Detroit Wayne Integrated Health Network (DWIHN) is the PIHP for Wayne County (region 7), including Detroit. For a Wayne County child on Medicaid, Healthy Michigan Plan or MIChild, DWIHN, not the family’s Medicaid Health Plan, owns the autism evaluation, the ABA authorization and the network of ABA agencies. The state rules in our Michigan Medicaid guide are the floor; this guide covers how DWIHN runs the front door and what its published documentation rules add.
DWIHN runs a "no wrong door" model: a parent, a physician, a therapist or a teacher can refer to the Access Call Center at 1-800-241-4949. On the call, Access checks the child’s insurance, completes a CMH screening and an autism screening tool. If the screening shows elevated signs of autism, "An evaluation appointment will be scheduled with one of our independent evaluation centers"; if not, the family can ask for another screening later or send records showing autism-related concerns. Two appointments follow and both must be completed, in either order: a support coordination or case management appointment, where person-centered planning builds the Individual Plan of Service (IPOS), and the evaluation appointment that decides eligibility.[1]
Once eligible, the family works with the support coordinator to choose an ABA provider (DWIHN posts an ABA provider contact list), the agency completes the initial ABA assessment and plan of care, and the coordinator adds the ABA goals and hours to the IPOS. DWIHN warns families that "It may take up to 90 calendar days from the date of an autism diagnosis to begin one-to-one ABA therapy services." For Medicaid, DWIHN’s FAQ restates the state age rule: autism services "are generally available for individuals under 21 years of age."[1]
DWIHN’s ASD benefit document rules (revised 6/20/20) set the paperwork rhythm providers upload to the MH-WIN record: the ABA assessment and plan with ABLLS, VB-MAPP or AFLS grids every 180 days; the IPOS every 365 days; monthly supports-coordinator and BCBA/QBHP contact notes; quarterly IPOS service reviews; the comprehensive diagnosis evaluation and form within 7 days following the diagnosis feedback; and functional behavioral assessments as medically necessary. The same table lists ADOS-2/DD-CGAS re-evaluations on the "Annual MDHHS Approval Anniversary Date"; that line predates the current manual, which requires comprehensive re-evaluations no more than once every three years unless medically necessary, so confirm the current re-evaluation cadence with DWIHN.[2][3][4]
DWIHN’s outside diagnostic evaluation form records the tools administered (ADOS-2 with module, ADI-R, cognitive, adaptive, DD-CGAS), the ADOS-2 total and DD-CGAS scores, and a classification of autism (comprehensive), ASD (focused) or non-spectrum, followed by the manual’s criteria A and B checklist.[2][3][4]
DWIHN’s Utilization Management department publishes its 2025 performance: a 99% standard prior-authorization approval rate, 0% timeframe extensions, standard authorizations averaging 3.2 days (median 0 days) and expedited authorizations averaging 16.5 hours; 32.6% of appealed standard denials were approved on appeal. Claims are processed for four lines of business including a separate "Autism" line; authorization questions go to pihpauthorizations@dwihn.org and claims to pihpclaims@dwihn.org. DWIHN procures ABA agencies competitively: its Children’s Initiative and Procurement departments ran RFQ 2026-007 (rebid, closed July 30, 2026) for ABA services for children 0–21 in Wayne County.[5][1][4][6][7]
Everything else follows the state floor: 1:10 supervision, the MDHHS code-chart same-time rules and modifiers, telehealth limited to 97155–97158, and Medicaid as payer of last resort.[5][1][4][6][7]
The federal managed care rule covers this PIHP. When the network “is unable to provide necessary services, covered under the contract, to a particular enrollee,” the PIHP “must adequately and timely cover these services out of network for the enrollee, for as long as” the network cannot provide them. It must require the out-of-network provider “to coordinate with the MCO, PIHP, or PAHP for payment,” and the family’s cost must be no greater than in network (42 CFR 438.206(b)(4)–(5)). DWIHN’s own out-of-network or single-case-agreement procedure and rate were not reviewed for this guide. Ask its utilization management or provider network team for an out-of-network authorization and the rate before the first session.[13]
What changes on Jan. 1, 2027. CMS records that at its September 2025 meeting the AMA CPT Editorial Panel "deleted CPT codes 0362T" and "0373T," "revised eight existing CPT codes" (97151 through 97158) and "created six new CPT codes" for adaptive behavior services; the AMA released the CPT 2027 code set on Sept. 9, 2026, with changes in effect on January 1. The ABA Coding Coalition’s 2027 guidance gives the final numbers: 97148 and add-on +97149 (behavior identification supporting assessment of harmful behavior, delivered by two technicians, additional technicians on the add-on), 97159 and add-on +97160 (adaptive behavior treatment of harmful behavior, same two-technician structure), 97173 (adaptive behavior treatment with analysis by a physician or other QHP, face-to-face with one patient) and 97180 (non-face-to-face services personally performed by the QHP, such as data review and modifying protocols). "Protocol modification" becomes "analysis" in the descriptors, and "since there is no grace period, 0362T and 0373T are invalid for dates of service on or after January 1, 2027." No state "approves" the codes themselves: they are Category I CPT codes that HIPAA requires on electronic claims, but, as the Coalition notes, HIPAA "does not, however, govern whether a payer covers a code / service, what a payer pays for a code / service, or what a payer requires to authorize" it, so each payer has to load them, price them and say how authorizations that list 0362T or 0373T carry over.[14][15][16][17][6][12]
MDHHS had not announced how Michigan Medicaid will handle the 2027 adaptive-behavior codes as of Nov. 1, 2026. Its bulletins run to MMP 26-48 (issued Oct. 30, 2026); one of them, MMP 26-46, does apply a 2027 CPT change (maternity codes), but none addresses ABA. The SFY 2027 Behavioral Health Code Charts (updated Sept. 30, 2026), the code list for behavioral health encounters, still list 0362T and 0373T and none of the new codes, and none of the proposed policies posted for public comment concerns them. DWIHN reports ABA encounters on those MDHHS code charts, and we found no DWIHN notice on the 2027 codes (its provider newsletter page, checked Nov. 1, 2026). Ask DWIHN how it will load the new codes and whether authorizations that list 0362T or 0373T carry over to dates of service from Jan. 1, 2027.[14][15][16][17][6][12]
MDHHS publishes no ABA fee screen for the autism benefit; the rate floor is in the Medicaid Provider Manual, Section 18.13: “All PIHPs will reimburse BHT-ABA services at a minimum to the rate outlined with the most recent executed PIHP contract.” The rate a provider is actually paid is the one in its network contract, so the answer to “what does DWIHN pay for 97153?” comes from the contract or rate sheet: ask DWIHN (provider network / contracting) for the current ABA rates by code and credential before signing.[4]
The questions that decide whether a family can start with Detroit Wayne Integrated Health Network (DWIHN), and what they have to bring. Each maps onto something intake should ask on the first call.
Under 21 for the Medicaid autism benefit. DWIHN’s FAQ: "Medicaid autism services are generally available for individuals under 21 years of age when services are medically necessary," matching the manual’s "Child is under 21 years of age." (DWIHN’s page header says autism services are available to members of all ages; ABA under the Medicaid BHT benefit stops at 21.)[1][4]
The manual rule applies: comprehensive diagnostic re-evaluations are required "no more than once every three years, unless determined medically necessary more frequently." DWIHN’s own document table (revised 6/20/20) still lists ADOS-2/DD-CGAS re-evaluations on the annual MDHHS approval anniversary and ABA assessments every 180 days; the three-year manual rule is newer, so confirm the current re-evaluation cadence with DWIHN.[4][2]
DWIHN applies the state rule; its published autism material sets nothing different. A qualified licensed practitioner "qualified and experienced in diagnosing ASD": a physician with a specialty in psychiatry or neurology; a physician with a subspecialty in developmental pediatrics, developmental-behavioral pediatrics or a related discipline; a physician with a specialty in pediatrics or other appropriate specialty with ASD training, experience or expertise; a psychologist; an advanced practice registered nurse or a physician assistant with ASD and/or behavioral health training; or a master’s-level, fully licensed clinical social worker qualified and experienced in diagnosing ASD. The PIHP is responsible for arranging the comprehensive diagnostic evaluation.[4][1][5][2][3]
DWIHN’s Comprehensive Diagnostic Evaluation & Re-Evaluation Form lists the tools administered as ADOS-2 (with module), ADI-R, cognitive, adaptive and DD-CGAS, records the ADOS-2 total and DD-CGAS scores, and classifies the result as autism (comprehensive), ASD (focused) or non-spectrum before the manual’s criteria A/B checklist. Access uses an autism screening tool first (DWIHN posts the M-CHAT-R with scoring guide). The manual itself requires only "valid evaluation tools."[3][1][4]
No wrong door. DWIHN takes referrals from families, medical providers, treatment providers and education providers through the Access Call Center (1-800-241-4949), which completes a CMH screening and an autism screening; DWIHN also posts a physician referral form for ASD screening. The state manual still expects the PCP screening and a full medical and physical examination before referral for the diagnostic evaluation.[1][4]
DWIHN applies the state rule; its published autism material sets nothing different. Only the analyst-level codes. The MDHHS Bureau of Specialty Behavioral Health Services Telemedicine Database lists 97155, 97156, 97157 and 97158 as allowed via simultaneous audio/visual telemedicine (reported with POS 02 or POS 10, no modifier), and its revision log records that 0362T, 97151, 97153 and 97154 were removed from the database on 4/28/23 — so technician-delivered direct treatment and the behavior identification assessment are in-person. The diagnostic-evaluation codes 96112/96113 and 96116 remain allowed via audio/visual "for reporting BHT/ABA eligibility assessments and re-evaluation assessments related to Autism." The SFY 2027 code charts note on 97155 and 97156 to use POS 02 "if MDHHS has authorized tele-practice for an individual."[7][6][1][5][2][3]
DWIHN reports its 2025 timeliness: standard prior authorizations averaged 3.2 days (median 0 days) and expedited authorizations averaged 16.5 hours (median 11 hours), with 0% of requests extended. The regulatory ceiling is the federal managed-care rule: a PIHP must decide a standard request within state-set timeframes that "may not exceed 14 calendar days" for rating periods starting before January 1, 2026 and "may not exceed 7 calendar days" for rating periods starting on or after that date, extendable by up to 14 days, and expedited requests within 72 hours. The manual requires the PIHP to authorize the level of services before they are delivered.[5][9][4]
DWIHN applies the state rule; its published autism material sets nothing different. Medicaid pays last. "Medicaid is considered the payer of last resort. If a beneficiary with Medicare or Other Insurance coverage is enrolled in a Medicaid Health Plan (MHP), or is receiving services under a Prepaid Inpatient Health Plan (PIHP) or Community Mental Health Services Program (CMHSP), that entity is responsible for the Medicaid payment liability." Providers "must utilize other payment sources to their fullest extent" before billing Medicaid, and "Medicaid is not liable for payment of services denied because coverage rules of the primary health insurance were not followed" — so get the commercial plan’s prior authorization and use its network. The ABA section adds that the IPOS must not duplicate services that are the responsibility of "a private insurance or other funding authority." Nothing in Section 18 exempts a child with other coverage from the PIHP’s own eligibility determination and pre-service authorization. Federally, the agency rejects a claim when third-party liability is established and pays only the amount its schedule exceeds the third party’s payment (42 CFR 433.139).[4][4][11][1][5][2][3]
Coverage decides whether Detroit Wayne Integrated Health Network (DWIHN) 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.
DWIHN applies the state rule; its published autism material sets nothing different. The behavior technician works under the supervision of the BCBA/LBA or other professional (BCaBA or QBHP) overseeing the behavioral plan of care, "with minimally one hour of clinical observation and direction for every 10 hours of direct treatment." BHT services "must be provided under the direction of a BCBA/LBA or a Master’s prepared QBHP," and the BCBA/LBA is responsible for clinical skill development and supervision of BCaBAs, QBHPs and technicians and for communicating progress on goals to parents or guardians at least every three to six months. The manual gave licensed psychologists (LP/LLP) and QBHPs a deadline to be certified and licensed as a BCBA/LBA by September 30, 2025, and the SFY 2027 code charts (for the state fiscal year that began October 1, 2026) list the ABA codes for the Licensed Behavior Analyst (HO) and Licensed Assistant Behavior Analyst (HN), plus the behavior technician (HM) on 97153, 97154 and 0373T, with no separate QBHP row.[4][6][1][5][2][3]
DWIHN applies the state rule; its published autism material sets nothing different. Allowed for the pairs MDHHS names. The SFY 2027 code charts (from October 1, 2026) say 97155 reported by a licensed behavior analyst "May co-occur with 97153 & 97154," and 97155 reported by a licensed assistant behavior analyst "Must co-occur with 97153, 97154, and 0373T in order to be reported," and the same-time reporting rules state that 97153 and 97155 "can occur at the same time, just not by the same person" (the technician delivers 97153 while the BCBA/LBA supervising delivers 97155); 97156 may be delivered by the BCBA/LBA to the caregiver while a technician delivers 97153 to the child; a 97151 reassessment may be reported at the same time as 97153, 97154, 0373T (and potentially 97157/97158) "IF there are two separate providers"; and 0362T may be reported at the same time as 0373T. Targeted case management may also run at the same time as a direct ABA service.[6][1][5][2][3]
DWIHN applies the state rule; its published autism material sets nothing different. No per-day or per-week unit cap is published. The manual sets planning averages, not ceilings: focused behavioral intervention averages 5–15 hours a week and comprehensive behavioral intervention 16–25 hours a week, with actual hours set by the behavioral plan of care. A PIHP "may not deny services based solely on preset limits of the cost, amount, scope, and duration of services," and the level of service is re-determined at least every six months on measurable progress. Authorizations may run up to 365 days.[4][4][1][5][2][3]
DWIHN states that "ABA services may be provided at home, in a clinic, in the community, or in school and daycare settings when appropriate," based on the child’s needs and the provider’s recommendations. The state rule bounds this: BHT is designed primarily for home and community settings, must not supplant educational responsibilities, and cannot include IDEA special education and related services available through the local education agency.[1][4]
DWIHN applies the state rule; its published autism material sets nothing different. Services are reported to the PIHP/CMHSP under the provider’s network contract, with a modifier naming the rendering staff level. The SFY 2027 code charts list the qualifying provider types and modifiers for each ABA code: HO for a licensed behavior analyst (master’s level), HN for a licensed assistant behavior analyst (bachelor’s level), and HM for a behavior technician on the technician codes (97153, 97154, 0373T); group codes carry the UN–US group-size modifiers. (The U5 autism modifier the SFY 2026 charts put on 97151 is not in the SFY 2027 modifier list.) Which codes: ABA is billed with CPT codes, not H-codes. The SFY 2027 code charts list 97151, 97153, 97154, 97155, 97156, 97157, 97158, 0362T and 0373T for ABA (97152 does not appear); the diagnostic evaluation behind eligibility is reported with 96112, 96113 or 96116 “For reporting BHT/ABA eligibility assessments and re-evaluation assessments related to Autism”; and H0031 with the 6Y modifier is the behavior identification assessment for people outside the ABA benefit (“97151 for non-ABA was removed effective 10/1/24 so the H0031 with the 6Y is for these individuals”). A technician does not need a license or BACB registration, but must complete BACB-approved RBT training and work under the BCBA/LBA’s supervision.[6][4][1][5][2][3]
DWIHN applies the state rule; its published autism material sets nothing different. Section 18 of the Medicaid Provider Manual and the SFY 2027 code charts do not state who signs an ABA session note or by when. The manual requires the individual plan of service (IPOS) to specify amount, scope and duration of each authorized service and permits electronic signatures for the beneficiary on the plan of service and consents; session-note signature standards sit in each PIHP’s provider contract and documentation standards.[4][4][6][1][5][2][3]
Blocked on: DWIHN (or its CMHSP) provider manual / documentation standards (ask the PIHP’s autism benefit or provider network office for the ABA progress-note requirements).
There is no public state fee screen. The Medicaid Provider Manual (Section 18.13) says PIHPs reimburse BHT-ABA “at a minimum to the rate outlined with the most recent executed PIHP contract”; your rate is in your network contract, so ask DWIHN for the current ABA rate sheet.
Call the DWIHN Access Call Center at 1-800-241-4949. Access screens the child, and if autism signs are elevated schedules an evaluation at an independent evaluation center plus a support coordination appointment.
DWIHN says it may take up to 90 calendar days from the autism diagnosis to begin one-to-one ABA, depending on provider availability and completing the required appointments.
DWIHN lists home, clinic, community, and school or daycare settings "when appropriate"; state policy bars billing BHT for IDEA special-education services the school is responsible for.
Not yet, as of Nov. 1, 2026. MDHHS has not announced the 2027 ABA codes (its SFY 2027 code charts still list 0362T and 0373T), and we found no DWIHN notice. CPT 2027 deletes 0362T and 0373T and adds 97148/97149, 97159/97160, 97173 and 97180 from Jan. 1, 2027; ask DWIHN how authorizations carry over.
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