CDPHP — Capital District Physicians' Health Plan, Inc., covering 80,854 Medicaid Managed Care members per the state's July 2026 enrollment report — runs its NY Medicaid ABA benefit through its own "Medicaid–Select Plan" and "Medicaid–HARP" products, with behavioral health managed entirely in-house through an internal Behavioral Health Access Center rather than an outside BH vendor. CDPHP's Provider Office Administrative Manual (POAM) names the ABA CPT codes directly and states the benefit carries no annual maximum, which is more than several plans in this directory publish — but the manual repeatedly defers the actual prior-authorization mechanics and code-level limits to a "Prior Authorization Guideline" document that sits behind the secure provider-portal login, so this guide covers what CDPHP states plainly and flags what to confirm before booking.
CDPHP's Provider Office Administrative Manual, Section 18 (Behavioral Health), names the ABA benefit directly: "Applied behavior analysis — Coverage is not subject to a maximum benefit and the individual is covered until the services are no longer medically necessary." It lists the CPT codes in scope — 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158 — and requires that "ABA services must be provided by or supervised by a NYS-licensed, board-certified behavior analyst (BCBA/BCBA-D)," noting CDPHP maintains a credentialed ABA provider network. For the operational detail — code-level prior-authorization requirements, unit or session limits, and documentation specifics — the manual repeatedly points providers to "the complete policy by logging in securely at provider.cdphp.com," so those specifics aren't independently confirmable from public materials.[1]
CDPHP's general behavioral-health rule is that no authorization is required for outpatient mental health or substance-use-disorder treatment by participating psychiatrists, psychiatric NPs, psychologists, LMSWs, and mental health counselors — but "certain behavioral health services in Medicaid–Select Plan and Medicaid–HARP require prior authorization by calling the Behavioral Health Access Center," with the complete list held in the secure-portal "Prior Authorization Guideline" document. Nothing in CDPHP's public materials confirms whether the ABA assessment (97151) is treated under that general no-PA rule or is one of the "certain services" requiring authorization, nor whether the treatment codes carry unit caps. Route ABA authorization questions to the Behavioral Health Access Center directly, and get the answer in writing per case before scheduling.[1][2][6]
What a reauthorization must show. CDPHP publishes no reauthorization packet or progress-data rule of its own in the documents we checked, so the state’s floor is the reference: the eMedNY ABA manual requires the treatment plan to be updated “at least every 6 months or as needed” with “updated goals and data,” each goal carrying “baseline data reported in objective terms” and “current data expressed by the same data collection method as the baseline data so that progress can be measured.” The state does not require graphs; ask the plan whether it wants graphed data before the first concurrent review.[1][2][6]
CDPHP has no published ABA-specific telehealth billing policy (place-of-service code, modifier, or reimbursement parity) in any document we could access; its behavioral-health provider resources instead link out to the American Telemedicine Association's 2017 "Practice Guidelines for Telemental Health with Children and Adolescents" — a third-party clinical-practice standard, not a CDPHP coverage commitment. On claims: CDPHP's Claim Submission manual repeatedly references a filing deadline "within established filing limits" without stating the specific day count in the sections we could access, so confirm the exact timely-filing window with Provider Services; claim disputes use a "Provider Review Form" filed within 6 months of the claim's adjudication date, mailed to CDPHP Provider Services, 6 Wellness Way, Latham, NY 12110.[4][3]
CDPHP sets its own filing limit in its provider agreement and manual; New York law sets the floor. Ins. Law § 3224-a, which covers New York insurers, Article 43 corporations and Article 44 HMOs, requires claims to be submitted within 120 days of the date of service unless the contract is more favorable to the provider — and for Medicaid managed care contracts lets the parties agree on a different period "but in no event less than ninety days." Undisputed claims must be paid within 30 days of receipt when submitted electronically and 45 days on paper, with interest at the greater of the corporate-tax rate or 12% per annum when paid late.[12][13][3][7][1][8]
Electronic Visit Verification does not reach ABA: the Department of Health’s EVV list for fee-for-service and managed care Medicaid covers personal care and home health care codes (CDPAP, home care, HCBS habilitation and respite) and no ABA code (97151–97158).[12][13][3][7][1][8]
What CDPHP’s Claim Submission section does say about corrections and payment: rejected claims “must be corrected and can be resubmitted electronically in their entirety as long as they are within the timely filing requirements”; “Requests for claims adjustments or review must be received by CDPHP within six months of the adjudication date”; and providers should “check your CDPHP payment vouchers weekly to determine the claim status” and not resubmit a claim that has appeared, which signals a weekly remittance. No day-count filing limit, payment day or submission cut-off is stated in the section.[12][13][3][7][1][8]
For Medicaid managed care specifically, the state’s model contract adds a payment rule: the plan “shall make payments to Participating Providers and to Non-Participating Providers, as applicable, for items and services covered under this Agreement on a timely basis, consistent with the claims payment procedures described in SIL § 3224-a,” and must comply with 42 CFR 447.45(d)(5) and (6).[12][13][3][7][1][8]
Code set: CDPHP’s Behavioral Health manual section lists ABA under CPT 97151–97158, with no Category III or HCPCS H-code. For a Medicaid member, the state baseline is narrower still: New York Medicaid’s ABA fee schedule (effective October 1, 2026) and the eMedNY manual’s billing table carry only CPT 97151–97158 — no 0362T or 0373T and no HCPCS H-code (H0031, H0032, H2019, H2014).[12][13][3][7][1][8]
The questions that decide whether a family can start with CDPHP (NY Medicaid), and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the New York Medicaid rule: ABA is covered for members “under 21 years of age with a diagnosis of Autism Spectrum Disorder (ASD) as defined by… (DSM-5) and/or Rett Syndrome.” No minimum age and no adult pathway — the 21st birthday is a hard cliff. CDPHP’s Provider Office Administrative Manual names ABA as a covered Medicaid–Select Plan and Medicaid–HARP benefit without setting an age of its own, and adds that “coverage is not subject to a maximum benefit and the individual is covered until the services are no longer medically necessary.”[6][1]
Follows the New York Medicaid rule — the two-year referral is the clock and no maximum age is set on the diagnostic evaluation. CDPHP publishes no recency rule of its own; its manual defers documentation specifics to a “Prior Authorization Guideline” document behind the secure provider-portal login.[6][1]
Ask the plan: The secure Prior Authorization Guideline at provider.cdphp.com, or the CDPHP Behavioral Health Access Center (518-641-3600 / 1-888-320-9584).
Follows the New York Medicaid rule: the diagnosis and referral must come from a NYS-licensed, NYS Medicaid-enrolled physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner or physician assistant, following DSM-5 criteria and NYSDOH’s Clinical Practice Guideline on ASD. LBAs and CBAAs sit outside that list — they may not diagnose and may not self-refer. CDPHP names a delivery credential rather than a diagnostic one: “ABA services must be provided by or supervised by a NYS-licensed, board-certified behavior analyst (BCBA/BCBA-D),” with a credentialed ABA provider network maintained.[6][1]
Follows the New York Medicaid rule: no instrument is mandated. What the state requires with the referral is the “DSM-5 Diagnostic Checklist for ASD diagnoses” plus the severity level when the referral comes from an ASD-diagnosing provider; the treatment plan need only record the assessment methodology used and, “as appropriate, identify standardized assessment used (e.g., adaptive behavior scales, symptom inventories, aggression ratings) and results.” No CDPHP-specific instrument requirement is published; documentation specifics sit behind the secure-portal Prior Authorization Guideline.[6][1]
Ask the plan: The secure Prior Authorization Guideline at provider.cdphp.com, or the Behavioral Health Access Center.
Follows the New York Medicaid rule: the member “must be referred for ABA services by a NYS-licensed and NYS Medicaid-enrolled physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner, or physician assistant,” the referral is “valid for no more than two years,” and it must carry age, the ASD/Rett diagnosis, date of initial diagnosis, co-morbid diagnoses, symptom severity level, a statement the patient needs ABA, and the DSM-5 Diagnostic Checklist. CDPHP’s own authorization posture is genuinely ambiguous from public materials: outpatient mental health and substance-use treatment by participating psychiatrists, psychiatric NPs, psychologists, LMSWs and mental health counselors needs no authorization, but “certain behavioral health services in Medicaid–Select Plan and Medicaid–HARP require prior authorization by calling the Behavioral Health Access Center,” with the list held in the secure-portal Prior Authorization Guideline. Nothing published confirms whether the ABA codes are among them.[6][1][2]
Ask the plan: The CDPHP Behavioral Health Access Center (518-641-3600 / 1-888-320-9584) — confirm per case in writing whether 97151 and the treatment codes require PA.
The NYS Medicaid Telehealth Policy Manual (Version 2026-V2, July 2026) applies to services delivered “under contracted Medicaid Managed Care (MMC) Plans,” lists “Providers licensed or certified by the New York State Education Department (NYSED) to provide Applied Behavioral Analysis (ABA) therapy” among telehealth providers, and requires that “Providers must meet all elements of the procedure code via telehealth.” Its managed-care section says plans “are required to cover, at a minimum, services that are covered by NYS Medicaid FFS and included in the MMC benefit package… and must provide telehealth coverage as described in this guidance,” must “ensure claims allow the use of the telehealth modifiers in this guidance” and “may establish additional claiming requirements.” Billing baseline: modifier 95 or GT for audio-video; place of service 02 (not the home), 10 (the member’s home) or 11 where the in-person visit would be POS 11; payment parity with in-person until April 1, 2028. A code defined as face-to-face with the patient (97152, 97153) qualifies only if every element can be met by video. The state ABA manual separately allows LBA supervision of technicians by synchronous audio-video, but the two monthly supervision contacts must be real time and never by phone, email or text. CDPHP publishes no ABA telehealth rule of its own: its Behavioral Health and Government Programs manual sections carry no ABA telehealth, modifier or place-of-service provision, and its only telehealth resource is a hosted copy of the American Telemedicine Association’s 2017 telemental-health guideline, a clinical standard rather than a coverage rule. So, for CDPHP Medicaid members, the state rule above governs. Neither the state manuals nor the plan say whether the authorization itself must flag telehealth — state the delivery mode in the treatment plan and ask at authorization.[9][6][1][10][4]
CDPHP’s provider manual publishes no Medicaid decision clock of its own: it says CDPHP “complies with all specific time frames for decision making and notification under the law” and points to “established timeframes in the Medicaid Managed Care Model Contract.” That contract governs: a standard prior authorization is decided “within three (3) business days of receipt of necessary information, but no more than fourteen (14) days after receipt”; expedited within 72 hours; a concurrent request (reauth or more units) within one business day of the necessary information; each extendable up to 14 days. Federal rules cap the standard decision at 7 calendar days for plan rating periods starting on or after January 1, 2026. No ABA reauth lead time is published in the public manual; CDPHP’s full ABA policy sits behind the provider login.[2][10][7][14]
“If CDPHP is secondary, the provider must wait for the explanation of benefits (EOB) from the primary carrier first before billing CDPHP,” then “submit a duplicate claim with the total amount billed (just as if CDPHP were the only insurance company) with the primary carrier’s explanation of benefits (EOB) attached.” A claim with no EOB when CDPHP has another carrier on file denies automatically (“RPC” — check the secure provider site for the primary carrier). For a Medicaid member this sits on the state rule that Medicaid pays last and providers “must bill all applicable insurance sources before submitting claims to Medicaid.” The COB section (revised January 2020) does not say whether CDPHP’s ABA authorization is still required when it is secondary — ask the Behavioral Health Access Center (518-641-3600).[15][16]
Coverage decides whether CDPHP (NY Medicaid) 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.
CDPHP states the credential — “ABA services must be provided by or supervised by a NYS-licensed, board-certified behavior analyst (BCBA/BCBA-D)” — but publishes no ratio. The numbers come from the state and apply to managed care alike: 5% of each unlicensed individual’s monthly service hours supervised, at least two face-to-face real-time contacts per month with one observation of service delivery, and no more than six CBAAs/unlicensed individuals per LBA.[1][6]
No annual maximum — “coverage is not subject to a maximum benefit and the individual is covered until the services are no longer medically necessary” — but that does not rule out per-authorization unit limits, which sit behind the secure-portal Prior Authorization Guideline along with the code-level PA requirements. Confirm before assuming unlimited units.[1]
Ask the plan: The secure Prior Authorization Guideline at provider.cdphp.com, or the Behavioral Health Access Center — confirm per-authorization unit limits.
Follows the New York Medicaid rule: the LBA supervisor must “review and sign treatment notes and reports prepared by the CBAA supervisee,” and documentation of supervision itself “should be recorded in the patient file.” Clinical documentation must carry the treatment plan with assessment and goals, the goal data, total hours of service per week by who delivered them, and the location(s) of services. Records are kept “for a minimum of six years and, for minors, until the patient turns 22 years of age.” CDPHP publishes no additional session-note signature rule; its documentation specifics are deferred to the secure provider portal.[6][1]
Follows the New York Medicaid rule: “LBAs and CBAAs may work in any legally authorized setting. Examples of such settings include private practice, settings where patients/clients reside full-time or part-time, clinics, hospitals, residences, and community settings” — but “NYS Medicaid does not reimburse for ABA services in a school setting.” The treatment plan must record the location(s) of services. CDPHP publishes no setting rule of its own; the state’s school bar is the operative constraint.[6][1]
Not published. CDPHP’s manual names the ABA codes in scope (97151–97158) but defers code-level rules to the secure-portal Prior Authorization Guideline, and the state manual is silent on 97153 with 97155.[1][6]
Ask the plan: The CDPHP Behavioral Health Access Center (518-641-3600 / 1-888-320-9584) and the secure Prior Authorization Guideline at provider.cdphp.com.
Not published as a claim convention. CDPHP requires ABA to be provided or supervised by a NYS-licensed BCBA/BCBA-D within its credentialed network, but names no rendering-versus-supervising NPI rule, and its Claim Submission manual references a filing deadline “within established filing limits” without stating the day count in the sections we could access. At the fee-for-service layer New York is explicit: LBAs bill “using the LBA’s National Provider Identification (NPI) number for the ‘Billing’ provider and/or ‘Supervising’ provider,” with “the NPI number of the CBAA that provided the ABA service… reported as the ‘Rendering’ provider on each claim”; for unlicensed aides and LBA limited-permit holders the supervising LBA’s NPI fills all three roles. CBAAs cannot bill directly and enroll as OPRA providers.[1][6]
Ask the plan: CDPHP Provider Services (518-641-3500 / 1-800-926-7526) — confirm the rendering/supervising NPI convention and the exact timely-filing window.
Yes — CDPHP's Provider Office Administrative Manual names ABA (CPT 97151–97158) as a covered Medicaid–Select Plan and Medicaid–HARP benefit with no maximum benefit limit, provided or supervised by a NYS-licensed BCBA/BCBA-D.
Not confirmed from public materials — CDPHP states that "certain" behavioral health services in its Medicaid lines require prior authorization via the Behavioral Health Access Center, but doesn't specify whether ABA codes are among them. Confirm per case at 518-641-3600 / 1-888-320-9584.
CDPHP's manual states the benefit "is not subject to a maximum benefit," but doesn't rule out per-authorization unit limits, which sit behind the secure-portal Prior Authorization Guideline — confirm before assuming unlimited units.
Six at a time. New York Medicaid, which applies the rule to fee-for-service and managed care alike, says an LBA "can supervise no more than six CBAAs/unlicensed individuals at a time," must supervise each for at least 5% of their monthly service hours, and must hold at least two face-to-face real-time contacts a month, observing service delivery in one. In New York the supervisor must be a NYSED-licensed behavior analyst; BCBA certification alone is not a license.
Your contract sets it, but New York Ins. Law § 3224-a bars a Medicaid managed care contract from setting less than 90 days from the date of service (120 days is the default without a contract term). Clean electronic claims must be paid within 30 days, paper within 45.
No. CDPHP’s Behavioral Health manual lists ABA under CPT 97151–97158 only.
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.
Carelu collects all of this automatically.
Every ID, document, and detail this payer requires — gathered conversationally the moment a family reaches out, with insurance verified before your team touches the file.
Get a Demo