In Pennsylvania Medicaid, ABA is not a stand-alone benefit: it is delivered as Intensive Behavioral Health Services (IBHS) under 55 Pa. Code Chapters 1155 and 5240, and in HealthChoices it is paid by the county’s behavioral health managed care organization, not by the child’s physical-health plan. Community Care Behavioral Health Organization (Community Care), part of the UPMC Insurance Services Division, is that BH-MCO in 41 counties, including Allegheny, Berks, Chester, Delaware, Erie, Lackawanna, Luzerne and York.
Community Care splits IBHS approval in two. The written order and the assessment are registered in its ePortal (registration, not prior authorization); ABA treatment itself needs prior authorization by packet review. From September 17, 2026 every IBHS authorization is capped at six months, the ePortal allows up to 200 units for an ABA assessment (“ASSESS-ABA”), and its own medical necessity guidelines for one-to-one center-based ABA took effect July 8, 2026. Commercial insurance, CHIP and Medicare always pay first.
Community Care’s provider manual sends providers to its “Guidelines for Obtaining Approval” (Appendix A) to see whether a service needs registration, notification or prior authorization. The July 2026 grid lists “IBHS — Written Order: 60 Days from Service Start, ePortal, Registration” and “IBHS — Assessment: 30 Days from Service Start, ePortal, Registration”; IBHS treatment is “45 Days from Service Start … Before Last Covered Day … Packet Review … Prior Auth”. The manual’s own list of registration services includes “IBHS ORDER and ASSESS”, and its prior-authorization list starts with “Intensive Behavioral Health Services (IBHS)”.[2][1][3]
Provider Alert 18 (August 17, 2026) changes the clock: “Effective September 17, 2026: IBHS authorizations will be approved for a maximum of 6 months per authorization period” (previously up to 12 months), and requests for longer periods “will not be processed as submitted”. The same alert sets ePortal assessment maximums of 100 units for Individual/Group/EBP “ASSESS” and “200 units for ABA Individual ‘ASSESS-ABA’ authorizations”. A full formal assessment is still required at least every 12 months, with a reassessment/update acceptable for the in-between six-month request, and written orders stay valid for up to 12 months. Authorizations issued before September 17, 2026 run to their approved end date.[2][1][3]
Community Care does not require the authorization number on the claim, but warns that an authorization “is not a guarantee of payment” and that claims should not be held while an authorization is pending.[2][1][3]
Community Care’s IBHS Performance Standards make a face-to-face evaluation by a licensed prescriber the first step, and list ways to get one: a PCP or CRNP wellness check, an outpatient intake or therapy session, a psychological or psychiatric evaluation, testing, a discharge from inpatient/RTF/partial, or a mental health assessment by a PROMISe-enrolled prescriber at an IBHS agency. It “requires the face-to-face evaluation occur within 1 year/365 days from the date a recommendation is made for IBHS”; written orders are “valid for 12 months”, and for an initial request “the Written Order must precede the Assessment”. A Community Care Written Order Letter template is available to prescribers.[4][11][12]
For new BHT or BHT-ABA services Community Care “requires a Functional Behavior Assessment (FBA) be completed by an FBA certified GLP” when behavior change is the primary goal; when skill development is the goal, a commercial skill-based assessment such as the VB-MAPP “will be accepted in lieu of an FBA”. A new FBA is not required for later BHT/BHT-ABA requests. State medical necessity guidelines (Appendix S) govern ABA; Community Care hosts them on its site.[4][11][12]
Community Care issued its own medical necessity guidelines for ABA one-to-one center-based services (effective 7/8/2026; providers had to comply by July 10, 2026 per Provider Alert 10). Children appropriate for center-based ABA “are typically under the age of 6 years old, and present with documented neurodevelopmental delays”, and the written order must recommend center-based services. The assessment must include direct observation “across all settings, including the home, school, and community, as well as in the center”, and the ITP must include “a plan to taper attendance hours”. Full-day attendance “for family/caregiver or program convenience … is not sufficient for establishing medical necessity”, children who moved on to preschool or school are not re-admitted for summer breaks without a new written order and assessment, and a child not progressing within 180 days may be discharged to other services.[6][5]
Community Care’s Act 62 page tells providers they “are required to bill private health insurance for the costs associated with ASD for children under the age of 21”, to “verify eligibility, benefits, and cap amount each time an ASD member presents”, and to include the commercial plan’s explanation of payment “with each ASD claim” (plus an exhaustion letter once a cap is exhausted). Provider Alert 5 (March 13, 2026) adds that neither provider nor member may use HealthChoices first “or to avoid the requirements of the primary payer”, that the provider must be eligible under the primary plan, and that a primary denial must be appealed through “all appeal levels” before Community Care pays. “Denials issued due to the provider being out-of-network … are not considered for payment”. A COB claim outside the county timely-filing window must reach Community Care within 30 calendar days of the primary payer’s decision date.[9][7][16]
Community Care also manages the autism behavioral health benefit for UPMC Health Plan commercial members under 21 (a separate line of business with its own autism care-management number, 1-877-822-3167, and fax forms).[9][7][16]
The questions that decide whether a family can start with Community Care Behavioral Health Organization (HealthChoices BH-MCO), and what they have to bring. Each maps onto something intake should ask on the first call.
Under 21. IBHS serves children, youth and young adults under 21 (55 Pa. Code Ch. 1155/5240). Community Care’s member handbook lists IBHS as a “(child/adolescent)” service and sets no other age limit. For center-based 1:1 ABA, children are “typically under the age of 6” under Community Care’s own MNG.[12][10][6]
What must be recent is the written order, not a diagnosis. Community Care “requires the face-to-face evaluation occur within 1 year/365 days from the date a recommendation is made for IBHS”, and written orders are “valid for 12 months”. If the order expires during an authorization, service is not interrupted. A full formal assessment is required at least every 12 months (Provider Alert 18). Neither Community Care nor the state sets a separate age limit on the autism diagnosis itself.[4][3][12]
The written order must come from a licensed physician, licensed psychologist, CRNP or another licensed professional whose scope covers diagnosing and treating behavioral health disorders and prescribing BH services (55 Pa. Code § 1155.33). Community Care lists acceptable routes: a PCP/CRNP wellness check, an outpatient intake or therapy session, a psychological or psychiatric evaluation, psychological testing, a discharge from inpatient/RTF/PHP, or a mental health assessment by a “licensed and PROMISe enrolled prescriber from an IBHS agency”.[12][4]
No diagnostic instrument is required. Neither Community Care’s IBHS/ABA standards nor state Appendix S names one (such as the ADOS-2). The required tool is on the treatment side: an FBA by an FBA-certified GLP before new BHT/BHT-ABA when behavior change is the goal, or a commercial skill-based assessment (for example the VB-MAPP) “in lieu of an FBA” when skill building is the goal. A current school FBA/CSBA may be used.[4][5][11]
A written order is required. It is based on a face-to-face evaluation within the past year and must include the diagnosis, the maximum hours of each ABA service per month, the settings and measurable discharge markers (55 Pa. Code § 1155.33). A family may take a valid order to any in-network IBHS-ABA provider. Community Care has a Written Order Letter template, and its IBHS care managers call back the same or next business day to connect a family with a prescriber or provider. No PCP referral beyond the written order is required.[4][12]
Community Care’s member handbook: it “will tell you of its decision within two business days of the date Community Care received the request if Community Care has enough information”. If information is missing, it must tell the provider “within 48 hours” and “allow 14 days” to send it, then decide within two business days of receiving it. This matches the Act 146 rule for MA plans. Federal floor: 42 CFR 438.210(d), 7 calendar days standard / 72 hours expedited for rating periods from 1/1/2026. Deadlines on the provider side: the IBHS treatment packet is due within 45 days of service start, and continued-stay requests “Before Last Covered Day”. Authorizations max out at 6 months from 9/17/2026, so reauthorize at least twice a year.[10][2][3][19][20]
Community Care “is always the insurance payer of last resort”. The provider must identify the primary plan, be eligible under it and meet its authorization and billing rules. Neither provider nor member may use HealthChoices first “or to avoid the requirements of the primary payer”. Primary denials must be appealed through all levels. “Denials issued due to the provider being out-of-network … are not considered for payment”. Community Care pays patient liability up to its fee schedule. For ASD, providers must bill private insurance first (Act 62) and attach the EOB, or an exhaustion letter, to every ASD claim. A COB claim outside the county timely-filing window must arrive within 30 calendar days of the primary’s decision date. The handbook: with other (non-Medicare) insurance, follow “the rules of your other insurance and Community Care, such as prior authorization”, so get Community Care’s IBHS authorization as well. State and federal backstops: 55 Pa. Code § 1101.64 and § 1155.31(e); TRICARE pays ahead of Medicaid (10 U.S.C. 1079(i)(1)).[7][1][9][10][21][22]
Partly published. OMHSAS-22-02 says HealthChoices providers “must follow the billing instructions of the BH-MCO”. Community Care’s billing manual says only that telehealth “require[s] a specific Place of Service Code, which is 02”. It does not mention POS 10 (home) or the FQ audio-only modifier from the state bulletin. Its member handbook lists telehealth as needing no separate prior authorization. We found no ABA- or IBHS-specific telehealth policy; its only telemedicine standard (2018) covers telepsychiatry. The IBHS written-order evaluation may be face-to-face in person or by telehealth.[1][14][10][18][4]
Blocked on: The POS column of the Community Care fee schedule for each ABA code (Provider Alert 15: “allowable POSs vary by level of care and even billing code”), or your Community Care Provider Relations Representative. Confirm which ABA codes allow POS 02/10 and whether FQ is accepted.
Coverage decides whether Community Care Behavioral Health Organization (HealthChoices BH-MCO) 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 rule. Community Care’s IBHS Performance Standards send providers to “the IBHS regulations (specifically sections … 5240.82 for ABA …) and the ‘Staff Supervision’ Section of the OMHSAS IBHS FAQ”; its ABA standards add no ratios of their own. Under § 5240.82, BHT-ABA staff get one hour of supervision a week if they work at least 37.5 hours (otherwise twice a month), including one hour of individual face-to-face supervision a month, 6 hours of onsite supervision before working alone if new to BHT-ABA, and 1 hour of direct observation every 4 months. BA and BC-ABA staff get 1 hour of face-to-face supervision a month (plus 1 more if they supervise assistants or BHTs) and 30 minutes of direct observation every 6 months.[4][13]
Follows the state rule. 55 Pa. Code § 5240.41 requires each service note to be signed by the staff person who provided the service. Community Care’s manual, ABA and IBHS standards set no different signer or deadline (we checked). For telehealth, OMHSAS-22-02 allows physical or electronic consent/verification signatures if an audit trail validates the signer.[13][14][4]
Home, school and community, in the settings the written order names. School participation in the FBA is “necessary when services are recommended to occur while the member is attending school”. One-to-one center-based ABA requires an IBHS provider “licensed and approved by OMHSAS” for it, and both the written order and the assessment must recommend it. Community Care’s center-based MNG (eff. 7/8/2026) expects mostly under-6 children and requires the ITP to taper hours. Provider Alert 15 says the claim’s POS must match where the service was documented, and “allowable POSs vary by level of care and even billing code” on your fee schedule.[4][6][8]
Not published by Community Care. The OMHSAS IBHS FAQ says that “in fee for service”, BA, BC-ABA or BCaBA-level assistant staff “can separately bill for direct observation and supervision of staff providing BHT-ABA services while the individual is working with a child”. That supports billing 97155 at the same time as 97153 in FFS, but the FAQ limits it to FFS. Community Care’s manual and ABA/IBHS standards say nothing about same-clock-time billing, and its fee schedule (attached to each provider contract) sets the billing rules.[17][1]
Blocked on: The Community Care fee schedule attached to your IBHS-ABA contract (the manual says to “reference the fee schedule attached to the contract for both approval and billing rules”), or Provider Reimbursement at 1-888-251-2224, option 1. Get the answer on overlapping 97155/97153 units in writing.
No per-day unit ceiling for ABA treatment is published by Community Care. Its published unit limits are ePortal assessment maximums (200 units for “ASSESS-ABA”, 100 for other IBHS “ASSESS”). Treatment hours are set per member by the written order’s monthly maximums and the authorization, and billing units come from the contracted fee schedule.[3][1]
Blocked on: The billing-unit column of the Community Care fee schedule in your contract, or Provider Reimbursement at 1-888-251-2224, option 1.
The licensed, MA-enrolled IBHS agency contracted with Community Care bills on the CMS-1500/837P (payer ID 23282), using the procedure codes and modifiers on its Community Care fee schedule. The manual requires a rendering provider NPI (box 24j / loop 2310B) and ordering (ORP) provider data. It does not say whether a BHT-ABA’s own NPI or a supervising clinician’s NPI goes in the rendering field.[1]
Blocked on: Your Community Care contract and fee schedule, or Provider Reimbursement at 1-888-251-2224, option 1. Ask which NPI goes in the rendering field for BHT-ABA and assistant BC-ABA lines.
No — the IBHS written order and assessment are registered in the ePortal (assessment within 30 days of service start; up to 200 units for “ASSESS-ABA”). ABA treatment itself needs prior authorization by packet review.
For requests submitted on or after September 17, 2026, at most six months per authorization period. Written orders stay valid for up to 12 months, and a full formal assessment is still needed at least every 12 months.
The commercial plan (or CHIP/Medicare). Community Care is always the payer of last resort: you must be eligible in the primary plan’s network, follow its authorization rules, appeal its denials to the last level, and send its EOB with each claim. Out-of-network denials are not paid.
Yes, one-to-one center-based ABA by an OMHSAS-approved IBHS provider, when the written order and assessment both recommend it. Community Care’s July 2026 guidelines expect mostly under-6 children with documented neurodevelopmental delays and a plan to taper center hours.
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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