---
title: Excellus BlueCross BlueShield ABA coverage (NY Medicaid Managed Care).
url: "https://carelu.com/payers/excellus-bcbs-new-york"
markdown_url: "https://carelu.com/payers/excellus-bcbs-new-york.md"
state: NY (New York)
payer: Excellus BlueCross BlueShield (NY Medicaid)
kind: Medicaid managed care plan (MCO)
parent_program: New York Medicaid
description: "How Excellus BlueCross BlueShield administers NY Medicaid ABA — its own named ABA medical policy (3.01.11), the 13-county Central/Western NY and Southern Tier footprint, in-house behavioral health with no vendor carve-out, and what prior-auth and telehealth specifics remain unpublished."
last_reviewed: October 2026
vob_data_updated: 2026-10-15
---

# Excellus BlueCross BlueShield ABA coverage (NY Medicaid Managed Care).

_Payer Guide · Excellus BCBS (NY) · Last updated October 2026 · 12 primary sources_

> Central/Western NY + Southern Tier; own named ABA medical policy (3.01.11) — but outpatient PA specifics sit behind the portal login.

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.

This plan administers the **New York Medicaid** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [New York Medicaid (NYS DOH / eMedNY) guide](https://carelu.com/payers/new-york-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment** _(ask the plan)_: Not published for outpatient ABA — 97151–97158 do not appear on Excellus’s Clinical Review Preauthorization List (the current October 1, 2026 edition, the posted November 1, 2026 and January 1, 2027 editions, and the August 1, 2026 edition before them; re-checked 10/11/2026) in any column, Managed Medicaid, CHP and HARP included; but that list says it is “NOT inclusive” and that some services need preauthorization or notification without clinical review. Medical Policy 3.01.11 describes “medical necessity review… when applicable,” and Excellus directs providers to check eMedNY for code coverage first; confirm with Provider Services [1][2][3]
  - Ask the plan: Excellus Provider Services. Ask whether 97151 carries a code-level PA requirement for outpatient ABA and get it in writing; no Excellus-published outpatient ABA PA list or form was located, and the plan directs providers to check eMedNY code coverage first.
- **Prior auth for treatment** _(ask the plan)_: Not published — no standalone outpatient ABA PA form was located, no ABA code (97151–97158, 0362T, 0373T) appears on the current October 1, 2026 Clinical Review Preauthorization List or the posted November 2026 and January 2027 editions (each says it is not all-inclusive), and BH/ABA is not delegated to eviCore; BH requests for all lines go through Excellus’s CareAdvance Provider portal, so confirm requirements and turnaround in writing before booking [1][2][3]
  - Ask the plan: Excellus Provider Services — BH Care Management for Medicaid and HARP runs through Excellus directly, not eviCore. Confirm outpatient ABA PA requirements, turnaround times and the submission channel in writing before booking.
- **Autism diagnosis required?**: Yes — DSM-5-TR ASD per Excellus's own ABA medical policy (3.01.11), layered on the state's under-21 ASD/Rett baseline; Rett-specific language isn't in the Excellus policy itself [1][8]

## At a glance

- **Plan type:** Mainstream MMC (Excellus Health Plan, Inc.) — HMOBlue Option, Blue Choice Option, Premier Option; HARP: Blue Option Plus
- **Footprint:** 13 counties: Broome, Erie, Herkimer, Livingston, Monroe, Oneida, Onondaga, Ontario, Orleans, Otsego, Seneca, Wayne, Yates
- **Clinical policy:** Own Medical Policy 3.01.11, "Applied Behavior Analysis" (current eff. 6/18/2026) — names 97151–97158, 0362T, 0373T
- **BH/ABA UM:** In-house — no vendor carve-out found; eviCore handles only radiology, cardiology, MSK, oncology, and sleep for Excellus, not BH
- **Prior auth specifics:** Not published for outpatient ABA — plan directs providers to check eMedNY for MMC/HARP code coverage, then confirm via BH Care Management
- **Claims:** 120-day timely filing for professional claims

## A named medical policy — filling the gaps eMedNY leaves open

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]

## Documentation and licensure — heavier than the state referral alone

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]

## Prior authorization: what's published, and what to confirm

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]

## Telehealth and billing basics

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]

## Claims: filing floor, payment clock and EVV

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]

## Intake gates

The questions that decide whether a family can start with Excellus BlueCross BlueShield (NY Medicaid), and what they have to bring.

- **Age limit**: 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]
- **Diagnosis recency**: 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]
- **Who may diagnose**: 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]
- **Diagnostic tools required**: 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]
- **Referral required?**: 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.
- **Prior-auth decision time**: 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]
- **Telehealth** _(plan-dependent)_: 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).

## Delivery and billing rules

Coverage decides whether Excellus BlueCross BlueShield (NY Medicaid) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: 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]
- **Daily limits / MUEs**: 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]
- **Session-note signature**: 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]
- **Place of service**: 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]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: 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.
- **Bill as provider** _(ask the plan)_: 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.

## What intake should collect for Excellus BlueCross BlueShield (NY Medicaid)

- **Complete state referral packet:** Under-21 ASD/Rett dx, referral with severity and DSM-5 checklist — the clinical baseline Excellus's medical policy sits on top of.
- **IEP and Early Intervention records:** Excellus's policy asks for an IEP copy where one exists, plus EI/Preschool progress notes — pull these at intake, not at review time.
- **Target-behavior treatment plan + supervision hours:** The medical policy expects an assessment/treatment plan naming target behaviors and the requested supervision hours.
- **PA confirmation in writing:** Outpatient ABA PA specifics aren't published — confirm the process and turnaround through Provider Services before booking.
- **Telehealth confirmation:** ABA-code telehealth coverage isn't confirmed by any Excellus document we found — verify per case.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How Excellus BlueCross BlueShield (NY Medicaid) ABA benefits route and read on an eligibility check. Data last updated 2026-10-15.

### EDI routing

- **Payer ID (pVerify):** 00465 — Listed as "BCBS of New York (Excellus)" (00465, Elig/Claim: Yes) — pVerify also separately lists regional sub-brand entries with no Medicaid designation on any of them: BCBS of Central New York (00330), Univera (00451), BCBS of the Rochester Area (00308), BCBS of Utica-Watertown (00309). No Medicaid-specific Excellus line item exists in this list — confirm which code routes Medicaid Managed Care eligibility checks before automating.
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** none — in-house BH Care Management; no vendor carve-out found
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Not published for outpatient ABA specifically — medical policy describes a "medical necessity review... when applicable," not a hard per-code PA gate | — | — | — | — |
| 97152 | Yes | Not published for outpatient ABA specifically — medical policy describes a "medical necessity review... when applicable," not a hard per-code PA gate | — | — | — | — |
| 97153 | Yes | Not published for outpatient ABA specifically — medical policy describes a "medical necessity review... when applicable," not a hard per-code PA gate | — | — | — | — |
| 97154 | Yes | Not published for outpatient ABA specifically — medical policy describes a "medical necessity review... when applicable," not a hard per-code PA gate | — | — | — | — |
| 97155 | Yes | Not published for outpatient ABA specifically — medical policy describes a "medical necessity review... when applicable," not a hard per-code PA gate | — | — | — | — |
| 97156 | Yes | Not published for outpatient ABA specifically — medical policy describes a "medical necessity review... when applicable," not a hard per-code PA gate | — | — | — | — |
| 97157 | Yes | Not published for outpatient ABA specifically — medical policy describes a "medical necessity review... when applicable," not a hard per-code PA gate | — | — | — | — |
| 97158 | Yes | Not published for outpatient ABA specifically — medical policy describes a "medical necessity review... when applicable," not a hard per-code PA gate | — | — | — | — |
| 0362T | Yes | Not published for outpatient ABA specifically — medical policy describes a "medical necessity review... when applicable," not a hard per-code PA gate | — | — | — | — |
| 0373T | Yes | Not published for outpatient ABA specifically — medical policy describes a "medical necessity review... when applicable," not a hard per-code PA gate | — | — | — | — |

Code notes:

- **97151:** Code 97151 named in scope by Medical Policy 3.01.11. Verify PA specifics, unit limits, and telehealth billing in writing via BH Care Management (no vendor carve-out; handled in-house) before booking.
- **97152:** Code 97152 named in scope by Medical Policy 3.01.11. Verify PA specifics, unit limits, and telehealth billing in writing via BH Care Management (no vendor carve-out; handled in-house) before booking.
- **97153:** Code 97153 named in scope by Medical Policy 3.01.11. Verify PA specifics, unit limits, and telehealth billing in writing via BH Care Management (no vendor carve-out; handled in-house) before booking.
- **97154:** Code 97154 named in scope by Medical Policy 3.01.11. Verify PA specifics, unit limits, and telehealth billing in writing via BH Care Management (no vendor carve-out; handled in-house) before booking.
- **97155:** Code 97155 named in scope by Medical Policy 3.01.11. Verify PA specifics, unit limits, and telehealth billing in writing via BH Care Management (no vendor carve-out; handled in-house) before booking.
- **97156:** Code 97156 named in scope by Medical Policy 3.01.11. Verify PA specifics, unit limits, and telehealth billing in writing via BH Care Management (no vendor carve-out; handled in-house) before booking.
- **97157:** Code 97157 named in scope by Medical Policy 3.01.11. Verify PA specifics, unit limits, and telehealth billing in writing via BH Care Management (no vendor carve-out; handled in-house) before booking.
- **97158:** Code 97158 named in scope by Medical Policy 3.01.11. Verify PA specifics, unit limits, and telehealth billing in writing via BH Care Management (no vendor carve-out; handled in-house) before booking.
- **0362T:** Code 0362T named in scope by Medical Policy 3.01.11. Verify PA specifics, unit limits, and telehealth billing in writing via BH Care Management (no vendor carve-out; handled in-house) before booking.
- **0373T:** Code 0373T named in scope by Medical Policy 3.01.11. Verify PA specifics, unit limits, and telehealth billing in writing via BH Care Management (no vendor carve-out; handled in-house) before booking.

### Contacts

- **Benefits by phone:** Yes
- **Provider services phone:** 1-800-920-8889
- **Phone menu path:** Press #2 for Eligibility and Benefits (same number listed as "Medical Provider Customer Care" on the Provider FAQ page and as general Customer Care on the Contact Us page).
- **Hours:** Mon-Thu 8:00 a.m.-5:00 p.m. ET; Fri 9:00 a.m.-5:00 p.m. ET (closed 12:00-1:00 p.m. ET weekdays)
- **Portal:** [Excellus Provider Website](https://provider.excellusbcbs.com)

Questions to ask on a verification call:

- Which Excellus BCBS payer ID (00465 vs. the regional sub-brand codes) should we use for ABA eligibility checks, and does Excellus support real-time 270/271 responses?
- Is ABA subject to a hard per-code prior authorization, or just a general medical-necessity review "when applicable"?
- What per-code daily/annual unit caps apply to 97151-97158, 0362T, and 0373T?
- Are ABA codes reimbursable via telehealth, and if so, what POS code and modifier should we use?
- Is the ABA cost share a copay or coinsurance, and is it charged per-visit or per-day?
- Does the plan's deductible apply to ABA services?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.excellusbcbs.com/prior-authorization (accessed 2026-10-11)
- https://www.emedny.org/providermanuals/allproviders/pdfs/information_for_all_providers_managed_care_information.pdf (accessed 2026-07-23)
- https://provider.excellusbcbs.com/authorizations/sds-portal (accessed 2026-07-23)
- https://www.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23)
- https://www.excellusbcbs.com/documents/d/global/exc-prv-applied-behavior-analysis (accessed 2026-07-23)
- https://provider.excellusbcbs.com/documents/20152/127460/EXC-PRV-Telehealth_Telemedicine+Corporate+Medical+Policy.pdf (accessed 2026-07-23)
- https://provider.excellusbcbs.com/resources/faq (accessed 2026-07-23)
- https://provider.excellusbcbs.com/contact (accessed 2026-07-23)

## Common questions

### Does Excellus BlueCross BlueShield cover ABA therapy?

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.

### Does Excellus require prior authorization for ABA?

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.

### Does a BH vendor manage ABA for Excellus Medicaid members?

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.

### How many RBTs can a BCBA supervise for Excellus BCBS Medicaid members in New York?

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.

### What is the timely filing limit for Excellus BCBS Medicaid ABA claims?

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.

### Does Excellus BCBS accept H0031 or H0032 for ABA?

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.

### Does Excellus require graphs for ABA reauthorization?

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.

## Primary sources

1. [Excellus Medical Policy 3.01.11 — Applied Behavior Analysis (eff. 6/18/2026)](https://www.excellusbcbs.com/documents/d/global/exc-prv-applied-behavior-analysis)
2. [Excellus — Prior Authorization](https://www.excellusbcbs.com/prior-authorization)
3. [Excellus BCBS — Clinical Review Preauthorization List (eff. October 1, 2026, the current edition)](https://www.excellusbcbs.com/documents/d/global/ex_10-1-26_master_2026_pa_pdf_versioncontrol_8-11-26)
4. [Excellus provider portal — SDS authorization portal](https://provider.excellusbcbs.com/authorizations/sds-portal)
5. [Excellus Telemedicine and Telehealth Corporate Medical Policy (#1.01.49)](https://provider.excellusbcbs.com/documents/20152/127460/EXC-PRV-Telehealth_Telemedicine+Corporate+Medical+Policy.pdf)
6. [Excellus — "Navigating the Blues" Billing Orientation Guidebook (Oct 2025)](https://provider.excellusbcbs.com/documents/53971/224461/Navigating+the+Blues+Billing+Orientation+Guidebook.pdf)
7. [NYS DOH Medicaid Managed Care Enrollment Report, July 2026](https://www.health.ny.gov/health_care/managed_care/reports/enrollment/monthly/2026/docs/en07_26.pdf)
8. [eMedNY ABA Provider Policy Manual (state baseline)](https://www.emedny.org/ProviderManuals/ABA/PDFS/ABA_Policy.pdf)
9. [NYS Medicaid Managed Care / FHPlus / HIV SNP / HARP Model Contract (March 1, 2019), §22.6 Timely Payment](https://www.health.ny.gov/health_care/managed_care/docs/medicaid_managed_care_fhp_hiv-snp_model_contract.pdf)
10. [NYS Medicaid ABA Fee Schedule (effective October 1, 2026)](https://www.emedny.org/ProviderManuals/ABA/PDFS/ABA_Fee_Schedule.xls)
11. [NYS Medicaid Telehealth Policy Manual (Version 2026-V2, updated July 2026)](https://www.health.ny.gov/health_care/medicaid/redesign/telehealth/docs/provider_manual.pdf)
12. [Excellus BCBS — Provider news (provider portal news)](https://provider.excellusbcbs.com/resources/news)
13. [NY Insurance Law § 3224-a — Standards for prompt, fair and equitable settlement of claims (NY Senate, rev. 9/19/2025)](https://www.nysenate.gov/legislation/laws/ISC/3224-A)
14. [NYSDOH — Electronic Visit Verification (EVV) Applicable Billing Codes (FFS and Managed Care, rev. March 2022)](https://www.health.ny.gov/health_care/medicaid/redesign/evv/repository/app_billing_codes.htm)
15. [Excellus BCBS Blue Choice Option (Medicaid Managed Care) Member Handbook (revised April 2025)](https://www.excellusbcbs.com/documents/d/global/exc-inp-mdm-blue-choice-option-handbook)
16. [Excellus BCBS HMOBlue Option Member Handbook (revised April 2025)](https://www.excellusbcbs.com/documents/d/global/exc-inp-mdm-hmo-blue-option-handbook)
17. [eMedNY Information for All Providers — General Policy (Version 2022-2)](https://www.emedny.org/ProviderManuals/AllProviders/PDFS/Information_for_All_Providers-General_Policy.pdf)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.