Fidelis Care, the Centene-owned plan and largest Medicaid plan in New York, is the clearest illustration of the state's FFS-versus-MMC split: while the state FFS layer needs only a referral, Fidelis layers a full Centene-style clinical policy (FC.CP.BH.301.04) on the state baseline — named assessment instruments, graphed data requirements, a 6-month reauthorization cycle, and heavy concurrent-review documentation. Eligibility mirrors the state (under 21, ASD/Rett, 2-year referral), but the authorization work is entirely Fidelis's own.
A behavioral assessment by a BCBA/LBA-equivalent must be completed before treatment is requested, and the treatment request must show results from at least one specified functional behavior assessment (descriptive FBA, traditional FA, or IISCA) and/or a named skill assessment — VB-MAPP, ABLLS-R, AFLS, PEAK, SSIS, EFL, or Socially Savvy; a Vineland alone is explicitly insufficient — with graphs and tables attached. Concurrent reviews are the heaviest in the state: updated graphs and goal-grid performance, one session note per month for each authorized CPT code (including supervision and family-guidance notes), an updated assessment scoring grid, an updated treatment plan, and a signed visit attestation. Treatment plans update every 6 months, and the Medical Director may adjust review frequency. Intensity: the current policy (last revised 2/26) dropped the old Focused/Comprehensive split; requested hours must be justified against impairment, age, school attendance (“less than 20 hours per week if attending school full-time”) and daily activities, and anything beyond “six hours of direct treatment per day up to a total of 30 hours of direct treatment per week” needs specific clinical documentation plus parent and BCBA signatures on the revised plan. Discharge is indicated when “there has been no clinically significant progress or measurable improvement towards treatment plan goals for a period of at least six months, and there is not a reasonable expectation that a revised treatment plan could lead to clinically significant progress.”[2]
Fidelis runs two clocks: the diagnostic evaluation supporting the request must be within 2 years of the authorization request, and initial requests need a DSM-5 diagnosis made with a validated assessment tool administered within the past 60 months (not required for continuing services). That instrument requirement is stricter than the state's referral rule; the 60-month window is looser in time. The plan also offers a genuine waitlist workaround: if a diagnostic assessment can't be obtained within 6 months of the request, Fidelis will accept a letter of confirmation from a NYS-licensed qualified professional to start services — but only if the member is in, or recently was in, ABA. For intake, that letter can be the difference between starting now and losing a family to a diagnostic waitlist.[2][3]
No ABA in school settings since September 1, 2023 — and for treatment during school hours, providers must first contact the local Committee on Special Education for an independent evaluation, so a school-hours request is a coordination project, not a form field. Every ABA practitioner must complete both Fidelis credentialing and MMIS Medicaid enrollment before serving members, and claims are due within 90 days of the date of service — a short window that punishes slow authorization cleanup. Requests run through the Fidelis Provider Portal at fideliscare.org, with the ABA form on the Provider Policies page. Rates are negotiated per contract; whether Fidelis pays the state fee schedule is not published.[3]
Fidelis Care 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.[9][10][5][6][3][7]
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).[9][10][5][6][3][7]
Fidelis’s own rules, from its Medicaid provider manual: “Claims for services provided to Medicaid and Child Health Plus enrollees must be submitted within 90 days.” Acceptable reasons for a late claim are litigation, primary-insurance processing delays, retroactive eligibility determination and rejection of the original claim for reasons other than timely filing, and a late claim must carry proof of prior billing to another carrier or a letter giving the reason. As secondary payer, file with the primary carrier’s EOB attached “within ninety (90) calendar days of receiving the primary carrier’s explanation of benefits”; a COB corrected claim carries resubmission code 7 and the previous claim number (corrected claims for all lines go to Fidelis Care, Attn: Corrected Claims, 480 Crosspoint Parkway, Getzville, NY 14068). The manual publishes no separate day-count for corrected claims. Payment: “Fidelis Care reimburses providers for services that are billed correctly to Fidelis Care on a weekly basis,” with clean claims paid within § 3224-a; no weekly submission cut-off is published.[9][10][5][6][3][7]
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).[9][10][5][6][3][7]
Code set: Fidelis’s ABA Provider Tip Sheet (01/01/2026) lists CPT 97151–97158 plus the Category III codes 0362T and 0373T, and no HCPCS H-code. 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).[9][10][5][6][3][7]
Taxonomy: Fidelis tells providers with multiple specialties “to submit the appropriate taxonomy code when submitting claim forms” so payment and cost-sharing apply correctly, and says the authorization number and taxonomy code should be on the bill for specialty services; it publishes no ABA-specific taxonomy rule beyond that.[9][10][5][6][3][7]
The questions that decide whether a family can start with Fidelis Care New York (Centene), and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the New York Medicaid rule: ABA is covered for members “under 21 years of age with a diagnosis of Autism Spectrum Disorder (ASD) as defined by… (DSM-5) and/or Rett Syndrome.” No minimum age and no adult pathway — the 21st birthday is a hard cliff. Fidelis applies the same under-21 eligibility and adds F84.3 to the diagnosis list it will accept.[4][2]
The strictest recency stack in New York, and it runs on two clocks. The diagnostic evaluation supporting the request must be within 2 years of the authorization request, and an initial request additionally needs a DSM-5 diagnosis made with a validated assessment tool administered within the past 60 months (the instrument rule does not re-trigger for continuing services). Fidelis also publishes a genuine waitlist workaround: where a diagnostic assessment cannot be obtained within 6 months of the request, it will accept a letter of confirmation from a NYS-licensed qualified professional to start services, provided the member is in or recently was in ABA. Treatment plans then update every 6 months, and the Medical Director may tighten review frequency.[2][3]
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. Fidelis adds its own escape hatch rather than its own credential: where the diagnostic assessment cannot be scheduled within 6 months, a letter of confirmation from a NYS-licensed qualified professional will start services for a member already in or recently in ABA.[4][2]
Named instruments, with graphs — this is where Fidelis departs hardest from the state baseline. The treatment request must show results from at least one specified functional behavior assessment (descriptive FBA, traditional functional analysis, or IISCA) and/or a named skill assessment — VB-MAPP, ABLLS-R, AFLS, PEAK, SSIS, EFL or Socially Savvy — with graphs and tables attached; a Vineland alone is explicitly insufficient. Initial requests separately need the DSM-5 diagnosis made with a validated diagnostic tool administered within the past 60 months. Concurrent review is the heaviest in the state: updated graphs and goal-grid performance, one session note per month for each authorized CPT code including supervision and family-guidance notes, an updated assessment scoring grid, an updated treatment plan, and a signed visit attestation.[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. On top of that, Fidelis is authorization-based: a behavioral assessment by a BCBA/LBA-equivalent must be completed before treatment is requested, and requests run through the Fidelis Provider Portal with the ABA form on the Provider Policies page. Every ABA practitioner must complete both Fidelis credentialing and MMIS Medicaid enrollment before serving members.[4][2][3]
Fidelis publishes a clock tighter than the state model contract: a non-urgent pre-service request is decided “within 3 business days of receipt of necessary information,” and “for standard service authorizations the decision and notification will be made no more than seven (7) calendar days from receipt of the request (unless an extension is requested)”; urgent requests within 72 hours of receipt. A continuing (non-urgent concurrent) request gets a verbal decision “within 1 business day,” “extended up to 14 calendar days with request for additional clinical information,” and “Preservice and concurrent review timeframes may be extended by an additional 14 days.” No ABA reauth lead time is published, but the ABA policy puts reviews on a 6-month cycle and the tip sheet says concurrent reviews “require updated graphs and charts,” monthly session notes per authorized CPT code, an updated treatment plan and a signed visit attestation — so assemble the packet well before the auth ends.[5][2][3]
Bill the other insurance first. “In the event a claim is initially filed with Fidelis Care for which another carrier is determined to be the primary payer, the provider will be notified on a remittance advice to file with the primary insurer.” After the primary pays or denies, “File the claim with Fidelis Care along with the primary carrier’s Explanation of Benefits (EOB) attached” within 90 calendar days of receiving that EOB; “Fidelis Care will coordinate benefits up to Fidelis Care’s allowable as secondary payer.” This sits on the state rule that Medicaid pays last and that the plan must “alert the provider and ask them to bill the TPHI that should be primary.” The manual does not say whether Fidelis’s own ABA prior authorization is still required when it is secondary — confirm with Provider Services (1-888-343-3547) before starting on the primary’s approval alone.[5][6]
Case by case, tied to the state telehealth manual. Fidelis’s ABA clinical policy (FC.BH.301.04, last revised 2/26) says: “The appropriateness of any use of telehealth is determined on an individual basis. Some telehealth may be allowed when clinically appropriate and in alignment with the telehealth manual. Any use of telehealth should be documented in the treatment plan,” linking the NYS Medicaid Telehealth Policy Manual — which includes NYSED-licensed ABA providers, counts assessment among telehealth services and requires that all elements of the billed code be met remotely. No ABA code (assessment 97151/97152, 97155 supervision or otherwise) is pre-approved for telehealth by Fidelis; its Medicaid provider manual says telehealth claims carry modifier GT or 95 and follow NYS Medicaid FFS billing guidance. What Fidelis publishes about setting cuts the other way: no ABA in school settings since September 1, 2023, and treatment during school hours requires contacting the local Committee on Special Education for an independent evaluation first.[2][5][1][3]
Ask the plan: Document the telehealth plan in the treatment plan submitted for authorization and get Fidelis’s approval of it in writing per case (Fidelis provider services).
Coverage decides whether Fidelis Care New York (Centene) 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.” Fidelis adds its own supervision dosage: its ABA policy (last revised 2/26) requires that “Adaptive Behavior Treatment with Protocol Modification occurs for at least two hours per week or 10% of the direct service hours provided (whichever is greater); and no more than 20% of direct service hours provided (unless clinical documentation justifies)” — a 97155 floor well above the state’s 5% — but no technician caseload cap beyond the state’s six. It also adds a documentation consequence: concurrent review requires one session note per month for each authorized CPT code, supervision notes included.[4][2]
No hard cap, but a justification threshold. Fidelis’s ABA policy (last revised 2/26) removed its old Focused/Comprehensive intensity tiers. Requested hours must be justified by impairment, symptom severity and response to treatment and must consider “school attendance requirements, and other daily activities (i.e., less than 20 hours per week if attending school full-time)”; treatment hours either “do not exceed six hours of direct treatment per day up to a total of 30 hours of direct treatment per week” or carry clinical documentation justifying more (data on severe or escalating behaviors, multidisciplinary coordination, and signatures from the parent or guardian and the direct-care BCBA on the revised plan). Fidelis may authorize less than requested when documentation shows lower intensity is sufficient. Discharge is indicated when there has been “no clinically significant progress or measurable improvement towards treatment plan goals for a period of at least six months” without a reasonable expectation that a revised plan would help. The practical ceiling is the authorized units; Fidelis publishes no per-day claim edit.[2][3]
Fidelis requires a “signed visit attestation” at concurrent review alongside one session note per month for every authorized CPT code (supervision and family-guidance notes included), updated graphs and goal-grid performance, an updated assessment scoring grid and an updated treatment plan. The signer of the individual session note is not specified by Fidelis, so the state rule governs underneath: the supervising LBA must review and sign treatment notes and reports prepared by a CBAA supervisee.[2][4]
Stricter than the state baseline in one respect and equal in the rest. New York Medicaid already does not reimburse ABA in a school setting; Fidelis stopped covering school-setting ABA specifically on September 1, 2023, and adds a coordination gate for treatment during school hours — providers “must first contact the local Committee on Special Education for an independent evaluation,” which makes a school-hours request a coordination project rather than a form field. Home, clinic and community remain available per the state’s any-legally-authorized-setting rule.[3][4]
Fidelis publishes no rendering-versus-supervising NPI convention of its own; what it does say is that “All ABA practitioners are expected to go through credentialing and MMIS Medicaid enrollment prior to servicing Fidelis members,” which mirrors the state’s enrollment architecture. 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 managed-care claim format with Fidelis, since the state manual directs MMC providers to their plan for billing guidance.[3][4]
Ask the plan: Fidelis provider services for the MMC claim format — the eMedNY convention above is the FFS reference, not a Fidelis-published rule.
Not published. Fidelis’s ABA policy governs medical necessity and documentation, not claim edits, and says nothing about billing 97153 and 97155 for the same clock time; the state manual is silent too.[2][4]
Ask the plan: Fidelis provider services and the plan’s claim-editing/reimbursement policies on fideliscare.org.
Case by case. Fidelis’s ABA policy says some telehealth “may be allowed when clinically appropriate and in alignment with the” NYS telehealth manual, and it must be documented in the treatment plan. No code is pre-approved, so get the telehealth plan approved with the authorization.
Yes — for NY Medicaid members under 21 with ASD or Rett syndrome, under its own Centene-derived clinical policy: assessment completed first, treatment authorized with named instruments and graphed data, and 6-month reauthorization cycles.
Initial requests need a DSM-5 diagnosis using a validated assessment tool administered within the past 60 months, and the supporting diagnostic evaluation must be within 2 years of the authorization request. Continuing services don't re-trigger the instrument rule.
No — Fidelis stopped covering school-setting ABA September 1, 2023. For treatment during school hours, contact the local Committee on Special Education for an independent evaluation first.
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.
Medicaid and Child Health Plus claims are due within 90 days. Fidelis pays correctly billed claims weekly, with clean claims paid within Insurance Law § 3224-a (30 days electronic, 45 days paper). As secondary payer, file within 90 calendar days of the primary EOB; corrected claims use resubmission code 7 with the original claim number. No weekly submission cut-off is published.
No H-code appears on Fidelis’s ABA code list: its tip sheet lists CPT 97151–97158 plus 0362T and 0373T. The New York Medicaid ABA fee schedule underneath carries only 97151–97158. Bill ABA on the CPT codes and confirm 0362T/0373T with Fidelis before using them.
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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