---
title: "Harvard Pilgrim ABA coverage in Maine: the intake guide."
url: "https://carelu.com/payers/harvard-pilgrim-maine"
markdown_url: "https://carelu.com/payers/harvard-pilgrim-maine.md"
state: ME (Maine)
payer: Harvard Pilgrim Health Care (Maine)
kind: Commercial insurance
description: "How Harvard Pilgrim Health Care (Point32Health) covers ABA in Maine: the July 2026 InterQual-based guideline, prior authorization on every ABA code, what it won’t pay for, telehealth at 100%, and Maine’s autism mandate (age 10 and under, $36,000 ABA cap allowed)."
last_reviewed: October 2026
---

# Harvard Pilgrim ABA coverage in Maine: the intake guide.

_Payer Guide · Harvard Pilgrim · Maine · Last updated October 2026 · 22 primary sources_

> Point32Health’s Maine commercial plan: PA on all ABA codes via InterQual (MNG eff. 7/1/2026), ME behavioral telehealth paid at 100%.

Harvard Pilgrim Health Care, part of Point32Health, sells commercial plans in Maine. One medical necessity guideline covers ABA for Harvard Pilgrim and Tufts Health Plan commercial products, and its reference list cites Maine’s autism statute (24-A M.R.S. § 2768). It relies on InterQual criteria, which are licensed, so the decision logic is not public. What is public: which codes need authorization, which diagnoses qualify, how to submit, and what Point32Health will not pay for.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Yes: 97151 and 97152 require prior authorization for Harvard Pilgrim commercial products (MNG effective July 1, 2026) [1]
- **Prior auth for treatment**: Yes: 97153–97158, 0362T and 0373T require prior authorization; request through HPHConnect’s InterQual questionnaire, with clinical notes uploaded or faxed to 800-232-0816 [1]
- **Autism diagnosis required?**: Yes: a definitive ASD diagnosis, ICD-10 F84.0, F84.3, F84.5, F84.8 or F84.9 (the Down syndrome codes apply to Massachusetts products only) [1]

## At a glance

- **Covers ABA?:** Yes, for a definitive ASD diagnosis, per the Point32Health commercial MNG
- **Criteria:** InterQual (licensed), via HPHConnect questionnaire; MNG effective 7/1/2026
- **State mandate:** 24-A M.R.S. § 2768 (individual), § 2847-T (group), § 4259 (HMO)
- **Mandate age:** 10 years of age or under (raised from 5 by P.L. 2013, c. 597, from 1/1/2015)
- **Mandate caps:** Plans may cap ABA at $36,000 per year; no visit limits allowed
- **Exempt from mandate:** Self-funded ERISA employer plans (outside state insurance law)
- **Licensure:** None: Maine does not license behavior analysts; the mandate requires national-board (BACB) certification or supervision
- **Fee schedule:** Not public — paid at your contracted rates and fee schedule (Point32Health ABA payment policy)

## The Point32Health guideline, applied in Maine

The Point32Health guideline "Applied Behavioral Analysis (ABA) for Commercial Products and Tufts Health Direct" (effective July 1, 2026) applies to Harvard Pilgrim commercial products, marks prior authorization "Yes," and lists 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T and 0373T. Harvard Pilgrim requests go through the automated InterQual questionnaire on HPHConnect, with clinical notes uploaded there or faxed to 800-232-0816; the criteria can be viewed in HPHConnect or through the commercial Provider Service Center at 800-708-4414. Outside Massachusetts, the guideline says to use the "Autism Spectrum Disorder Services Prior Authorization Request Form." Since March 1, 2026, for members aged 13–20 the plan "will not use the age-related ‘Limited Evidence’. Age alone will not initiate secondary review." Point32Health’s ABA authorization form carries a code grid for Harvard Pilgrim and Tufts commercial products in NH, ME and RI, requested in units per six-month period. [1][2][8]

The payment policy (rev. 05/2026) lists what Point32Health does not pay for: recreational therapy, respite, "Services provided in a school setting that are covered by the educational system’s special education resources as part of the individual education plan (IEP)," escorting a member to another therapy, "Services provided by an immediate family member," vocational rehabilitation, and unproven treatments such as facilitated communication. For self-insured groups, "coverage may vary depending on the terms of the benefit document." [1][2][8]

## The Maine mandate: what it guarantees

Maine’s autism mandate is written three times, once for each kind of contract: 24-A M.R.S. § 2768 for individual health insurance, § 2847-T for group policies, and § 4259 for individual and group HMO contracts. The operative text is the same in all three. The plan "must provide coverage for autism spectrum disorders for an individual covered under a policy or contract who is 10 years of age or under." It must cover "any assessments, evaluations or tests by a licensed physician or licensed psychologist to diagnose whether an individual has an autism spectrum disorder," and must cover treatment "when it is determined by a licensed physician or licensed psychologist that the treatment is medically necessary," with ongoing medical necessity demonstrable "at least annually." It "may not include any limits on the number of visits," but it "may limit coverage for applied behavior analysis to $36,000 per year" (the group and HMO versions add "to the extent allowed by federal law"), and payments for unrelated care may not count toward that cap. ABA is covered as a habilitative or rehabilitative service, and "To be eligible for coverage, applied behavior analysis must be provided by a person professionally certified by a national board of behavior analysts or performed under the supervision of" such a person. The mandate does not change a school’s obligations under an IEP or IFSP. The age ceiling was 5 until P.L. 2013, c. 597 raised it to 10 for policies issued or renewed from January 1, 2015. Two practical consequences: a child turns out of the mandate at 11, after which ABA depends on the plan’s own terms; and the mandate binds fully insured plans regulated in Maine, not self-funded employer plans, which answer to ERISA and their plan documents. [9][10][11][12]

## Credentialing, licensure and rates

Maine does not license behavior analysts. The BACB’s U.S. licensure table, which lists every state with a behavior-analyst licensure law and its board, does not include Maine, and Title 32 of the Maine Revised Statutes (professions and occupations) has no behavior-analyst chapter (chapter 141, sometimes cited for this, is the professional land surveyors chapter). The working credential is BACB certification, which the mandate itself requires for whoever provides or supervises ABA. Maine’s credentialing statute still helps: under 24-A M.R.S. § 4303(2)(D) a carrier must decide a completed credentialing application "within 60 days," must review a new application within 30 days and return an incomplete one "with a comprehensive list of all corrections needed," and "may not require that a provider have a home address within the State." Under § 4303(2-A), once credentials are granted the carrier pays claims for services rendered "from the date a complete application for credentialing is submitted," though you may not submit those claims until the carrier tells you the credentialing outcome and effective date. Commercial ABA rates are negotiated and unpublished, and the MaineCare ABA rate (Section 28, H2021 U1 HK) sits on a fee schedule we could not retrieve this month. [18][19][15][10][23]

## What is Harvard Pilgrim’s fee schedule for ABA?

Harvard Pilgrim publishes no ABA rate table. Point32Health’s ABA payment policy (rev. 05/2026) says: "Providers are reimbursed according to the applicable contracted rates and fee schedules." Its telehealth payment policy (rev. 07/2026) pays Maine behavioral health telehealth at 100% of the applicable fee schedule, the same as in person (Maine medical telehealth is listed at 80%). Get your rates from your Harvard Pilgrim agreement or the Provider Service Center (800-708-4414). [2][7]

## Claims in Maine: payment timing, retro denials and appeals

Maine’s prompt-pay law, 24-A M.R.S. § 2436, makes a health claim "payable within 30 days after proof of loss is received"; a claim "neither disputed nor paid within 30 days is overdue" and bears interest at 1½% a month. A provider may submit a claim to every carrier that may be liable, primary and secondary, at the same time, and each must pay or deny "within 30 calendar days after the carrier has received all information needed," whether or not the other carrier has acted. A claim the carrier rejects for not using the standard claim form cannot be billed to the family; fix and resubmit it. After payment, § 4303(10) bars a carrier from retrospectively denying a paid claim more than 12 months after payment unless it gives the reason in writing and the claim falls within narrow exceptions (up to 36 months for duplicate payment, services not delivered, adjustment with another insurer or legal action; beyond that only for fraud or Medicaid/Medicare/CHIP claims). Appeals of an adverse treatment decision must be heard by a clinical peer who was not involved in the first decision (§ 4304(7)). The timely-filing limit itself is a contract term, not a statute. Point32Health’s ABA documents do not state a filing limit; use the one in your Harvard Pilgrim agreement. [16][15][13][2]

## Intake gates

The questions that decide whether a family can start with Harvard Pilgrim Health Care (Maine), and what they have to bring.

- **Referral required?**: No PCP referral for ABA. Harvard Pilgrim's provider manual (Referral Policy, March 2026) says "Harvard Pilgrim does not require referrals for behavioral health services"; members are pointed to member services to access mental health care, and PPO members never need referrals. What the plan does require is prior authorization under the ABA medical necessity guideline. Harvard Pilgrim publishes no ABA physician-order form. Where a referral is needed for other specialty care, it is shown on the CMS-1500 with the PCP's name in box 17 and NPI in box 17b, and standing referrals last 364 days; ABA, as behavioral health, falls outside that rule. For a fully insured Maine plan, the mandate covers treatment "when it is determined by a licensed physician or licensed psychologist that the treatment is medically necessary," and the plan may require that physician or psychologist to demonstrate ongoing medical necessity "at least annually." Self-funded ERISA plans sit outside the statute. [3][1][10]
- **Telehealth**: Covered under Point32Health’s Telehealth/Telemedicine payment policy (rev. 07/2026), which applies to Harvard Pilgrim commercial products and pays "medically necessary telehealth/telemedicine services consistent with applicable state mandates" when the service is clinically appropriate as a substitute for in-person care, the patient is present and consents, both locations are documented and the platform is HIPAA compliant. Commercial claims use POS 02 or 10 with modifier 93, 95 or GT, and Maine behavioral health telehealth is paid at 100% of the fee schedule. The ABA documents publish no ABA telehealth code list. For a fully insured Maine plan, 24-A M.R.S. § 4316 says a carrier "may not deny coverage on the basis that the health care service is provided through telehealth if the health care service would be covered if it were provided through in-person consultation," that "Prior authorization is required for telehealth services only if prior authorization is required for the corresponding covered health care service," and that "An in-person consultation prior to the delivery of services through telehealth is not required." Coverage may not be limited "on the basis of geography, location or distance for travel," and the carrier may not add telehealth-only credentialing. Self-funded employer plans are outside the statute. [7][14][1]
- **Age limit** _(plan-dependent)_: The MNG sets no age cap, and since March 1, 2026 age alone does not trigger secondary review for members 13–20. For fully insured Maine plans, 24-A M.R.S. §§ 2768, 2847-T and 4259 require autism coverage for a covered person "10 years of age or under" and allow ABA to be capped at $36,000 a year; from age 11 the plan’s own terms decide. Self-funded ERISA plans are outside the statute. [1][9][10][11]
  - Ask the plan: Live benefits verification: establish fully insured vs. self-insured, then the benefit document’s age terms for a child 11 or older.
- **Who may diagnose** _(plan-dependent)_: The MNG requires "a definitive diagnosis" of ASD but does not name who may make it. For a fully insured Maine plan, the mandate covers diagnostic testing by a licensed physician or licensed psychologist. [1][10]
  - In licensed criteria: HPHConnect InterQual criteria view, or Provider Service Center, 800-708-4414.
- **Prior-auth decision time** _(plan-dependent)_: Depends on how the plan is funded. Fully insured Maine plans fall under 24-A M.R.S. § 4304(2): a provider’s prior-authorization request for a nonemergency service "must be answered by a carrier within 72 hours or 2 business days, whichever is less." The same clock restarts when the carrier asks for more information (from receipt of it) or says outside consultation is needed. "If a carrier does not grant or deny a request for prior authorization within the time frames required under this subsection, the request for prior authorization by the provider is granted." Once approved, the carrier "may not retrospectively deny coverage or payment for the originally approved service" absent fraudulent or materially incorrect information, and may not deny the claim when the service is delivered within 14 days before or after the approved date. Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1 instead: pre-service decisions "not later than 15 days after receipt of the claim," one 15-day extension. Harvard Pilgrim publishes no Maine-specific ABA turnaround or reauthorization lead time. [13][20]
  - Ask the plan: At benefits verification ask whether the plan is fully insured (Maine-regulated) or self-funded (ERISA), and what reauthorization lead time Harvard Pilgrim expects.
- **Other insurance (who pays first)** _(plan-dependent)_: Maine lets a provider bill every potentially liable carrier at once: under 24-A M.R.S. § 2436(1-A) each carrier, primary or secondary, must pay or deny "within 30 calendar days after the carrier has received all information needed to pay or deny the claim whether or not another carrier with which it is attempting to coordinate has acted." If two carriers cannot agree on the order of benefits within 30 days of having everything they need, Bureau of Insurance Rule ch. 790 says they "shall immediately pay the claim in equal shares" and settle up afterward, with neither paying more than it would have as primary. We did not find Maine’s order-of-benefit (birthday-rule) text this month, so ask the carriers which plan is primary. If the child also has MaineCare, Harvard Pilgrim pays first: "MaineCare is the payer of last resort," and a medical-necessity denial from the commercial plan must be appealed before MaineCare will consider the claim (MaineCare Benefits Manual Ch. I, § 1.07-3). TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270). [16][17][21][24][25][26]
  - Ask the plan: Ask Harvard Pilgrim at benefits verification for the member’s coordination-of-benefits order (and whether a self-funded plan follows its own order), and record every other coverage the child has, including MaineCare.
- **Diagnosis recency** _(licensed criteria)_: Not published; any recency expectation sits in the licensed InterQual criteria. [1]
  - In licensed criteria: HPHConnect InterQual criteria view, or Provider Service Center, 800-708-4414.
- **Diagnostic tools required** _(licensed criteria)_: Not published; any instrument requirement sits in the licensed InterQual subsets ("Initial Applied Behavior Analysis Assessment" and the ABA Program subsets). [1]
  - In licensed criteria: HPHConnect InterQual criteria view, or Provider Service Center, 800-708-4414.

## Delivery and billing rules

Coverage decides whether Harvard Pilgrim Health Care (Maine) 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.

- **Daily limits / MUEs**: Harvard Pilgrim applies Medicare's per-day MUEs. Point32Health's Maximum Units payment policy (rev. 09/2026) says that for Harvard Pilgrim "CMS unit values (MUE) for CPT or HCPCS codes will be utilized when available," with a maximum frequency per day where none exists, and "Additional reimbursement will not be made for those services that exceed the CMS MUE." CMS's practitioner MUE table effective 10/1/2026 sets, per date of service: 97151, 8 units; 97152, 16; 97153, 32 (8 hours); 97154, 18; 97155, 24; 97156, 16; 97157, 16; 97158, 16; 0362T, 16; 0373T, 24. Units correctly billed above a maximum frequency per day can be appealed with medical records. The authorization form requests units per six-month period, not per week. [4][6][8]
- **Place of service**: Not paid: "Services provided in a school setting that are covered by the educational system’s special education resources as part of the individual education plan (IEP)," and services "primarily educational in nature." The InterQual subsets include consultation with school personnel. No other setting restriction is published. [2][1]
- **Supervision** _(licensed criteria)_: Point32Health requires InterQual’s "Applied Behavior Analysis (ABA) Program-Applied Behavior Analysis Supervision" subset for supervision requests, but the criteria inside it are licensed and not published. The Maine mandate requires ABA to be provided by, or supervised by, a national-board certificant. [1][10]
  - In licensed criteria: HPHConnect (Researched → InterQual link) shows the criteria to registered providers; or the commercial Provider Service Center, 800-708-4414.
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: Harvard Pilgrim's Code Auditing Reference Tool (HPHConnect login) for the 97153 + 97155 same-date edit, or the commercial Provider Service Center, 800-708-4414. [1][2][5]
- **Bill as provider** _(ask the plan)_: Point32Health pays ABA "rendered by appropriately credentialed providers" at contracted rates and does not pay "Services provided by an immediate family member." The authorization form asks for the agency NPI and the BCBA’s NPI, and "will not approve the request if completed by a non-BCBA provider." No rule is published on whose NPI a technician’s service is billed under. [2][8]
  - Ask the plan: Harvard Pilgrim commercial Provider Service Center, 800-708-4414, or your provider agreement.

## What intake should collect for Harvard Pilgrim Health Care (Maine)

- **Plan funding type:** Fully insured (Maine mandate applies) vs. self-insured (benefit document governs).
- **Child’s age:** The Maine mandate covers children 10 and under; from 11 the plan’s own terms decide.
- **ICD-10 code:** F84.0, F84.3, F84.5, F84.8 or F84.9. F84.2 (Rett) is not on the list.
- **HPHConnect access:** The InterQual questionnaire runs there; register before the first request.
- **Other coverage:** Second parent’s plan, MaineCare (pays last), TRICARE or CHAMPVA.

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

## Common questions

### Does Harvard Pilgrim cover ABA in Maine?

Yes, for members with a definitive ASD diagnosis, under Point32Health’s commercial ABA guideline (effective July 1, 2026), with prior authorization on every ABA code.

### What criteria does Harvard Pilgrim use for ABA?

InterQual, through an automated questionnaire on HPHConnect. The criteria are licensed; registered providers can view them in HPHConnect.

### Does Harvard Pilgrim pay for ABA by telehealth in Maine?

Its telehealth payment policy pays medically necessary telehealth when it is an appropriate substitute for in-person care, billed POS 02 or 10 with modifier 93, 95 or GT, at 100% of the fee schedule for behavioral health in Maine. No ABA code list is published, so confirm codes at authorization.

### What does Harvard Pilgrim pay for ABA in Maine?

Point32Health pays ABA “according to the applicable contracted rates and fee schedules” and publishes no ABA rate table.

## Primary sources

1. [Point32Health MNG — Applied Behavioral Analysis (ABA) for Commercial Products and Tufts Health Direct (eff. July 1, 2026)](https://wwwassets.point32health.org/documents/aba-commercial-iq-comm-mng)
2. [Point32Health Payment Policy — Applied Behavioral Analysis (ABA) Services (rev. 05/2026)](https://www.point32health.org/documents/applied-behavioral-analysis-aba-services-pp)
3. [Harvard Pilgrim Health Care Provider Manual — Referral Policy and Procedures (March 2026)](https://www.point32health.org/documents/d-1-referral-policy-pm)
4. [Point32Health Payment Policy — Maximum Units (rev. 09/2026)](https://www.point32health.org/documents/maximum-units-pp)
5. [Point32Health Payment Policy — General Coding and Claims Editing (rev. 10/2026)](https://www.point32health.org/documents/general-coding-and-claims-editing-pp)
6. [CMS — Medicare NCCI Practitioner Services MUE table, effective 10/1/2026 (97151–97158, 0362T, 0373T)](https://www.cms.gov/files/zip/medicare-ncci-2026-q4-practitioner-services-mue-table.zip)
7. [Point32Health Payment Policy — Telehealth/Telemedicine (rev. 07/2026; ME behavioral health paid at 100%)](https://www.point32health.org/documents/telehealth-ent-pp)
8. [Point32Health — Applied Behavioral Analysis Prior Authorization Form (rev. 9/2025; code grid for NH, ME, RI commercial)](https://www.point32health.org/documents/applied-behavioral-analysis-form)
9. [24-A M.R.S. § 2768 — Coverage for the diagnosis and treatment of autism spectrum disorders (individual policies)](https://legislature.maine.gov/statutes/24-A/title24-Asec2768.html)
10. [24-A M.R.S. § 2847-T — Coverage for the diagnosis and treatment of autism spectrum disorders (group policies)](https://legislature.maine.gov/statutes/24-A/title24-Asec2847-T.html)
11. [24-A M.R.S. § 4259 — Coverage for the diagnosis and treatment of autism spectrum disorders (HMO contracts)](https://legislature.maine.gov/statutes/24-A/title24-Asec4259.html)
12. [P.L. 2013, c. 597 — An Act To Amend Insurance Coverage for Diagnosis of Autism Spectrum Disorders (age 5 → 10; applies from Jan. 1, 2015)](https://legislature.maine.gov/legis/bills/bills_126th/chapters/PUBLIC597.asp)
13. [24-A M.R.S. § 4304 — Utilization review (prior authorization timeframes)](https://legislature.maine.gov/statutes/24-A/title24-Asec4304.html)
14. [24-A M.R.S. § 4316 — Coverage for telehealth services](https://legislature.maine.gov/statutes/24-A/title24-Asec4316.html)
15. [24-A M.R.S. § 4303 — Plan requirements (sub-§ 2 credentialing, 2-A payment during credentialing, 10 retrospective denials)](https://legislature.maine.gov/statutes/24-A/title24-Asec4303.html)
16. [24-A M.R.S. § 2436 — Interest on overdue payments (30-day claim payment)](https://legislature.maine.gov/statutes/24-A/title24-Asec2436.html)
17. [Bureau of Insurance Rule 02-031 ch. 790 — Procedures for Resolving Coordination of Benefits Disputes](https://www.maine.gov/sos/sites/maine.gov.sos/files/content/assets/031c790.doc)
18. [BACB — U.S. Licensure of Behavior Analysts (Maine not listed)](https://www.bacb.com/u-s-licensure-of-behavior-analysts/)
19. [Maine Revised Statutes, Title 32 (Professions and Occupations) — chapter list (no behavior-analyst chapter; ch. 141 is Professional Land Surveyors)](https://legislature.maine.gov/statutes/32/title32ch0sec0.html)
20. [29 CFR 2560.503-1 — ERISA claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
21. [MaineCare Benefits Manual, Ch. I, Section 1 — General Administrative Policies and Procedures (1.07 TPL, 1.10 claims, 1.14 prior authorization, 1.23 provider appeals)](https://www.maine.gov/sos/sites/maine.gov.sos/files/inline-files/c1s001.docx)
22. [Point32Health — Insights and Updates for Providers (Harvard Pilgrim / Tufts provider news archive)](https://www.point32health.org/provider/office-resources/provider-newsletter)
23. [MaineCare Benefits Manual, Ch. II, Section 28 — Adaptive Behavior Services for Children (eff. April 29, 2026, filing 2026-101)](https://www.maine.gov/sos/sites/maine.gov.sos/files/inline-files/c2s028-2026-101%20NEW.docx)
24. [42 CFR 433.139 — Medicaid third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
25. [10 U.S.C. 1079(i)(1) — TRICARE pays after other coverage except Medicaid](https://www.govinfo.gov/content/pkg/USCODE-2023-title10/html/USCODE-2023-title10-subtitleA-partII-chap55-sec1079.htm)
26. [38 CFR 17.270 — CHAMPVA is the last payer](https://www.ecfr.gov/current/title-38/section-17.270)

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.