EmblemHealth — operating NY Medicaid through its HIP entities (HIP of Greater New York, Westchester, and Nassau) — is the closest thing to a pure pass-through among the downstate plans: its published Medicaid ABA benefit content is a verbatim restatement of the state criteria effective with the January 1, 2023 carve-in, and we located no distinct EmblemHealth ABA clinical policy. That makes the state guide your clinical rulebook here — but it does not mean no PA exists. The plan's authorization specifics simply aren't published, so verify the process in the portal before booking.
EmblemHealth's published ABA benefit page restates the state program: members under 21 with ASD and/or Rett syndrome per DSM-5, referred by the state's practitioner list, effective with the 2023 carve-in. No named assessment instruments, no plan-specific recency rules, no published intensity framework — the clinical criteria are the state's. What the public materials don't answer: whether the assessment or treatment requires prior authorization on the Medicaid line, what the authorization periods are, and whether Carelon Behavioral Health (which has historically managed Emblem's behavioral benefit) runs ABA UM. Treat those as portal questions — confirm the ABA authorization workflow through emblemhealth.com provider services per case, and get answers in writing.[1][2]
What a reauthorization must show. EmblemHealth 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]
EmblemHealth 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.[13][14][3][1][4][2][10]
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).[13][14][3][1][4][2][10]
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).[13][14][3][1][4][2][10]
Code set: EmblemHealth publishes no ABA code list of its own in the documents we checked (its Medicaid ABA benefit page and provider-manual chapters), so the state’s applies: 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). Bill ABA on the CPT codes; confirm the plan’s fee schedule before billing anything else.[13][14][3][1][4][2][10]
Taxonomy is mandatory on Medicaid claims. EmblemHealth’s NPI and taxonomy guide: “Taxonomy codes are required on Medicaid claims… If not included on an electronic submission, the claim will reject as an unclean claim,” and “Paper claims will be denied for missing information.” On the CMS-1500, always include the billing provider’s taxonomy in box 33b with qualifier ZZ and the rendering provider’s in box 24J with ZZ in 24I; use the codes registered in NPPES, not generic ones.[13][14][3][1][4][2][10]
The questions that decide whether a family can start with EmblemHealth (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, restated verbatim on EmblemHealth’s own Medicaid ABA benefit page: members under 21 with ASD per DSM-5 and/or Rett syndrome, effective with the January 1, 2023 carve-in. No minimum age; no adult pathway.[1][2]
Follows the New York Medicaid rule: the referral is valid no more than two years and no maximum age is set on the diagnostic evaluation. EmblemHealth publishes no recency rule of its own — we located no distinct EmblemHealth ABA clinical policy, and its published benefit content is a verbatim restatement of the state criteria.[1][2]
Follows the New York Medicaid rule, restated on EmblemHealth’s benefit page: referral from the state’s practitioner list — a NYS-licensed, NYS Medicaid-enrolled physician, psychologist, psychiatric NP, pediatric NP or PA. LBAs and CBAAs may not diagnose or self-refer. No Emblem-specific credential was located.[1][2]
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.” EmblemHealth names no assessment instruments and publishes no plan-specific recency or intensity framework — its ABA content is the state criteria restated.[1][2]
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. What EmblemHealth does not publish is whether it layers prior authorization on top: no distinct ABA clinical policy was located and the authorization specifics are absent from the public materials. That is not evidence there is no PA — verify the workflow in the emblemhealth.com provider portal before booking, and get the answer in writing.[1][2]
Ask the plan: The emblemhealth.com provider portal or provider services — confirm whether assessment and treatment require prior authorization, and whether Carelon Behavioral Health runs ABA utilization management for the Medicaid line.
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. EmblemHealth publishes no ABA telehealth rule of its own: its Medicaid ABA benefit page restates the state eligibility criteria, and its provider-manual Claims and Behavioral Health chapters carry no ABA telehealth, modifier or place-of-service provision. So the state rule above is the Emblem rule. 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.[5][2][1][6][7]
“Preauthorization or notification is always required” for autism treatment, and EmblemHealth’s behavioral health UM is run by Carelon Behavioral Health. Emblem’s manual says determinations “for most non-urgent requests, must be made within three (3) business days of receipt of the necessary information, but depending on the line of business, and if additional information is required, the plan may have additional time,” and concurrent determinations within one business day of the necessary information; for Medicaid it points to “authorization request timeframes as described in the Medicaid Managed Care Model Contract.” That contract fills the gaps: expedited within 72 hours, standard no more than 14 days after receipt (extendable up to 14 days), and federal rules cap the standard decision at 7 calendar days for plan rating periods starting on or after January 1, 2026. Neither Emblem nor Carelon’s NY Medicaid addendum publishes an ABA reauth lead time.[15][7][3][16]
Medicaid pays last: providers “must bill all applicable insurance sources before submitting claims to Medicaid,” and under the state contract the plan must “alert the provider and ask them to bill the TPHI that should be primary to the Plan.” Emblem’s own rule is about when it may hold a claim: it “does not deny a claim, in whole or in part, based on coordinating benefits unless we have a reasonable basis to believe the member has other health insurance coverage that is primary,” and if it asks the member about other coverage and hears nothing in 45 days it adjudicates the claim. Behavioral health claims go through Carelon Behavioral Health; COB billing mechanics are in Emblem’s claim submission guides. Whether Emblem/Carelon still requires its own ABA authorization when it is secondary is not published — ask Carelon (800-397-1630).[6][17][3]
Coverage decides whether EmblemHealth (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.
Follows the New York Medicaid rule, which the state applies to FFS and managed care alike: “an LBA can supervise no more than six CBAAs/unlicensed individuals at a time,” “LBAs are required to supervise unlicensed individuals for a minimum of five percent of the hours the unlicensed individual spends providing behavior analysis services each calendar month,” and “supervision must include at least two face-to-face, real-time contacts per month” with the LBA observing service delivery in at least one. Supervision may run over synchronous audio-and-video where on-site is impractical. 97155 counts toward the 5% “only when the LBA joins the patient and the unlicensed individual during a treatment session to direct the unlicensed individual/technician in implementing a new or modified treatment protocol.” CBAAs need direct supervision, and the supervisor “should assess each patient’s/client’s progress at least every 6 months… and review and sign treatment notes and reports prepared by the CBAA supervisee.” EmblemHealth publishes no supervision rule of its own — we located no distinct EmblemHealth ABA clinical policy, so the state rule is the whole answer here.[2][1]
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.” No EmblemHealth-specific documentation or signature rule was located.[2][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. EmblemHealth publishes no setting rule of its own; the state’s school bar is the operative constraint.[2][1]
Not published. No distinct EmblemHealth ABA clinical policy was located, and the state manual is silent on 97153 with 97155.[1][2]
Ask the plan: The emblemhealth.com provider portal or provider services; Carelon Behavioral Health has historically managed Emblem’s behavioral benefit, but its role in ABA utilization management is unconfirmed.
Not published — authorization periods, unit ceilings and hour-cap logic are all absent from EmblemHealth’s public ABA materials, and no distinct clinical policy was located. The state sets no per-day ceiling either. Per-day claim edits: the federal Medicaid NCCI medically unlikely edits (October–December 2026: 97153 – 32 units a day, 97155 – 24, 97151 – 32, 97152/97156/97157/97158 – 16, 97154 – 18) are mandatory for fee-for-service claims, but CMS calls applying them to managed-care claims “desirable but optional,” and EmblemHealth does not say whether it applies them — treat the authorized units as the ceiling and ask the plan about any per-day edit.[8][9][1][2]
Ask the plan: The emblemhealth.com provider portal or provider services — confirm authorization periods and any unit limits per case in writing.
Not published. 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. EmblemHealth states no managed-care claim convention of its own, and the state manual directs MMC providers to their plan for billing guidance — so confirm the claim format with Emblem before billing CBAA- or technician-delivered units.[2][1]
Ask the plan: The emblemhealth.com provider portal or provider services — confirm the rendering/supervising NPI convention and the correct HIP entity for the member.
Yes — its Medicaid plans carry the NY ABA carve-in on the state criteria, restated verbatim in its published benefit content: under 21, ASD/Rett per DSM-5, with the state practitioner referral.
The plan publishes no ABA-specific PA details — no distinct clinical policy was located. Verify the authorization workflow through the emblemhealth.com provider portal before booking, and get the answer in writing.
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.
Not on anything EmblemHealth publishes. It posts no ABA code list of its own, and the New York Medicaid ABA fee schedule it builds on lists only CPT 97151–97158, with no H-codes and no 0362T/0373T. Bill ABA on the CPT codes.
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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