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 replaced its commercial ABA guideline effective January 1, 2026. 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. The guideline’s history records “H0031 and H0032 removed from list of applicable codes for HPHC Commercial” from January 1, 2026, 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). Since February 2026, Point32Health wants ABA prior-authorization requests “under the billing NPI of your practice (type 2) rather than under the NPI of the individual therapist,” for every Point32Health product. Down syndrome coverage without an ASD diagnosis applies to Massachusetts products only.[1][2][16]
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."[1][2][16]
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.[7][8]
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).[11][9][7][13][26]
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 New Hampshire behavioral health telehealth at 100% of the applicable fee schedule, the same as in person. Get your rates from your Harvard Pilgrim agreement or the Provider Service Center (800-708-4414). For a public benchmark, NH Medicaid’s 2026 fee-for-service schedule pays 97153 at $17.79 per 15 minutes; commercial contracts are negotiated separately.[2][14][13]
New Hampshire’s RSA 420-J:8-a makes health carriers pay clean claims for services rendered in New Hampshire "within 30 calendar days upon receipt of a clean non-electronic claim or 15 calendar days upon receipt of a clean electronic claim," with 1.5% interest per month on overdue claims. A carrier is not in violation for a claim submitted more than 90 days after the service.[25][18][19][20][21][22][23][17]
Harvard Pilgrim’s provider manual sets a standard filing limit of “90 days from the date of service,” and rejected or returned claims must be “corrected, resubmitted and accepted by Harvard Pilgrim no later than 90 days from the date of service.” Replacement claims (frequency code 7, or 8 to void) “must be submitted 90 days from the date of the first Explanation of Payment of the original claim.” When Harvard Pilgrim is secondary, a claim past the 90-day limit must arrive within 90 days of the primary carrier’s EOB, with a copy of it; in New Hampshire, when a primary insurer retroactively denies a previously paid claim, the limit is 180 days from that denial. Benefits for a child on two parents’ plans follow the NAIC birthday rule. Filing-limit appeals are due within 90 days of the original EOP. Harvard Pilgrim says it pays clean claims “within an average of 30 calendar days after receipt.”[25][18][19][20][21][22][23][17]
On a paper CMS-1500, box 17 (referring provider) and 17b (its NPI) are optional fields, “the professional who referred or ordered the service”; 24J carries the individual rendering provider’s NPI and 33a the billing NPI. The manual sections read do not ask for a taxonomy code or mention electronic visit verification. Separately, Point32Health now requires every contracted ABA provider to be accredited by an ABA-specific body (it names the Autism Commission on Quality, Jade Health, formerly BHCOE, and Global Autism Project Accreditation): providers in New Hampshire, including center-based ones, by January 1, 2028.[25][18][19][20][21][22][23][17]
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.
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 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.[3][1][7]
Covered under Point32Health’s general telehealth policy; the ABA guideline and ABA payment policy add nothing. The Telehealth/Telemedicine payment policy (rev. 07/2026), which applies to Harvard Pilgrim commercial products, reimburses “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. It does not pay “Services that require equipment and/or direct hands-on care that cannot be provided remotely.” Bill POS 02 or 10 with modifier 93, 95 or GT; in New Hampshire behavioral health telehealth is paid at 100% of the fee schedule. No ABA code list is published. For a fully insured New Hampshire plan, RSA 415-J:3 says an insurer “may not deny coverage on the sole basis that the coverage is provided through telemedicine” and must cover and reimburse it “on the same basis” as in person, with “no restriction on eligible originating or distant sites,” for “all modes of telehealth.” Its list of providers who may use all modes includes “Professionals certified by the national behavior analyst certification board or persons performing services under the supervision of” a BACB certificant “as required by RSA 417-E:2.” Self-funded employer plans are outside the state statute.[14][15][1][2]
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][7][8]
Ask the plan: Live benefits verification: establish fully insured vs. self-insured, then the benefit document’s age terms.
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.[9][12]
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).[10][9][27][28][29][30]
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. LCSW: no published rule. The plan names no diagnosing-provider list, so ask it whether an LCSW's diagnosis is accepted.[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.
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.[4][6]
The ABA guideline and payment policy set no rule on who signs a session note. Point32Health’s General Coding and Claims Editing payment policy (rev. 10/2026) sets the timing rule that matters for claims: it “will not accept retrospectively amended medical records or physician queries beyond 30 days from the date of service,” and documentation amended after that “will not be accepted to defend reimbursement, increase reimbursement, or for consideration of a previously denied claim.” Services are billed only once delivered.[5][1][2]
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.
Not published. The MNG and the ABA payment policy do not address billing 97153 and 97155 for the same time, and the General Coding and Claims Editing payment policy (rev. 10/2026) has no ABA rule either — it applies generic incidental, mutually-exclusive and unbundling edits through claims-editing software. On other therapies, the ABA payment policy refuses payment for "Services provided concurrent with another treatment modality, such as occupational or speech therapy, where the ABA provider's role is to escort/accompany the member to the appointment."[1][2][5]
Blocked on: 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.
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.
Ninety days from the date of service. Replacement claims are due 90 days from the first EOP, and a secondary claim within 90 days of the primary carrier’s EOB.
Yes, from January 1, 2028 for New Hampshire providers: accreditation by an ABA-specific body such as the Autism Commission on Quality, Jade Health (formerly BHCOE) or Global Autism Project.
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.
Its general 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 NH. No ABA code list is published, so confirm the codes at authorization. Fully insured NH plans must also follow RSA 415-J.
Point32Health pays ABA “according to the applicable contracted rates and fee schedules,” and publishes no ABA rate table. Telehealth for behavioral health in NH is paid at 100% of the fee schedule. NH Medicaid’s FFS rate for 97153 ($17.79 per 15 minutes) is the only public benchmark.
Fifteen calendar days for a clean electronic claim and 30 for paper (RSA 420-J:8-a), on plans subject to the Managed Care Law. Claims filed more than 90 days after service lose that protection.
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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