Geisinger Health Plan (with Geisinger Quality Options and Geisinger Indemnity) is the integrated health system’s insurer across central and northeastern Pennsylvania. For ABA it is the easiest of the Pennsylvania commercial plans at the front door: in-network ABA for a child with a valid autism diagnosis no longer needs prior authorization.
That changes what intake has to get right. Instead of assembling an authorization packet, confirm three things: the provider is directly contracted and credentialed with GHP, the diagnosis on the claim is autism, and the plan is not a self-funded or TPA group that has kept its own rules. This guide sets out GHP’s policy MP232, its prior authorization list and forms, and the Act 62 mandate underneath.
Geisinger’s ABA coverage lives in medical policy MP232, "Autism Spectrum Disorder – Evaluation and Medical Management", which applies to Commercial, ACA, CHIP, Medicaid and Medicare lines. The policy says it "is consistent with Pennsylvania state mandated coverage for autism spectrum disorder" and that some provisions "may apply only to those contracts subject to PA Act 62." For ABA it says one thing: "Criteria for coverage will be in accordance with the OMHSAS Bulletin Medical Necessity Guideline for ABA using BSC-ASD & TSS Services for Children & Adolescents with ASD issued Jan 13th 2017."[1][5][11]
MP232 was revised in March 2026 to "revise requirements for parity". The current version no longer contains the treatment-plan documentation checklist or the physician-documentation criteria for PT/OT/speech that the plan’s May 2026 update shows being removed. The 2023 wording that limited ABA to members "eligible for state mandated services" is also not in the current text. The evaluation section lists what GHP treats as medically necessary in an ASD workup for under-21s: screening tools (M-CHAT, SCQ, PDDST-II and others), standardized diagnostic tools (CARS, ADI-R, ADOS), targeted genetic and lab testing, and speech, vision and audiology evaluations.[1][5][11]
The guideline MP232 points to is OMHSAS-17-01, a Medical Assistance bulletin written for the old BSC-ASD/TSS model. For a prior-authorization request it asks for: the most recent face-to-face evaluation or re-evaluation by a board-certified or board-eligible child and adolescent psychiatrist, developmental pediatrician, pediatric neurologist or licensed child psychologist (or, where none is available, a licensed physician or psychologist), "performed not more than 60 days prior to the requested begin date"; a prescription for ABA; and an individualized behavior-based treatment plan.[6][1]
Now that in-network ASD ABA needs no prior authorization, these documents are what GHP would look for on review or when an authorization does apply (non-ASD diagnosis, out-of-network). How strictly GHP applies the Medical Assistance paperwork parts of the bulletin to a commercial member is not stated. Treat it as a question for the Care Connector team.[6][1]
GHP’s prior authorization list (updated August 24, 2026) groups ABA with other non-routine behavioral health services and lists 97151–97158, 0362T and 0373T. Its note reads: "Effective 7/15/2023, ABA service will require a Prior Authorization when billed for any diagnosis except Autism." The provider forms page says the same for network providers: "In-network applied behavioral analysis for autism with a valid diagnosis no longer needs prior authorization." Referrals to non-participating providers still need authorization, and the list marks behavioral health requirements as "Contract Dependent". For Medicare, Commercial, CHIP and most TPA plans, the behavioral health number is 888-839-7972.[2][3][4][7]
Where authorization does apply, GHP’s ABA Request Form covers initial assessment, initial treatment and concurrent review. It asks for hours by setting (home, school, facility/clinic, other) and computes units as hours × 4 × 26, which is a 26-week request. Submit by fax to 570-214-3573 or through the Cohere portal. GHP also requires behavioral health providers to "have a direct contract and be credentialed with GHP to see GHP patients." Commercial ABA rates are negotiated and not published.[2][3][4][7]
On Geisinger policies issued to groups of 51 or more employees (and on GHP Kids, which is CHIP), Act 62 guarantees coverage of the diagnostic assessment and treatment of ASD, including ABA, for members under 21. The CPI-adjusted statutory maximum is $51,908 for 2026 ($53,310 in 2027), which the Insurance Department expects to have no effect under parity. Act 62 lets the insurer review a treatment plan every six months and bars making coverage depend on an IEP. Individual, small-group and self-funded plans are outside it.[8][9][12][13]
Pennsylvania has no behavior-analyst licensure law; the State Board of Medicine licenses Behavior Specialists. MP232 separately treats services by unlicensed practitioners, or services that need no license, as unproven. Whether that reaches BCBAs who hold no Pennsylvania license is something to confirm with GHP credentialing.[8][9][12][13]
The questions that decide whether a family can start with Geisinger Health Plan in Pennsylvania, and what they have to bring. Each maps onto something intake should ask on the first call.
MP232’s evaluation services are framed for "children and adolescents under age 21", and the OMHSAS guideline it adopts covers ABA for children and adolescents under 21. On Act 62 plans the mandate covers members under 21. GHP publishes no separate age cap for commercial ABA, so an adult or individual/self-funded case depends on the plan.[1][6][8]
Ask the plan: GHP Behavioral Health Care Connector, 888-839-7972 — ask whether the plan covers ABA at the member’s age.
GHP asks only for "a valid diagnosis" for authorization-free in-network ABA and defines no expiry. Where the OMHSAS-17-01 documentation applies (authorized requests), it wants the most recent evaluation or re-evaluation "performed not more than 60 days prior to the requested begin date". On Act 62 plans, diagnostic results are "valid for a period of twelve (12) months" unless a physician or psychologist decides otherwise.[3][6][8]
Ask the plan: GHP Behavioral Health Care Connector, 888-839-7972 — ask what makes a diagnosis "valid" (evaluation age, evaluator) for authorization-free ABA.
GHP names no diagnosing-provider list for commercial ABA. The OMHSAS-17-01 guideline MP232 adopts expects the evaluation from a board-certified or board-eligible child and adolescent psychiatrist, developmental pediatrician, pediatric neurologist or licensed child psychologist (or a licensed physician or psychologist when none is available). Act 62 defines the diagnostic assessment as one by a licensed physician, physician assistant, psychologist or CRNP.[6][8]
Ask the plan: GHP Behavioral Health Care Connector, 888-839-7972 — confirm whether a primary-care or nurse-practitioner diagnosis is accepted.
MP232 lists the ASD workup GHP treats as medically necessary: validated screening (Autism Screening Questionnaire, PDDST-II, CHAT, M-CHAT, SCQ) and standardized diagnostic tools (CARS, ADI-R, ADOS). It does not say a particular instrument must be behind the diagnosis before ABA is paid. The ABA request form lists skills assessments such as VB-MAPP, ABLLS-R, functional behavior assessment and functional analysis under 97151.[1][4]
Ask the plan: GHP Behavioral Health Care Connector, 888-839-7972 — ask whether a standardized diagnostic instrument must appear in the evaluation.
GHP does not state a referral requirement for in-network autism ABA, which needs no prior authorization. Out-of-network care needs an authorized referral ("Any referral to a nonparticipating provider/facility for nonemergency services", contract dependent). The OMHSAS-17-01 guideline expects "A prescription for ABA" with an authorization request. On Act 62 plans, treatment must be in a treatment plan developed by a licensed physician or licensed psychologist.[2][6][8]
Ask the plan: GHP Behavioral Health Care Connector, 888-839-7972 — ask whether a physician prescription must be on file for authorization-free ABA.
For in-network autism ABA there is no prior authorization, so no clock. Where authorization applies (non-ASD diagnosis, out of network, some TPA groups): fully insured plans follow Act 146 (Insurance Company Law § 2155) — non-urgent "within 15 days", urgent care not yet started within 72 hours, an ongoing urgent course within 24 hours when requested at least 24 hours before it would be cut, and peer-to-peer offered on denial (GHP Medical Management 800-544-3907). Self-funded plans follow ERISA, 29 CFR 2560.503-1: 15 days plus one 15-day extension, 72 hours urgent.[3][10][15]
Ask the plan: GHP Behavioral Health Care Connector, 888-839-7972 — confirm the group follows the no-auth rule; if not, confirm the review turnaround and concurrent-review lead time.
If the child also has Pennsylvania Medical Assistance (often PH-95, which disregards parental income), GHP commercial pays first. 55 Pa. Code § 1101.64 requires other insurance to be "utilized before billing the MA Program", and IBHS is not paid when a third party is available (§ 1155.31(e)). DHS tells providers to bill the child’s private insurance before MA for ASD assessment and treatment. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA "would be the last payer" (38 CFR 17.270). No Pennsylvania rule fixing the order for a child on both parents’ plans was located, and GHP’s ABA documents do not state one — ask GHP which plan is primary.[16][17][18][19][20][21]
Ask the plan: GHP customer/provider services at benefit verification — ask for the coordination-of-benefits order (birthday rule for two parents’ plans) and record every other coverage the child has.
Not found. GHP’s clinical-policy page loads its list by script and no telemedicine medical or reimbursement policy was retrievable, so which ABA codes GHP pays by telehealth, and with which POS/modifier, is unconfirmed.[14]
Blocked on: GHP Behavioral Health Care Connector, 888-839-7972, or GHP provider services — ask for the telehealth billing policy (eligible ABA codes, POS 02/10, modifier); request the policy document via carelu.com/sources.
Coverage decides whether Geisinger Health Plan in Pennsylvania 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.
GHP’s ABA Request Form (rev. 6/22) describes 97153 as treatment by a technician under the direction of a physician/QHP, "receiving 1 hour of supervision for every 5 to 10 hours of direct treatment". 0362T and 0373T require the physician/QHP to be on site with two or more technicians. MP232 itself sets no supervision ratio.[4]
The ABA Request Form asks for hours by setting — Home, School, Facility/clinic and Other — so GHP will consider requests in those settings. Whether a particular plan pays school-based ABA is contract-specific. Act 62 bars making coverage depend on an IEP but does not require covering a service just because it is in one.[4][8]
Ask the plan: GHP Behavioral Health Care Connector, 888-839-7972 — ask whether the member’s contract pays ABA in school or community settings.
"Behavioral health providers should have a direct contract and be credentialed with GHP to see GHP patients." The ABA request form captures a requesting provider and a servicing provider (each with NPI, TIN and certification/license number). No GHP document read says whose NPI goes in the rendering field for technician-delivered 97153.[3][4]
Ask the plan: GHP credentialing / provider services — ask whether technician services bill under the supervising BCBA’s or the group’s NPI.
Not addressed. MP232, the prior authorization list and the ABA request form say nothing on billing 97153 and 97155 for the same time.[1]
Ask the plan: GHP provider services or the provider agreement — ask whether 97153 and 97155 may be billed for overlapping time.
Not published. GHP posts no per-day or per-week ABA unit ceiling. Where authorization applies, the request form asks for hours and computes units as hours × 4 × 26, a 26-week request. On Act 62 plans the $51,908 (2026) statutory cap is, per the Insurance Department, not expected to affect coverage under parity.[4][9]
Ask the plan: GHP Behavioral Health Care Connector, 888-839-7972 — ask whether the plan applies any unit/hour limit to ABA billed without authorization.
Not addressed. The treatment-plan documentation list (including "Signature of the member ordering physician and therapist") was removed from MP232 in the March 2026 parity revision. No current GHP document read says who must sign an ABA session note.[5][1]
Blocked on: The GHP provider agreement / provider manual documentation section — ask GHP provider services for the behavioral health record standard.
Not in network for autism. GHP says in-network ABA for autism with a valid diagnosis no longer needs prior authorization. ABA billed for any other diagnosis, and out-of-network care, still does. Some self-funded or TPA groups may differ, so confirm at 888-839-7972.
Policy MP232 says ABA coverage follows the Pennsylvania OMHSAS Medical Necessity Guideline for ABA (bulletin OMHSAS-17-01, January 13, 2017). It was written for Medical Assistance and asks for a recent evaluation, a prescription and an individualized treatment plan.
Yes — insured Geisinger groups with 51 or more employees, and GHP Kids (CHIP), must cover ASD assessment and treatment, including ABA, for members under 21. Individual, small-group and self-funded plans fall outside Act 62; MP232 still governs ABA criteria where the benefit exists.
Commercial ABA rates are not published; they are negotiated in your GHP provider agreement.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 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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