Harvard Pilgrim Health Care, part of Point32Health, sells commercial plans in New Hampshire. Since January 1, 2026, one medical necessity guideline covers ABA for Harvard Pilgrim and Tufts Health Plan commercial products in Massachusetts, Maine, New Hampshire and Rhode Island. It relies on InterQual criteria, which are licensed, so the decision logic itself is not public. What is public: which codes need authorization, which diagnoses qualify, how to submit, and what Point32Health will not pay for.
Point32Health’s October 2025 notice replaced its ABA guideline for commercial plans effective January 1, 2026, and said the new version "will apply for Rhode Island Commercial products in addition to those in MA, ME, and NH." The current edition, "Applied Behavioral Analysis (ABA) for Commercial Products and Tufts Health Direct" (effective July 1, 2026), marks prior authorization "Yes" and lists 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T and 0373T for Harvard Pilgrim commercial products. Harvard Pilgrim requests go through the automated InterQual questionnaire on HPHConnect, with clinical notes uploaded there or faxed to 800-232-0816; outside Massachusetts, use the "Autism Spectrum Disorder Services Prior Authorization Request Form." Two 2026 changes matter for billing: "For Harvard Pilgrim Commercial plans, HCPCS codes H0031 and H0032 will no longer be covered," and for members aged 13–20 the plan "will not use the age-related ‘Limited Evidence’. Age alone will not initiate secondary review" (effective March 1, 2026). Down syndrome coverage without an ASD diagnosis applies to Massachusetts products only.[3][1][2]
The payment policy (revised May 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."[3][1][2]
New Hampshire’s autism mandate sits inside its mental-illness parity statute. RSA 417-E:1 requires every insurer, nonprofit health service corporation and HMO issuing or renewing accident or health coverage in the state to cover "pervasive developmental disorder or autism" on terms "no less extensive than the coverage provided for any other type of health care for physical illness." RSA 417-E:2 then defines the treatment: "applied behavioral analysis, necessary to produce socially significant improvements in human behavior or to prevent loss of attained skill or function," plus pharmaceuticals, psychiatric, APRN, psychologist and social-work services, and speech, occupational and physical therapy. Two conditions bind ABA specifically. It "must be provided by a person professionally certified by the national Behavior Analyst Certification Board or performed under the supervision of" one. And the insurer "may require submission of a treatment plan, including the frequency and duration of treatment," signed by the primary care provider or a listed specialist (child psychiatrist, developmental-behavioral pediatrician, child neurologist, or a psychologist trained in child psychology), updated "no more frequently than on a semi-annual basis." Coverage "shall not be denied on the basis that services are habilitative in nature." The age and dollar question has changed since enactment: HB 569 as passed in 2010 let a policy "limit coverage for applied behavior analysis to $36,000 per year for children 0 to 12 years of age, and $27,000 from ages 13 to 21." That paragraph does not appear in the current RSA 417-E:2, whose source note lists amendments in 2011 and 2022, and no other age or dollar limit appears in the section. Autism Speaks’ New Hampshire summary (last updated December 2019) still describes the caps, so expect some plan documents and benefit summaries to lag. The mandate reaches fully insured plans only; self-funded employer plans answer to ERISA and federal parity.[4][5]
New Hampshire does not license behavior analysts. The BACB’s state licensure table (updated 2026) lists no New Hampshire law or board, and the practical credential is therefore BACB certification, which the mandate itself requires. That shapes credentialing in two ways. First, carriers credential BCBAs on certification rather than a state license number, even where a form asks for one (WellSense’s New Hampshire ABA form has a "BCBA license #" field). Second, the state credentialing clock in RSA 420-J:4 does help: a carrier must tell you an application is incomplete within 15 business days and must "act upon and finalize the credentialing process within 30 calendar days" of a clean and complete application for primary care physicians and mental health providers (45 days for specialists). The statute does not say which bucket a BCBA falls in, so ask. The provisional-pay rule in RSA 420-J:8-c is keyed to "a valid license from the respective state licensing board," which New Hampshire BCBAs do not hold, so do not plan on being paid before credentialing completes. On rates: commercial ABA rates are negotiated and unpublished. RSA 417-E:1, V-b requires carriers’ contracts to pay mental health and substance use treatment services, on average, at least as favorably as non-hospital primary care, measured against relative Medicare reimbursement; the statute does not say whether ABA codes are in that comparison. The public benchmark is the NH Medicaid fee-for-service schedule, which is low (97153 $17.79 and 97155 $16.43 per 15-minute unit).[8][6][4][10][11]
The questions that decide whether a family can start with Harvard Pilgrim Health Care (New Hampshire), and what they have to bring. Each maps onto something intake should ask on the first call.
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 New Hampshire plans, the current RSA 417-E:2 carries no age or dollar limit on ABA (the 2010 caps of $36,000 a year for ages 0–12 and $27,000 for 13–21 are no longer in the text). Self-funded ERISA plans are outside the statute, so plan funding type decides whether that binds.[1][4][5]
Ask the plan: Live benefits verification: establish fully insured vs. self-insured, then the benefit document’s age terms.
The MNG requires prior authorization, not a physician referral; HMO referral rules for the member’s product are not addressed in the ABA documents. For a fully insured New Hampshire plan, RSA 417-E:2, II lets the insurer require a treatment plan, with frequency and duration, signed by the primary care provider or a listed specialist, updated no more than every six months. Self-funded ERISA plans sit outside the statute.[1][4]
Ask the plan: Harvard Pilgrim Member Services, 888-333-4742, or Provider Service Center, 800-708-4414: ask whether the member’s product needs a PCP referral for ABA.
Depends on how the plan is funded. Fully insured New Hampshire plans fall under RSA 420-J:6. For requests sent through the carrier’s electronic prior-authorization process, a non-urgent decision is due "within 7 calendar days of obtaining all information necessary to make the determination"; for paper or fax requests the limit is 14 calendar days; urgent requests are decided within 72 hours. Any request for more information must come within 7 calendar days of the request date, and information supplied in a peer-to-peer counts. A missed deadline means the request "shall be considered approved." Once approved, the carrier may not revoke or limit it "if care is provided within 60 business days" of the approval, and a peer-to-peer must be offered within 2 business days of a request. 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, urgent care within 72 hours. Harvard Pilgrim publishes no New Hampshire-specific ABA turnaround or reauthorization lead time.[6][9]
Ask the plan: At benefits verification ask whether the plan is fully insured (New Hampshire-regulated) or self-funded (ERISA), whether you are submitting electronically, and what reauthorization lead time Harvard Pilgrim expects.
For a child on two group plans, New Hampshire follows the birthday rule: when parents are married or living together, "the plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (Ins 1904.05(d)(2)); for separated parents a court decree controls, and otherwise the custodial parent’s plan pays first. That rule binds group plans regulated by the state; a self-funded plan sets its own order. When both plans require precertification, RSA 420-J:3-b says the member "shall obtain pre-certification from the primary plan," and the secondary plan "shall not refuse payment for such services solely on the basis that the services were not pre-certified by the secondary plan" (it can still apply its own criteria). If the child also has NH Medicaid, Harvard Pilgrim pays first: Medicaid is payer of last resort (42 CFR 433.139), and NH Medicaid will not pay a balance the primary denied for "incorrect billing, non-eligible provider, or lack of medical necessity." TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[7][6][12][13][14][15]
Ask the plan: Ask Harvard Pilgrim at benefits verification for the member’s coordination-of-benefits order (and whether a self-funded plan uses the birthday rule), and record every other coverage the child has.
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.
Not published; the MNG requires "a definitive diagnosis" of ASD but does not name who may make it.[1]
In licensed criteria: HPHConnect InterQual criteria view, or Provider Service Center, 800-708-4414.
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.
Coverage decides whether Harvard Pilgrim Health Care (New Hampshire) 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.
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." Point32Health’s InterQual subsets include consultation with school personnel. No other setting restriction is published.[2][1]
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.[1]
In licensed criteria: HPHConnect (Researched → InterQual link) shows the criteria to registered providers; or the commercial Provider Service Center, 800-708-4414.
The MNG and payment policy do not address billing 97153 and 97155 for the same time. The payment policy refuses payment where the ABA provider only escorts the member to another therapy.[1][2]
Blocked on: Point32Health General Coding and Claims Editing payment policy, or the commercial Provider Service Center, 800-708-4414.
No ABA-specific cap is in the MNG or ABA payment policy, which point to a separate Maximum Units payment policy.[2]
Blocked on: Point32Health Maximum Units payment policy (point32health.org, Payment policies).
Not addressed in the ABA MNG or payment policy.[1][2]
Blocked on: Harvard Pilgrim provider manual (documentation standards) or the commercial Provider Service Center, 800-708-4414.
Point32Health pays ABA "rendered by appropriately credentialed providers" at contracted rates and does not pay "Services provided by an immediate family member." It publishes no rule on whose NPI a technician’s service is billed under.[2]
Ask the plan: Harvard Pilgrim commercial Provider Service Center, 800-708-4414, or your provider agreement.
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.
InterQual, through an automated questionnaire on HPHConnect. The criteria are licensed; registered providers can view them in HPHConnect.
No. Since January 1, 2026 those codes are no longer covered for Harvard Pilgrim commercial plans.
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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