Delaware First Health, a Centene plan, is one of Delaware’s three Diamond State Health Plan MCOs. Its provider manual covers "Behavioral services to treat autism spectrum disorder (ASD) pursuant to EPSDT" for members under 21. Its benefits list says those services are not subject to the 30-visit limit on children’s outpatient behavioral health, and every ABA CPT code is on its prior authorization list.
The 2025 provider manual (v11.2, August 2026) covers ASD behavioral services "pursuant to EPSDT" for members under 21, and lists "Autism Spectrum Disorders and Habilitative Services - diagnosis and treatment" among services that typically need prior authorization. The plan’s Medicaid benefits list says "Behavioral services to treat autism spectrum disorder (ASD) for members under age 21 are not subjected to the 30-visit limit" that applies to other outpatient behavioral health for children 17 and under. The Delaware Healthy Children Program (CHIP) table lists ASD services for members under 18 with "30 units outpatient behavioral health benefits," so check which program the child is in. The CMS-0057-F prior authorization list (effective 12/31/2025) lists 97151–97158 under Applied Behavioral Analysis, and 0362T and 0373T under behavioral health. Submit standard requests at least five business days before services start, through the Medicaid Pre-Auth tool, portal, fax or phone.[1][4][3]
Standard pre-service decisions come "Within 7 calendar days," expedited ones within 72 hours, and concurrent reviews within 72 hours. Providers may appeal an adverse benefit determination in writing "within 60 days from the date of the Notice of Adverse Benefit Determination letter." First-time claims are due "no more than one hundred twenty (120) calendar days from the Date of Service." The plan adjudicates 90% of clean non-pharmacy claims within 14 calendar days and 99% within 60. Credentialing is "completely processed within 45 calendar days" of a complete file.[1][2]
The questions that decide whether a family can start with Delaware First Health, and what they have to bring. Each maps onto something intake should ask on the first call.
The plan publishes nothing different from the state plan, which requires a recommendation from a physician or other licensed practitioner and a medical/physical evaluation showing medical necessity before assessment or treatment.[1][5]
Delaware First Health "treats telehealth services with in-network providers in the same way as face-to-face visits," and "If the originating site is the member’s home, the originating site fee will not be paid." For the rest it refers providers to the Delaware Medicaid manual: same codes and rates as in person, POS 02, enrolled providers at both ends.[1][6]
Standard pre-service decisions "Within 7 calendar days," expedited within 72 hours (extendable up to 14 days in limited cases), concurrent review within 72 hours. Untimely decisions count as adverse benefit determinations.[1][8]
"Delaware First Health, like all Medicaid programs, is always the payer of last resort." Bill the primary insurer first and send its EOB, EOP or rejection with the claim, or it pends or denies. When Medicaid would be the third payer, the claim must go on paper.[2][9]
Not stated by the plan or the state.[1]
Ask the plan: Delaware First Health utilization management: ask how recent the diagnostic evaluation must be.
Not stated by the plan; the state plan does not name who may diagnose.[1][5]
Blocked on: Delaware First Health utilization management.
Not stated by the plan or the state.[1]
Ask the plan: Delaware First Health utilization management: ask which instruments it expects with the first request.
Coverage decides whether Delaware First 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.
The plan publishes no ABA supervision rule of its own. The state plan applies: a BCBA may work independently, a BCaBA only under a BCBA, and an RBT only under a BCaBA or BCBA, with supervision requirements set by the BACB and no numeric ratio.[1][5]
No daily unit cap is published. ASD services for DSHP members under 21 are not subject to the 30-visit limit; hours are set by prior authorization, and the state plan requires PA above 40 hours a week.[4][3][5]
The plan publishes no ABA setting rule. Under the state plan, ASD treatment is "designed to be delivered primarily in the home or in other community settings." For telehealth from the home, the plan does not pay the originating-site fee.[1][5]
Not addressed in the provider or billing manual.[1][2]
Ask the plan: Delaware First Health Provider Services, 1-877-236-1341, or your provider agreement.
The manuals publish no ABA session-note signature rule.[1][2]
Ask the plan: Delaware First Health Provider Services, 1-877-236-1341.
The billing manual gives general rendering-provider claim fields but no ABA-specific rule on whose NPI renders technician services.[2]
Ask the plan: Delaware First Health Provider Services, 1-877-236-1341: ask whether RBT services bill under the supervising BCBA and which modifier applies.
Yes. It covers behavioral services to treat ASD under EPSDT for members under 21, and its benefits list says those services are not subject to the 30-visit children’s limit.
Yes. Its prior authorization list includes 97151 and 97152 along with every ABA treatment code.
Standard requests within 7 calendar days, expedited within 72 hours.
120 calendar days from the date of service for first-time claims.
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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