Healthfirst — the large NYC-area provider-sponsored plan — maintains its own Policy for the Authorization of Applied Behavioral Analysis (ABA) Services, with an updated version announced with a reported effective date of October 2026. The honest caveat up front: the policy PDF itself was unavailable at review time, so this guide covers what's verified — the plan runs its own authorization machinery through Availity Essentials on top of state-baseline clinical criteria — and flags exactly what to confirm in the portal before promising a family timelines.
Verified: Healthfirst publishes its own ABA authorization policy (the prior version circulated as doc 0374-22, with an updated version announced carrying a reported October 2026 effective date), routes prior authorization through the Availity Essentials Online Authorization Tool with "Healthfirst (New York)" selected as the payer, and — on its commercial small/large group lines — requires PA on the full ABA code range 97151–97158, a strong signal of an authorization-first posture. Also verified: Healthfirst republished the state's October 1, 2025 technician-supervision requirements verbatim on its provider site, applying them to Healthfirst plans. Not verified: the Medicaid-line specifics — whether 97151 needs PA, authorization periods, documentation requirements, hour-cap logic, and rates — because the policy PDF 404s. Pull the current policy from hfproviders.org or provider services (1-888-801-1660) and confirm the Medicaid ABA workflow in Availity before committing to start dates.[1][2]
Healthfirst's published ABA content mirrors the state program: members under 21 with ASD and/or Rett syndrome, the practitioner referral, and — per its supervision post — the state's LBA/CBAA structure with the 5%-of-tech-hours, two-contacts-per-month supervision rule. So the intake package is the same one the state FFS manual defines; the open question at this plan is purely the authorization mechanics layered on top. Build the referral packet to the state spec, then confirm Healthfirst's submission requirements against the live policy.[1][3]
What a reauthorization must show. Healthfirst publishes no reauthorization packet or progress-data rule of its own in the documents we checked, so the state’s floor is the reference: the eMedNY ABA manual requires the treatment plan to be updated “at least every 6 months or as needed” with “updated goals and data,” each goal carrying “baseline data reported in objective terms” and “current data expressed by the same data collection method as the baseline data so that progress can be measured.” The state does not require graphs; ask the plan whether it wants graphed data before the first concurrent review.[1][3]
Healthfirst 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.[12][13][4][5][6][3]
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).[12][13][4][5][6][3]
Healthfirst’s own rules, from its New York Provider Manual (updated 10/1/2026), §17.3: “Providers should submit all claims within 30 (thirty) days of the date of service for prompt adjudication and payment,” the binding limit is the one in your Healthfirst agreement, and “In no event will Healthfirst pay claims submitted more than 180 (one hundred eighty) days after the date of service.” Late-claim exceptions run 60 calendar days from the time submission came within the provider’s control — including “Medicare or other third-party processing delays” and an original claim rejected or denied for a reason unrelated to the 180-day rule (submit with the original EOP). Corrected claims are stamped “CORRECTED” with the original claim number and “must follow timely filing guidelines for new claims”; a resubmitted rejected claim “is always treated as a new claim.” Healthfirst “adjudicates and pays all claims for its Medicaid, CHPlus, and commercial plans according to Section 3224-a.” No payment-cycle day or submission cut-off is published.[12][13][4][5][6][3]
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).[12][13][4][5][6][3]
Code set: Healthfirst publishes no ABA code list of its own in the documents we checked (its New York Provider Manual updated 10/1/2026 and its ABA provider pages), so the state’s applies: 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). Bill ABA on the CPT codes; confirm the plan’s fee schedule before billing anything else.[12][13][4][5][6][3]
The questions that decide whether a family can start with Healthfirst (New York), 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. Healthfirst’s published ABA content mirrors the state program rather than setting an age rule of its own.[3][1]
Follows the New York Medicaid rule — the referral is valid no more than two years and no maximum age is set on the diagnostic evaluation itself. Healthfirst’s own ABA authorization policy (the prior version circulated as doc 0374-22, with an updated version announced carrying a reported October 2026 effective date) was not retrievable at review time, so any plan-specific recency rule is unconfirmed.[3]
Ask the plan: Pull the current ABA authorization policy from hfproviders.org or Healthfirst provider services (1-888-801-1660) and confirm whether it adds a recency rule.
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. Healthfirst republishes the state’s LBA/CBAA structure on its provider site and names no additional diagnosing credential.[3][1]
Follows the New York Medicaid rule: no instrument is mandated. What the state requires with the referral is the “DSM-5 Diagnostic Checklist for ASD diagnoses” plus the severity level when the referral comes from an ASD-diagnosing provider; the treatment plan need only record the assessment methodology used and, “as appropriate, identify standardized assessment used (e.g., adaptive behavior scales, symptom inventories, aggression ratings) and results.” No Healthfirst-specific instrument requirement was located; its policy PDF was unavailable at review time.[3]
Ask the plan: The current Healthfirst ABA authorization policy via hfproviders.org or provider services (1-888-801-1660).
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. Healthfirst then runs its own authorization machinery on top: prior authorization goes through the Availity Essentials Online Authorization Tool with “Healthfirst (New York)” selected as the payer. On its commercial small and large group lines the full range 97151–97158 requires PA, a strong signal of an authorization-first posture; the Medicaid-line specifics are unconfirmed because the policy PDF 404s.[3][2]
Ask the plan: Confirm the Medicaid ABA authorization workflow in Availity and pull the current policy from hfproviders.org before quoting start dates.
The NYS Medicaid Telehealth Policy Manual (Version 2026-V2, July 2026) applies to services delivered “under contracted Medicaid Managed Care (MMC) Plans,” lists “Providers licensed or certified by the New York State Education Department (NYSED) to provide Applied Behavioral Analysis (ABA) therapy” among telehealth providers, and requires that “Providers must meet all elements of the procedure code via telehealth.” Its managed-care section says plans “are required to cover, at a minimum, services that are covered by NYS Medicaid FFS and included in the MMC benefit package… and must provide telehealth coverage as described in this guidance,” must “ensure claims allow the use of the telehealth modifiers in this guidance” and “may establish additional claiming requirements.” Billing baseline: modifier 95 or GT for audio-video; place of service 02 (not the home), 10 (the member’s home) or 11 where the in-person visit would be POS 11; payment parity with in-person until April 1, 2028. A code defined as face-to-face with the patient (97152, 97153) qualifies only if every element can be met by video. The state ABA manual separately allows LBA supervision of technicians by synchronous audio-video, but the two monthly supervision contacts must be real time and never by phone, email or text. Healthfirst publishes no ABA telehealth rule of its own: its New York Provider Manual (updated 10/1/2026) has no ABA telehealth, modifier or place-of-service provision, and its ABA supervision page only restates that supervision may run over synchronous audio-video “consistent with NYS Medicaid telehealth policy.” So the state rule above is the Healthfirst rule. Neither the state manuals nor the plan say whether the authorization itself must flag telehealth — state the delivery mode in the treatment plan and ask at authorization.[7][3][4][1]
Healthfirst decides prior authorization “within three (3) business days of receipt of all necessary information,” and urgent Medicaid requests within 72 hours of receipt; when the plan asks for more information, the provider must send it within 10 calendar days. For continuing ABA, “Providers must furnish clinical information to Utilization Management to support continued authorization of services before the expiration of the authorized treatment period,” with a decision within one day of receiving the necessary information. The manual publishes no Medicaid outer limit, so the state contract governs: no more than 14 days after receipt, extendable up to 14 days, with federal rules capping it at 7 calendar days for plan rating periods starting on or after January 1, 2026. A missed deadline counts as a denial the family can appeal.[4][5][14]
“Healthfirst requires a primary carrier Explanation of Payment (EOP) when Healthfirst is the secondary payer before appropriate claims payment can be issued.” So bill the other plan first and attach its EOP or denial. That sits on the state rule: Medicaid pays last, providers “must bill all applicable insurance sources before submitting claims to Medicaid,” and the plan must ask providers “to bill the TPHI that should be primary to the Plan.” The manual does not say whether Healthfirst’s ABA preauthorization is still required when it is secondary — confirm with Provider Services (1-888-801-1660) before relying on the primary plan’s approval.[4][15][5]
Coverage decides whether Healthfirst (New York) 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.
Healthfirst republished the state’s October 1, 2025 technician-supervision requirements on its provider site (posted December 22, 2025), stating they “apply to both Fee-for-Service (FFS) Medicaid and Medicaid Managed Care (MMC) plans, including Healthfirst”: LBAs must supervise unlicensed individuals/technicians “for a minimum of 5% of the ABA service hours provided each calendar month,” with at least two face-to-face, real-time contacts per month (not by phone, email or text), the LBA directly observing the technician in at least one; 97155 counts toward the 5% only when the LBA is present with the patient and technician and directing a new or modified protocol. The caseload cap is in Healthfirst’s New York Provider Manual (updated 10/1/2026): “CBAAs and unlicensed individuals must be supervised by an LBA. LBAs bill for services of CBAAs under their supervision and can supervise up to 6 CBAAs or unlicensed individuals.” Healthfirst adds one rule of its own on the same page: “MMC providers must retain records for 10 years.” That is the state rule, adopted by the plan rather than merely inherited.[1][4][3]
Follows the New York Medicaid rule: the LBA supervisor must “review and sign treatment notes and reports prepared by the CBAA supervisee,” and documentation of supervision itself “should be recorded in the patient file.” Clinical documentation must carry the treatment plan with assessment and goals, the goal data, total hours of service per week by who delivered them, and the location(s) of services. Records are kept “for a minimum of six years and, for minors, until the patient turns 22 years of age.” Healthfirst adds one documented deviation of its own: record retention stretches to 10 years for its managed-care providers, against the state’s six-year/age-22 floor.[3][1]
Follows the New York Medicaid rule: “LBAs and CBAAs may work in any legally authorized setting. Examples of such settings include private practice, settings where patients/clients reside full-time or part-time, clinics, hospitals, residences, and community settings” — but “NYS Medicaid does not reimburse for ABA services in a school setting.” The treatment plan must record the location(s) of services. No Healthfirst-specific setting rule was located.[3]
Ask the plan: Healthfirst provider services (1-888-801-1660) or the current ABA authorization policy for any plan-specific setting restriction.
The LBA bills. Healthfirst’s New York Provider Manual (updated 10/1/2026): “LBAs bill for services of CBAAs under their supervision”; LBAs enroll in NYS Medicaid as billing or OPRA non-billing providers; “CBAAs enroll as an OPRA non-billing provider (CBAAs cannot bill)”; “‘Unlicensed aides’ cannot enroll as a provider”; and “Providers should bill on a professional claim,” with “additional requirements” in Healthfirst’s ABA policy, which we could not locate publicly. The claim-field convention underneath is the state’s: LBAs bill “using the LBA’s National Provider Identification (NPI) number for the ‘Billing’ provider and/or ‘Supervising’ provider,” with the CBAA’s NPI as “Rendering,” and for unlicensed aides and LBA limited-permit holders the supervising LBA’s NPI fills all three roles. Confirm against Healthfirst’s ABA policy before billing CBAA-delivered units.[4][3]
Not published. Healthfirst’s retrievable ABA content covers supervision and the Availity authorization route; its ABA authorization policy PDF was unavailable at review time, and the state manual is silent on 97153 with 97155.[1][3]
Ask the plan: Healthfirst provider services (1-888-801-1660) and the current ABA authorization policy on hfproviders.org.
Not published for the Medicaid line — authorization periods, unit limits and hour-cap logic all sit in the ABA authorization policy that was unavailable at review time. What is verified is the authorization posture: on Healthfirst’s commercial small and large group plans all of 97151–97158 require prior authorization, so treat authorized units as the ceiling and confirm the Medicaid rule before booking. Per-day claim edits: the federal Medicaid NCCI medically unlikely edits (October–December 2026: 97153 – 32 units a day, 97155 – 24, 97151 – 32, 97152/97156/97157/97158 – 16, 97154 – 18) are mandatory for fee-for-service claims, but CMS calls applying them to managed-care claims “desirable but optional,” and Healthfirst does not say whether it applies them — treat the authorized units as the ceiling and ask the plan about any per-day edit.[8][9][2][1]
Blocked on: The current Healthfirst ABA authorization policy via hfproviders.org, or provider services (1-888-801-1660).
Healthfirst’s NY provider manual names no RBT requirement. It says ABA comes from LBAs, CBAAs or other individuals allowed under Education Law Article 167, that “unlicensed aides” cannot enroll as a provider, and that LBAs bill for the CBAAs and unlicensed staff they supervise (up to 6).
Yes — it carries the NY Medicaid ABA carve-in on the state's clinical baseline (under 21, ASD/Rett, practitioner referral) and maintains its own ABA authorization policy, with PA submitted through Availity Essentials.
On its commercial group plans, yes — 97151–97158 all require PA. For the Medicaid line, the policy text was unavailable at review time; confirm the current policy via hfproviders.org or provider services (1-888-801-1660) before booking.
Yes — Healthfirst republished the state's October 2025 requirements (LBA supervision of at least 5% of technician hours, 2 monthly face-to-face contacts, max 6 supervisees) as applying to its plans.
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.
Not on anything Healthfirst publishes. It posts no ABA code list of its own, and the New York Medicaid ABA fee schedule it builds on lists only CPT 97151–97158, with no H-codes and no 0362T/0373T. Bill ABA on the CPT codes.
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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