first. Ohio’s MCO rule: “The MCE is the payer of last resort when a member has third party resources available.” Providers must “take reasonable measures to obtain all third party payments and file claims with all TPPs prior to billing the MCE.” That means a remittance from the other payer showing a valid non-payment reason (service not covered, applied to the deductible or copay, benefit maximum reached), a partial payment with its remittance, or no response within ninety days of submitting to the other payer. The MCO pays at most its allowed amount minus the other payments, and must allow at least ninety days from the other payer’s remittance to file. Exception: “The MCE, except SPBM, pays first for preventive pediatric services before seeking reimbursement from any liable third party.” Children in the custody of a county children’s services agency are exempt from TPL cooperation (OAC 5160-26-09.1).[9][11]
Ask the plan: CareSource Provider Services: whether a CareSource ABA authorization is required when a commercial plan pays first.
Follows the Ohio Medicaid framework, which publishes no verifiable age bound for ABA; under-21 members carry EPSDT protections through the MCO. codes.ohio.gov now returns “No Ohio Administrative Code rule number corresponds to ‘5160-34’” (re-confirmed 10/1/2026) rather than refusing the connection, and the chapter remains absent from the Title 5160 index, so no in-force rule text exists to read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Per ODM’s 7/30/2026 provider stakeholder presentation, the rewrite was paused in 2025 for reevaluation (budget pressure, national ABA-spend scrutiny, other-state audit findings) and the draft (ERF188422B) still carries a “DRAFT — NOT FOR FILING” header and no JCARR filing, so draft content does not govern.[4][1][2]
Blocked on: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
No referral or physician order appears in CareSource's own ABA policy. OH MCD-MM-0028 (eff. 9/1/2026), read in full, lists what initiation needs: a definitive primary ASD diagnosis from a child and adolescent psychiatrist, psychologist, child neurologist or developmental pediatrician; ADOS, ADI-R or CARS-2 results; and, if the evaluation is over 24 months old, a provider letter on DSM symptoms in the past year. It names no ordering or referring practitioner, no order form and no validity period. Ohio's ordering requirement (psychologist trained in autism, developmental pediatrician, or pediatric CNS/CNP) is in the commercial mandate at R.C. 3923.84, not Medicaid, and the in-force Medicaid ABA rule text could not be read. So whether CareSource will ask for a referral is a question for the plan. Ask its behavioral health UM line before the first request whether a PCP or diagnosing-provider referral must be attached.[1][4]
Ask the plan: CareSource Ohio behavioral health utilization management (provider portal or the number on the member ID card): "Do you require a referral or physician order for ABA, and from whom?" Rules@Medicaid.Ohio.gov or JCARR for the in-force OAC 5160-34-02.
Coverage decides whether CareSource Ohio 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 Ohio framework (OAC 4783-6-02: a written supervision plan in each client’s treatment plan, consultation before initiation and modification, periodic direct observation, no fixed ratio). CareSource’s own addition is on records: supervision records must be retained 5 years for COBAs or 7 years for BCBAs and RBTs after supervision ends, and claims tied to documentation discrepancies are subject to recoupment.[4][1][2][1][5]
CareSource publishes real per-day maxima, moved from MM-0028 into companion reimbursement policy PY-1638 effective 9/1/2026 with the figures unchanged: daily units follow the CMS MUE maxima — 97151 at 32, 97153 at 32, 97155 at 24 and 97156 at 16 daily units, among others. Behavioral assessments should generally not exceed 6–10 hours per 6-month period without justification, and all ABA carries medical-necessity review at baseline and every 6 months, with discontinuation triggered by no meaningful progress across two successive 6-month authorization periods.[4][1][2][2]
The operational standout in Ohio: treatment records must be submitted to CareSource prior to claim submission — "claims will not be accepted without accompanying treatment documentation." MM-0028 adds explicit anti-boilerplate requirements on progress notes: generic, copy-pasted symptom language is no longer sufficient documentation.[4][1][2][2][1]
Follows the Ohio Medicaid framework (COBA or BACB BCBA/BCBA-D as the independent practitioner, ODM Provider Type 19 Specialty 190, BCaBAs and RBTs under supervision; OhioRISE never pays ABA). One rule narrowed in PY-1638: CareSource will no longer reimburse H0036 for ABA whenever a designated ABA CPT code is usable, so the older blanket acceptance of H0036 (CPST) billing from certified CBHCs in lieu of ABA CPT codes no longer holds.[4][1][2][2][6]
Not resolved. No state-level rule on billing 97153 and 97155 for the same clock time could be verified, and this plan publishes none. codes.ohio.gov now returns “No Ohio Administrative Code rule number corresponds to ‘5160-34’” (re-confirmed 10/1/2026) rather than refusing the connection, and the chapter remains absent from the Title 5160 index, so no in-force rule text exists to read — confirm with Rules@Medicaid.Ohio.gov or JCARR. Per ODM’s 7/30/2026 provider stakeholder presentation, the rewrite was paused in 2025 for reevaluation (budget pressure, national ABA-spend scrutiny, other-state audit findings) and the draft (ERF188422B) still carries a “DRAFT — NOT FOR FILING” header and no JCARR filing, so draft content does not govern.[4][1][2]
Blocked on: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
No plan-specific place-of-service rule found. The confirmed Ohio boundary is the school one: the MCO is not responsible for payment of services provided through the Medicaid School Program under OAC Chapter 5160-35, 5160-35-04 and 5160-26-03.[4][1][2]
Ask the plan: This plan’s provider portal or behavioral health UM line; Rules@Medicaid.Ohio.gov or JCARR for the in-force text of OAC 5160-34-02.
Yes — under policy MM-0028 (eff. 9/1/2026) plus its companion reimbursement policy PY-1638, with medical-necessity review on all ABA at baseline and every 6 months. Its requirements are stricter than the state rule on diagnostician specialty, instruments, and documentation.
A child/adolescent psychiatrist, psychologist, child neurologist, or developmental pediatrician, using ADOS, ADI-R, or CARS-2 — narrower than the state baseline.
A distinctive rule, now sited in reimbursement policy PY-1638: treatment documentation must be submitted before claims. Claims without accompanying treatment records are not accepted — check the documentation pipeline first.
Not as a blanket rule anymore. As of PY-1638 (eff. 9/1/2026), CareSource will not reimburse H0036 for ABA when a designated ABA CPT code is usable — confirm which code applies before billing.
365 days from the date of service; claim disputes within 12 months of the date of service or 60 calendar days after the payment or denial, whichever is later (CareSource Ohio provider manual).
Under OH MCD-MM-0028 (eff. 9/1/2026): a definitive primary ASD diagnosis from a child and adolescent psychiatrist, psychologist, child neurologist or developmental pediatrician, with ADOS, ADI-R or CARS-2 results. If the evaluation is more than 24 months old, add a provider letter describing DSM symptoms present in the past year. Then a BCBA behavior assessment (generally 6 to 10 hours per six months). The initial treatment plan must be signed by the parent or guardian and the BCBA and include biopsychosocial history, medications and prescriber, school hours with any IEP or 504 plan (required for consideration), prior ABA history and all behavioral health diagnoses. Medical necessity is reviewed at the start and every six months.
No graph requirement appears in MM-0028 or PY-1638. Every six months the continuation needs an updated progress report with assessment scores showing change from baseline using the same measures, a plan to step intensity down, and evidence of caregiver involvement — or, if progress stalled, the reasons and the treatment changes.
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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