Excellus BlueCross BlueShield — the nonprofit Rochester-based plan running Medicaid Managed Care as HMOBlue Option, Blue Choice Option, and Premier Option (HARP: Blue Option Plus) across 179,533 members per the state's July 2026 enrollment report — stands out among New York's upstate MCOs for actually publishing a named ABA clinical policy rather than leaving the benefit entirely to the state baseline. Medical Policy 3.01.11, "Applied Behavior Analysis," lists the covered CPT codes, documentation expectations, and licensure tiers directly, and its own "Product Disclaimer" spells out how it relates to the state program: where eMedNY hasn't published Medicaid-specific criteria, Excellus's medical policy fills the gap. What the plan does not publish is the outpatient prior-authorization mechanics themselves — so this guide covers the well-documented clinical policy and flags exactly what to confirm before booking.
Excellus publishes its own dedicated ABA clinical policy — Medical Policy 3.01.11, "Applied Behavior Analysis" (current version effective June 18, 2026) — rather than leaving coverage entirely to the state baseline. The policy deems ABA medically appropriate for DSM-5-TR autism spectrum disorder, treats alternative approaches (DIR/Floortime, TEACCH, RDI) as investigational, and names the codes in scope: 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, and 0373T. Its Product Disclaimer states the operative rule for Medicaid members directly: "If a Medicaid product covers a specific service, and there are no New York State Medicaid guidelines (eMedNY) criteria, medical policy criteria apply to the benefit" — so for anything eMedNY's ABA Policy Manual doesn't spell out, Excellus's own medical-necessity criteria govern.[1]
Beyond the state's referral packet, Excellus's medical policy calls for a specific documentation set at review: psychological/other testing reports, a copy of the IEP where one exists, Early Intervention or Preschool progress notes, the frequency/duration/location of requested sessions, the treating provider's certification/credentials, requested supervision hours, and an assessment/treatment plan naming target behaviors — with resubmission expected at least every 12 months (or more often where state rules require it, e.g., NY's own 6-month update cycle). The policy also restates New York's licensure tiers directly: LBA/BCBA for assessment, treatment planning, and oversight; CBAA/BCaBA to deliver services under supervision; and RBTs/behavior technicians restricted to protocol implementation and data collection, per NYS Education Law. One school-related note: ABA delivered as part of an IEP or Preschool/School Supportive Health Services Program is excluded as a school-district "free care" service, though supplemental, non-IEP ABA may still be covered.[1]
Reauthorization data, in Excellus’s own words: “Requests for continued therapy must include documentation of services received, as well as a graphic representation documenting the measurable progress made by the member,” showing a reasonable expectation of benefit from continued ABA (measurable progress toward or mastery of goals, or a plan modified in response to prior interventions), that treatment is not making symptoms worse, and that withdrawal would cause decompensation or loss of progress. The treatment plan is reviewed at least once every 12 months or as state mandated, and documentation “should demonstrate monthly updates, at a minimum.” So yes — Excellus requires graphed progress data.[1]
Excellus's published Clinical Review Preauthorization List (the current edition is effective October 1, 2026; November 1, 2026 and January 1, 2027 editions are already posted; re-checked October 11, 2026) has columns for Managed Medicaid, Child Health Plus and the Health and Recovery Program (HARP), and none of the ABA codes (97151–97158, 0362T, 0373T) appears on any edition. That is not proof ABA is PA-free: the list covers only services needing a clinical medical-necessity review, says "Certain services require preauthorization or notification without requiring clinical review," and calls itself "NOT inclusive of all insurance products and procedures requiring preauthorization." Behavioral health requests for all lines go through Excellus's CareAdvance Provider portal (provider.excellusbcbs.com/authorizations/request-authorization); the list's phone line, 1-888-333-9036, is eviCore's, for the services Excellus delegates to eviCore. Beyond that list, we found no Excellus-published document stating whether the assessment (97151) or the treatment codes require prior authorization for outpatient ABA specifically — the medical policy describes a "medical necessity review... when applicable" rather than a hard PA gate tied to each code. Excellus's general prior-authorization guidance for Medicaid Managed Care and HARP members instead directs providers to "review the eMedNY website for benefit coverage of specific codes prior to submitting a prior authorization request" — consistent with the Product Disclaimer above: check the state rule first, then Excellus's medical policy fills any gap. Behavioral health and ABA are not delegated to eviCore (Excellus's vendor for radiology, cardiology, musculoskeletal, oncology, and sleep) or to any other named UM vendor we could confirm — BH Care Management for Medicaid and HARP members runs through Excellus directly. An Inpatient Prior Authorization Form exists for institutional behavioral-health levels of care (partial hospitalization, psychiatric inpatient, SUD detox/rehab), submitted through Excellus's own SDS portal, but we located no equivalent standalone form for outpatient ABA. Treat outpatient ABA PA requirements, turnaround times, and the exact submission channel as open questions for Provider Services until the plan confirms them in writing.[2][3][4]
Excellus's general Telemedicine and Telehealth medical policy — its most recent confirmed revision markers run only through 2017 — does not list any ABA codes (97151–97158) in its covered CPT/HCPCS table, and the ABA medical policy itself only cites third-party guidance (the Council of Autism Service Providers' 2021 telehealth practice parameter) as supportive literature, not a coverage commitment. Whether Excellus Medicaid MMC will reimburse ABA codes delivered via telehealth, and under what modifier, is not confirmed — verify with Provider Services before scheduling remote sessions. On claims: professional timely filing is 120 days from the date of service (the clock for coordination-of-benefits claims starts at the primary payer's EOB date); a missed deadline can be appealed via a Timely Filing Review request within 120 days of the remittance.[5][6]
Excellus BCBS 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][9][1][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][9][1][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][9][1][10]
Code set: Excellus’s ABA medical policy (3.01.11, eff. 6/18/2026) lists CPT 97151–97158 plus 0362T and 0373T, and no HCPCS H-code; the H-codes on its master prior-authorization list are CORE/HCBS behavioral-health services, not ABA. 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).[13][14][9][1][10]
The questions that decide whether a family can start with Excellus BlueCross BlueShield (NY Medicaid), and what they have to bring. Each maps onto something intake should ask on the first call.
Excellus’s own Medical Policy 3.01.11 sets no age limit — it deems ABA medically appropriate for DSM-5-TR autism spectrum disorder without an age gate. The state baseline supplies the boundary underneath for Medicaid members: under 21 with ASD and/or Rett syndrome. Read them together per the policy’s own Product Disclaimer, which says medical-policy criteria fill the gaps eMedNY leaves open rather than override the state where it speaks.[1][8]
No recency rule on the diagnosis in either layer — the state’s 2-year referral clock is the only one. What Excellus does impose is a resubmission cadence: “the treatment plan and goal progress notes should be submitted for review at least once every 12 months or as state mandated,” with documentation that should “demonstrate monthly updates, at a minimum,” which in New York means the state’s own 6-month treatment-plan update cycle governs.[1][8]
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. Excellus’s medical policy restates New York’s licensure tiers on the delivery side — LBA/BCBA for assessment, treatment planning and oversight; CBAA/BCaBA to deliver under supervision; RBTs and behavior technicians restricted to protocol implementation and data collection, per NYS Education Law — but names no diagnosing credential of its own.[8][1]
No named instrument, but a heavier document set than the state asks for. Beyond the state’s referral packet, Excellus’s medical policy calls for psychological and other testing reports, a copy of the IEP where one exists, Early Intervention or Preschool progress notes, the frequency, duration and location of requested sessions, the treating provider’s certification and credentials, the requested supervision hours, and an assessment/treatment plan naming target behaviors. Pull the IEP and EI records at intake rather than at review time.[1]
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. Whether Excellus layers prior authorization on top is genuinely unsettled: we found no Excellus-published list stating that 97151 or the treatment codes require PA for outpatient ABA — the medical policy describes “medical necessity review… when applicable” — and the plan’s general Medicaid/HARP guidance instead directs providers to “review the eMedNY website for benefit coverage of specific codes prior to submitting a prior authorization request.” Behavioral health is not delegated to eviCore (radiology, cardiology, MSK, oncology and sleep only); BH Care Management runs through Excellus directly.[8][1][2]
Ask the plan: Excellus Provider Services — confirm outpatient ABA PA requirements, turnaround times and the submission channel in writing; no standalone outpatient ABA PA form was located.
Excellus publishes its Medicaid clock in its own member handbooks (the provider manual is behind the portal login): a standard prior authorization is decided “within 3 work days of when we have all the information we need, but no later than 7 days after we receive your request”; a fast-track request “within 72 hours”; a continued-service (concurrent) request within one work day of complete information, again no later than 7 days. When Excellus needs more information, the decision comes “no later than 14 days from the day we asked for more information.” The ABA medical policy asks for an updated treatment plan and progress notes “at least once every 12 months or as state mandated” but sets no reauth submission lead time.[15][16][1]
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. Excellus’s own documents do not settle it for ABA: its corporate Telemedicine and Telehealth policy (#1.01.49, revision markers through 2017) lists no ABA code (97151–97158) in its covered-code table, and its ABA medical policy (3.01.11, eff. 6/18/2026) cites the Council of Autism Service Providers’ telehealth practice parameter and notes ABA may be delivered “in-person, telehealth” as a clinical matter, not as a coverage or billing rule. For Excellus Medicaid members the state manual above is the floor the plan must meet; for commercial members the corporate policy 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.[11][8][5][1]
Ask the plan: Excellus Provider Services — confirm ABA telehealth reimbursement, modifier and whether the authorization must name telehealth, before scheduling remote sessions (cite the state telehealth manual’s MMC section for Medicaid members).
The state rule is clear: Medicaid is “the payer of last resort,” providers “must bill all applicable insurance sources before submitting claims to Medicaid,” and the plan must “alert the provider and ask them to bill the TPHI that should be primary to the Plan.” What Excellus’s own Medicaid claim procedure adds — attachments, filing window, and whether its ABA prior authorization is still required when it is secondary — sits in the provider manual behind the portal login and could not be checked. The only public Excellus billing guide (a general Blues billing orientation, not Medicaid-specific) says “For secondary paper claims, we require a copy of the primary carrier’s EOB.”[17][9][6]
Blocked on: Excellus provider manual (Government Programs / claims and UM sections) in the provider.excellusbcbs.com portal, or Excellus Provider Service 1-800-920-8889 — ask whether a Medicaid ABA prior authorization is needed when Excellus is secondary.
Coverage decides whether Excellus BlueCross BlueShield (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.
Excellus restates New York’s licensure tiers in its own policy — LBA/BCBA for assessment, treatment planning and oversight; CBAA/BCaBA to deliver services under supervision; RBTs and behavior technicians restricted to protocol implementation and data collection, per NYS Education Law — and requires the requested supervision hours to be stated in the submitted documentation. The numeric floor comes from the state and applies to managed care alike: 5% of each unlicensed individual’s monthly service hours, two face-to-face real-time contacts per month with one observation, and no more than six CBAAs/unlicensed individuals per LBA.[1][8]
No per-day unit ceiling or hour cap is published. The policy asks for the “frequency, duration, and location of the requested ABA sessions” and “the requested clinical supervision hours and documentation to support the request” rather than measuring them against a stated maximum, and the treatment plan and goal progress notes go in for review “at least once every 12 months or as state mandated” — which in New York means every 6 months. On claims: professional timely filing is 120 days from the date of service, with a Timely Filing Review request available within 120 days of the remittance.[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.” Excellus adds no session-note signature rule of its own; what it requires at review is the treating provider’s certification and credentials alongside the assessment and treatment plan.[8][1]
The state’s school bar plus an Excellus free-care exclusion. New York Medicaid does not reimburse ABA in a school setting; Excellus adds an IEP exclusion: “Coverage is not available for services stipulated in the IEP of a pre-school member (age three to five years) or a school-age member (ages five to 21 years) as these services are provided by the member’s school district and are considered free care or a government program.” An IEP should be completed through the school district before a request is submitted, and “ABA services denied by the school district, including summer services, and not covered in a child’s IEP, will be reviewed by the Health Plan for medical necessity.” The policy also requires the location of requested sessions to be stated in the submitted documentation, so setting is reviewed rather than assumed. Home, clinic and community remain available under the state’s any-legally-authorized-setting rule.[1][8]
Not published. Medical Policy 3.01.11 names the codes in scope (97151–97158, 0362T, 0373T) and the documentation expected, but states no same-clock-time rule for 97153 with 97155; the state manual is silent too.[1][8]
Ask the plan: Excellus Provider Services and the plan’s claim-editing guidance — confirm in writing before billing the overlap.
Not published as a claim convention — Medical Policy 3.01.11 governs who may deliver which service (LBA/BCBA for assessment, planning and oversight; CBAA/BCaBA under supervision; technicians for protocol implementation and data collection) but names no rendering-versus-supervising NPI rule. 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. Confirm the Excellus managed-care claim format before billing CBAA- or technician-delivered units.[1][8]
Ask the plan: Excellus Provider Services and the “Navigating the Blues” billing orientation guidebook — confirm the rendering/supervising NPI convention.
Yes — it carries the NY Medicaid ABA carve-in and publishes its own ABA Medical Policy (3.01.11) naming the covered codes (97151–97158, 0362T, 0373T) and documentation requirements, layered on the state's under-21 ASD/Rett baseline.
Not published for the specific codes — Excellus's guidance directs providers to check eMedNY for code-level Medicaid coverage first, then confirm any plan-level PA process with Provider Services; no standalone outpatient ABA PA form was found.
No vendor carve-out was found — eviCore manages only radiology, cardiology, musculoskeletal, oncology, and sleep for Excellus, and behavioral health/ABA runs through Excellus's own BH Care Management team.
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 H-code is on Excellus’s ABA policy: it lists CPT 97151–97158 plus 0362T and 0373T. For a Medicaid member the state ABA fee schedule carries only 97151–97158.
Yes. Excellus’s ABA policy says requests for continued therapy must include documentation of services received and a graphic representation documenting the member’s measurable progress, with documentation showing at least monthly updates.
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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