Fidelis Care New Jersey — the Centene plan formerly branded WellCare of NJ — administers the NJ FamilyCare ABA benefit with the least published detail of the five MCOs. Our best-evidence read: it runs the state benefit through generic Centene behavioral-health UM machinery, with no distinct ABA clinical policy, fee schedule, or unit-cap document surfaced anywhere public. That makes this a state-baseline plan with gaps — the clinical rules to plan against are NJ FamilyCare's, and the plan-specific specifics (forms, caps, rates) are phone calls, not lookups.
No Fidelis-specific ABA clinical policy, fee schedule, or hour-cap document has been published — the plan appears to defer to the state criteria (unverified). Practically, plan requests against the NJ FamilyCare baseline: an ASD diagnosis from a QHP, an MCO-authorized assessment, and treatment contingent on treatment-plan approval, with the state's daily unit guide as the likely claim-edit surface. Outpatient authorization requests go through the provider portal at provider.fideliscarenj.com (Fidelis calls it the fastest route) or by fax to (888) 339-2677 per the state's contact sheet, with progress reports uploaded via the portal or faxed. One recent tightening: "In preparation for the end of Phase 1 Flexibility for BHI, providers are now required to submit clinical documentation along with all prior authorization request[s]" — send the clinicals with the first request, not on request. Because nothing ABA-specific is published, confirm assessment-request format, authorization spans, and unit handling with the plan's UM contact before your first submission rather than after your first denial.[2][1][3]
The state's BH integration contact sheet — which still titles the plan "Fidelis Care (Formerly Wellcare)" — names the ABA UM/PA contact as Amber Johnson (770-809-7313, Amber.Johnson@centene.com) and the ABA contracting contact as Michael Czajkowski (862-702-6529, Michael.Czajkowski@fideliscarenj.com). Provider services runs at 1-888-453-2534; claims route through Availity under payor ID 14163, and claims disputes mail to Tampa, FL (Centene shared services). Watch the rebrand at intake: families, cards, and stale directory listings may still say WellCare — it's the same plan. Fidelis's own Medicaid Quick Reference Guide (October 2026 edition) names a different pair "For Autism Services including prior authorization": April Hames, Sr. Director, Clinical Operations (AHAMES@centene.com), and Stephanie Ryan, Manager, Clinical BH Utilization Management (Stephanie.C.Ryan@centene.com) — the plan's own document is the more current of the two.[1][11]
Only after retroactive eligibility or an emergency. Fidelis Care's 2026 New Jersey Medicaid manual: Fidelis "will review post-service requests for authorization of inpatient admissions or outpatient services only if, at the time of treatment, the Member was not eligible but became eligible with Fidelis Care retroactively or in cases of emergency treatment and the payer is not known at the time of service." The review uses "the same approved medical criteria used for the pre-service decisions," and "All services performed without Prior Authorization are subject to Retrospective Review by Fidelis Care." So ABA delivered before a family's Fidelis enrollment was made retroactive can be reviewed; a missed authorization for a member who was already enrolled cannot.[7]
Filing: “Unless otherwise stated in the Agreement, Provider must submit claims (initial and voided) within 180 calendar days from the date of service,” and corrected claims within 365 calendar days. Taxonomy: “Providers should submit claims with the correct taxonomy code consistent with Provider Demographic Information for the Covered Services being rendered in order to be reimbursed at the appropriate rate. Fidelis Care may pay the claim at the lower reimbursement rate if the taxonomy code is incorrect or omitted.” Fidelis also rejects claims without the tax ID and NPI.[7][8]
Payment: “Fidelis Care will pay Clean Claims within 30 days after receipt when submitted electronically, or 40 days after receipt when submitted in a manner other than electronically,” under N.J.A.C. 11:22-1.1 et seq.; a clean claim sent to a clearinghouse is not received until Fidelis gets it. The state contract holds behavioral health claims, ABA included, to 90% processed within 15 days electronic and 30 days paper. Disputes: “Claim payment disputes must be submitted to Fidelis Care in writing within 90 calendar days of the date of denial on the EOP.” Coordination of benefits: Fidelis says to bill the primary insurer first and send the balance with “a copy of the EOB,” but its manual sets no COB deadline, so the state contract’s required provider-contract term applies: COB claims within 60 days of the primary insurer’s EOB or 180 days from the date of service, whichever is later. Payment cycle: Fidelis pays through PaySpan (EFT and ERA; paper EOPs have stopped) and publishes no check-run day or weekly submission cutoff, so the prompt-pay clock runs from the day Fidelis receives a clean claim. EVV: Fidelis applies EVV to the provider types CMS has brought into the mandate and does not name ABA; the state contract limits EVV to personal care services.[7][8]
Fidelis Care’s 2026 New Jersey manual lists ABA among covered autism services but publishes no ABA code list and names no H-code for it. The state sets the code set: the NJ FamilyCare managed care contract’s ABA service description lists the “HIPAA Compliant Billing Codes” as CPT 97151–97158 plus 0362T and 0373T, in 15-minute units, the same codes as the founding DMAHS ABA newsletter. H0031 and H0032 are not on that list, so bill Fidelis Care ABA with those CPT codes.[7][8][3]
The questions that decide whether a family can start with Fidelis Care New Jersey (formerly WellCare), and what they have to bring. Each maps onto something intake should ask on the first call.
Two published numbers, and they differ in precision rather than in substance. The founding DMAHS newsletter sets the benefit for "any Medicaid eligible child, under the age of 21, who has been diagnosed with ASD as defined by ICD 10 diagnoses F84.0 through F84.9 by a qualified healthcare provider," delivered under EPSDT, which reaches "individuals under the age of twenty-one." Optum's New Jersey Medicaid entry adds the floor as well as the ceiling: "ABA services shall be made available to children 18 months to 21 years of age based on medical necessity," and its NJ FamilyCare provider orientation repeats it — "Must be 18 months – 21 years old," including in the specialized FamilyCare carve-out. No hour caps are attached to the age band. Fidelis publishes no NJ-specific ABA policy at all, so the state band is the only published answer.[3][4]
New Jersey names them twice, and the second list is narrower than the first. The newsletter's general test: "The need for ABA services must be determined by a qualified healthcare professional (QHP) capable of making a diagnosis of autism. QHPs include licensed health care professionals, who are qualified by education, training, or licensure/regulation (when applicable) to perform a professional service within his/her scope of practice." The enumerated list of acceptable QHPs "for the diagnosis and treatment planning for adaptive behavior services" is then: Physicians; Psychologists, which "Requires an active board certified behavior analyst (BCBA) certification in good standing and a qualifying doctoral-level degree (BCBA-D)"; and BCBAs, who appear for treatment planning rather than diagnosis. Optum's NJ entry restates the split: the diagnosis comes from "a physician or psychologist," and "It is not uncommon for one QHP to make the diagnosis (such as a physician) and a separate QHP (such as a BCBA) to develop and supervise the treatment plan." No Fidelis-specific diagnostician list is published.[3][4]
None required — and New Jersey is one of the few states that says so in terms. Optum's NJ Medicaid entry: "A comprehensive diagnostic evaluation is not required to access ABA services," with "ABA services … available to any child diagnosed with autism spectrum disorder as defined by ICD-10 diagnoses F84.0 through F84.9." The DMAHS newsletter names no instrument either. That makes this the friendliest diagnostic bar of the three states on this page — intake should not queue a New Jersey family for an ADOS-2 before starting the authorization. Fidelis Care New Jersey publishes no deviation from this, and its own material was checked for one.[4][3]
No PCP referral and no physician order. The sequence the state sets is QHP determination, then MCO authorization: "Once an individual is properly diagnosed with ASD, the MCO shall authorize a QHP to assess the child for the development of a proposed treatment plan," and treatment follows "Contingent upon approval of the treatment plan." The genuine intake asset sits one step earlier — members still fee-for-service pending MCO enrollment are covered through Gainwell with no prior authorization required at all, so enrollment status, not a referral, is the routing question. Plan practice adds paperwork rather than a referral: Horizon wants an ASD diagnosis "script" from a QHP attached to the assessment request, which is the diagnosis document under another name. Fidelis publishes no ABA-specific request format, so confirm what its UM expects in the packet before the first submission rather than after the first denial; outpatient authorization requests go through provider.fideliscarenj.com or fax (888) 339-2677.[3][2]
The plan publishes no ABA telehealth rule of its own, so the state statute governs. N.J.S.A. 30:4D-6k (as amended by P.L.2021, c.310) requires the State Medicaid and NJ FamilyCare programs to "provide coverage and payment for health care services delivered to a benefits recipient through telemedicine or telehealth, on the same basis as" in person, for services otherwise covered in person, with payment to the practitioner or the employing agency. The programs may limit coverage to participating providers, but may not restrict the originating site (the child's home counts) or the distant site except to keep the in-person standard of care, may not restrict the platform (audio-only included) if it meets that standard and HIPAA, and may not require a member to use telehealth instead of in-person care. Coverage can still be limited to medically necessary services. No DMAHS ABA document names an ABA telehealth code list, POS or in-person supervision minimum, so the 97151 assessment and 97155 supervision are covered by telehealth on the same basis as in person when medically necessary, and billing details come from the MCO. Claim coding comes from the state: DMAHS Medicaid Alert MA-2023-02 (April 2023) says “a provider must use the new Facility Code value of “10” for “Telehealth Provided in a Patient's Home”,” and POS 02 when telehealth is provided anywhere else, for “both Fee-For-Service and encounter claims,” so remote 97153 to a child at home goes out with POS 10. The last DMAHS billing instruction on modifiers, issued as temporary guidance in April 2020, says telehealth is billed with “the same billing codes and rates” as in person and “There is no need to use any additional procedure codes or additional modifiers.” Fidelis Care’s 2026 manual adds only that telehealth is an approved mode of delivery under NJ FamilyCare; it publishes no modifier, place-of-service rule or telehealth flag for the authorization, so confirm with Fidelis before billing a modifier.[6][3][9][10][7]
Fidelis Care's 2026 NJ manual: routine (non-urgent) prior authorization determinations "within seven (7) calendar days (or sooner as required by the needs of the Member) of receipt of necessary information sufficient to make an informed decision"; urgent determinations "within twenty-four (24) hours of receipt of the necessary information, but no later than seventy-two (72) hours after receipt of the request for service" — ask for expedited decisions by telephone or the portal, not fax. Continued or extended services (a reauthorization during an ongoing course of treatment) are "determined and communicated by telephone and in writing within one (1) business day of receipt of the necessary information." Federal floor for every NJ FamilyCare MCO: standard decisions within 7 calendar days of the request for contract rating periods starting on or after January 1, 2026 (14 days before that), extendable by up to 14 calendar days at the member's or provider's request or when the plan justifies needing more information; expedited within 72 hours.[7][13]
Fidelis Care's manual: "Providers shall bill primary insurers for items and services they provide to a Member before they submit claims for the same items or services to Fidelis Care," with the primary's EOB and payment amount on the claim; if the primary paid at least Fidelis's liability nothing more is paid, otherwise Fidelis pays the difference up to its allowed amount; if the primary coverage ended, submit proof of termination. The manual publishes no rule on whether Fidelis's own authorization is needed when it is secondary — confirm with Fidelis Provider Services (1-888-453-2534) before relying on the primary's authorization alone. State rule underneath: NJ FamilyCare pays last: "All TPL, for example, health insurance, Medicare, CHAMPUS, prepaid health plans… shall, if available, be used first and to the fullest extent." Bill the commercial plan first; supplementation claims "shall not be filed with the program unless accompanied by a statement of payment, Explanation of Benefits (EOB), or denial from the other carrier." Two traps: "No program payments shall be made when the third-party payer requires a contracting or participating provider to accept that third-party payer's payment as payment in full," and when NJ FamilyCare is secondary it pays the lesser of its allowed amount minus other payments, or the patient liability. TRICARE and CHAMPVA both pay ahead of Medicaid: TRICARE rules state "Medicaid is not a double coverage plan. In any double coverage situation involving Medicaid, CHAMPUS is always the primary payer," and CHAMPVA "assumes primary payer status" over Medicaid.[7][14][15][16]
Not published. Neither the DMAHS newsletter nor Optum's New Jersey entry sets a maximum age for the diagnostic evaluation, and the state's written position runs the other way: Optum's NJ Medicaid entry says flatly that "A comprehensive diagnostic evaluation is not required to access ABA services," so there is no comprehensive evaluation whose recency could be gated. What is dated in New Jersey is the authorization rather than the diagnosis — Horizon issues 32 units of 97151 valid for 30 days, and treatment authorizations run in 6-month spans.[3][4]
Ask the plan: Fidelis Care New Jersey's ABA UM contact (per the DMAHS BH integration contact sheet) before the first submission — nothing ABA-specific is published by the plan.
Coverage decides whether Fidelis Care New Jersey (formerly WellCare) pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
The state sets who supervises whom, but no ratio, percentage or caseload cap. The NJ FamilyCare managed care contract’s ABA service description (01/2026): “A BCaBA may only practice under the supervision of a BCBA or BCBA-D. A BCaBA may supervise a Registered Behavior Technician (RBT) or Behavior Technician (BT) but may not create or modify a treatment plan,” and “Behavior Technicians (BTs) are paraprofessionals practicing under the supervision of a BCaBA, BCBA, or BCBA-D.” A BT or RBT “may provide only those services delegated to them by a licensee,” the licensee may not delegate “the assessment of a client, the development of a treatment plan, or the development of interventions,” and the licensee “is responsible for the care a client receives.” The billing side of supervision is the founding DMAHS newsletter’s: 97155 counts only while the analyst is with the child or directing the technician, never for supervision without the technician present. Fidelis Care publishes no technician-per-analyst cap or supervision percentage of its own (its 2026 New Jersey provider manual checked), so no numeric cap applies beyond your contract and the BACB’s RBT supervision standard.[8][3]
New Jersey says yes, in writing, and draws the line precisely. “If the QHP is overseeing the activities of the technician, the time of direct supervision by the QHP shall be concurrently billable using code 97155.” But “billing for 97155 is limited to time where the QHP is either engaged directly with the patient or is directing a technician in implementing a modified protocol with the patient. Billing for supervision where the technician is not present is not allowed.” Two other concurrency rules ride along: 97156 may be billed while the RBT delivers direct treatment to the child “in a separate location”; and for 0373T “providers may not bill for the QHP time concurrently” and billing is limited to a single technician’s face-to-face time, never the combined time of multiple technicians (three technicians for two hours bills eight units, not twenty-four). This is NJ FamilyCare state policy and the operative floor for Fidelis Care New Jersey; no plan-specific deviation was found in Fidelis Care New Jersey’s published material.[3]
Ask the plan: Fidelis Care New Jersey provider services, to confirm the plan has not layered its own concurrency edit on top.
The current rule is the NJ FamilyCare managed care contract, not the 2020 newsletter. The contract’s ABA service description (Appendix B.4.4, 01/2026 edition) sets “Medically Unlikely Edit (MUE) Limits” per day, in 15-minute units: 97151 32, 97152 16, 97153 32, 97154 18, 97155 24, 97156 16, 97157 16, 97158 16, 0362T 16, 0373T 32. That is higher on three codes than the founding DMAHS newsletter’s April 2020 table (97152 8, 97154 12, 0362T 8), which the newsletter labelled “for guidance purposes only” and overridable “when medically necessary based on individual need” under EPSDT. Plan against the contract figures as the edits the MCOs run; a request above them needs explicit EPSDT medical-necessity framing rather than a quiet resubmission. Fidelis Care New Jersey publishes no daily table of its own, so the contract table is what to plan against.[8][3]
Ask the plan: Fidelis Care New Jersey’s provider manual / claim-edit list.
This one has moved and the two live sources disagree. The founding DMAHS newsletter is flat: “ABA services may be provided in the therapist’s office, a community setting or the child’s home. Services may not be provided within a school facility.” Optum’s ABA State Mandates document (annual review 7/2026), whose NJ Medicaid entry tracks the same state policy, now reads: “Services may be provided in the school setting as long as services are not provided during normal school hours.” Office, home and community are settled; school is plan-dependent and moving; group home is addressed by neither. The NJ FamilyCare managed care contract (01/2026) now says: “Services may be provided in the home, provider office or community settings,” and “Covered services do not include services required to be provided in school as part of a child’s Individual Education Plan (IEP).” That carves out IEP services rather than every school building, so school stays a question for the plan. Neither position is republished by Fidelis Care New Jersey, so resolve it with the plan before scheduling school-based sessions.[8][3][4]
Ask the plan: Fidelis Care New Jersey provider services.
Neither the state nor Fidelis Care New Jersey publishes a session-note signature rule for ABA — no named signer and no timeframe.
Blocked on: Fidelis Care New Jersey’s provider manual documentation chapter, or DMAHS’s Autism Line (609-588-8522).
Fidelis publishes no telehealth billing rule of its own. The state requires POS 10 when the child is at home and POS 02 elsewhere on Medicaid claims, and its last billing guidance needed no extra modifier. Confirm the modifier with Fidelis before billing.
Not as published. The NJ FamilyCare contract lists the ABA billing codes as 97151–97158, 0362T and 0373T, and Fidelis publishes no other ABA codes.
Yes — it administers the NJ FamilyCare ABA benefit (EPSDT, ASD diagnosis, MCO-authorized assessment and treatment plan). No plan-specific ABA policy is published, so the state baseline is the rulebook to plan against.
Yes — WellCare of NJ rebranded to Fidelis Care under Centene. The state's own contact documents still carry both names.
Unverified — no fee schedule or ABA rate document is published. Your provider contract is the only source of truth; benchmark against the state FFS schedule ($15.00/unit 97153, $21.25 97155, $25.00 97151/97156).
Yes. N.J.S.A. 30:4D-6k requires NJ FamilyCare to cover telehealth on the same basis as in-person care, with no originating-site restriction, so the child can be at home. That includes the 97151 assessment and 97155 supervision when medically necessary. No state ABA document sets a code list or POS, so confirm billing with the MCO.
Only when the member became eligible with Fidelis retroactively, or in an emergency where the payer was unknown. Fidelis then reviews the services against the same criteria it uses before services.
180 calendar days from the date of service unless your agreement says otherwise; corrected claims within 365 days. Payment disputes are due within 90 calendar days of the denial date on the EOP.
It asks for the correct taxonomy code on every claim and says it may pay at a lower rate if the taxonomy is wrong or missing.
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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