Healthy Blue in South Carolina is offered by BlueChoice HealthPlan, a BlueCross BlueShield of South Carolina company, not by Anthem as in other states. It is one of the five Healthy Connections MCOs. Its provider manual (effective January 1, 2026) covers autism spectrum disorder services for members under 21, requires prior authorization for all of them except diagnostic services, and names the SCDHHS Autism Provider Manual as the criteria it uses for autism services.
The benefit table lists autism spectrum disorder for "Members under the age of 21 who have been diagnosed with autism spectrum disorder," with the limitation that "Prior authorization for all covered services is required, excluding diagnostic services," and that services "must be recommended by a licensed psychologist, developmental pediatrician or licensed psycho-educational specialist (LPES)." Services may be provided in the home, a clinical setting or other settings. Healthy Blue covers behavioral health through its own "Healthy Blue Autism Services Network," and its criteria table names the "SCDHHS Autism Provider Manual" as the criteria for autism services (it uses MCG for most other behavioral health levels of care). In practice that makes the state manual’s documentation, assessment and code rules the yardstick for a Healthy Blue ABA request.[1][2]
Healthy Blue "accepts claims from all providers up to 365 days after the date of service," and corrected claims are due within 365 days of the date of service. Claims disputes filed more than 90 calendar days after the remittance are not accepted; the plan answers disputes within 30 calendar days. Its manual still describes routine prior-authorization review "not to exceed 14 calendar days from receipt of the request," and urgent review within 72 hours; federal managed-care rules cut the standard limit to 7 calendar days for rating periods starting on or after January 1, 2026.[1][6]
Healthy Blue considers only "clean claims received and entered into the claims processing system within one year from the date of service," and "We do not extend claim submittal time limits based on third-party liability requirements," so a secondary claim must still arrive within that year. Claims first rejected for missing or invalid data must be resubmitted within 365 calendar days, and corrected claims must be "clearly marked as a ‘corrected claim’" with the original claim number. The manual states no clean-claim payment deadline and no check-run schedule; ask Provider Services.[1][6]
The questions that decide whether a family can start with Healthy Blue by BlueChoice HealthPlan, and what they have to bring. Each maps onto something intake should ask on the first call.
Under 21, per the manual’s autism benefit entry.[1]
Healthy Blue states no rule; the SCDHHS manual it applies sets no expiry on the diagnosis and does not require re-diagnosis.[1][2][3]
Services must be recommended by a licensed psychologist, developmental pediatrician or LPES. Under the SCDHHS manual Healthy Blue uses as criteria: The comprehensive diagnostic assessment must be administered directly by a licensed physician (MD/DO), licensed psychologist (PhD/PsyD) or licensed psycho-educational specialist (LPES). A medical-care-home physician may confirm a prior diagnosis, or make an initial diagnosis for a medically uncomplicated child aged 18–36 months. SCDHHS "does NOT accept autism evaluations completed by any other provider type," naming nurse practitioners, physician assistants, LISWs, ABA providers and ST/OT/PT; a school IDEA designation of ASD or a BHDD-OIDD autism eligibility determination counts once a physician confirms it. Diagnoses made by telehealth are not valid.[1][2]
Healthy Blue names no instruments; under the SCDHHS manual it applies, the diagnostic assessment needs an in-person ADI-R, ADOS or CARS, a DSM checklist with severity levels and a cognitive or developmental measure.[1][2]
Yes: services "must be recommended by a licensed psychologist, developmental pediatrician or licensed psycho-educational specialist (LPES)."[1]
Healthy Blue publishes no ABA telehealth rule and uses the SCDHHS Autism Provider Manual as its criteria. The state rule: Under the SCDHHS ASD manual (July 1, 2026), only two ABA codes may be delivered by telehealth: 97156 (family guidance), with the GT modifier and no extra authorization, and 97155 (protocol modification), only when the QIO approves it during prior authorization, for up to 25% of authorized and rendered 97155 units, for a member receiving in-home ABA in a rural location with limited access. Telehealth must be synchronous audio and video, GT goes in the secondary modifier position, and POS is 02 or 10. "The BIA can not be completed by telehealth," and 97152, 97153, 97154, 97157, 97158, 0362T and 0373T are not deliverable by telehealth. An ASD diagnosis made by telehealth is not valid.[1][2]
Ask the plan: Healthy Blue Provider Services, 866-757-8286: confirm it has adopted the July 1, 2026 telehealth limits.
The manual says routine requests are decided within 14 calendar days and urgent ones within 72 hours. Federal rules cap standard managed-care decisions at 7 calendar days for rating periods starting on or after January 1, 2026.[1][6]
Ask the plan: Healthy Blue Provider Services, 866-757-8286: confirm which clock applies to your request.
Healthy Blue’s manual does not restate a payer-of-last-resort rule in its ABA sections; federal law makes Medicaid, and its managed care plans, pay after other coverage (42 CFR 433.139), and SCDHHS requires the ASD authorization only when the primary denies or does not cover the service.[7][2][1]
Ask the plan: Healthy Blue Provider Services, 866-757-8286: ask how to submit secondary ABA claims and whether it needs its own authorization when a commercial plan is primary.
Coverage decides whether Healthy Blue by BlueChoice HealthPlan 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.
Healthy Blue uses the SCDHHS Autism Provider Manual as its autism criteria, so the state rules apply: BACB supervision applies: "each RBT must be supervised for a minimum of 5% of the hours spent providing ABA services per month," with at least two face-to-face, real-time contacts a month, one of which observes the RBT with the member; that professional supervision is not billable. Caseload caps: a BCBA may carry 12 cases (16 with a BCaBA), a BCaBA 12, where 30–40 hours a week is one case, 10–25 hours half a case and under 10 hours a quarter case. A behavior technician gets one 90-day grace period to earn the RBT credential, and may work only in a clinic with a BCBA on site during it.[1][2]
Services "may be provided in the member’s home, clinical setting or other settings." The SCDHHS manual it applies limits school-based ABA to cases with a current IEP, FBA and BIP and requires an adult caregiver at home.[1][2]
Healthy Blue publishes no rule of its own. Under the SCDHHS manual it applies, 97153 may not be billed concurrently except as section 8 allows (97155 with 97153 when both providers deliver a direct service; 97153 with 97156 in separate spaces), and two providers may not bill the same code at the same time. On ABA alongside other therapies, Healthy Blue publishes nothing of its own; the state baseline: the SCDHHS ASD manual's non-covered list is explicit — "Concurrent billing of 97153 with any other service or therapy is excluded except as detailed in Section 8," and Section 8's exceptions are ABA-with-ABA only. It also excludes "ABA services while the member is at another medical appointment," and, in the other direction, ABA treatment "that precludes, or requires the member's family to stop engaging with other critical supports … speech therapy, occupational therapy, or IDEA recommended school-based curriculum and supports." So speech and ABA can both continue, but not on the same clock time as a billed 97153 unit. The manual also binds providers to the National Correct Coding Initiative edits and related coding policy unless it says otherwise.[1][2][3]
Ask the plan: Healthy Blue Provider Services, 866-757-8286: confirm it pays concurrent 97153/97155 claims under the state rule.
Healthy Blue publishes no ABA unit limits of its own; the SCDHHS section 8 limits it uses as criteria are 97153 160 units a week, 97155 up to 10% of rendered 97153 and 64 units a month, 97156 96 units a year, and 97151 32 units a year.[1][2]
Ask the plan: Healthy Blue Provider Services, 866-757-8286.
The manual publishes no ABA note rule; the SCDHHS manual requires each note signed by the enrolled BCBA/BCaBA and the rendering BT/RBT before the claim is filed.[1][2]
Ask the plan: Healthy Blue Provider Services, 866-757-8286, or the documentation standards in your Healthy Blue agreement.
No. Its manual says it does not extend claim time limits for third-party liability, so a claim where Healthy Blue is secondary is still due within one year of the date of service. The manual publishes no payment-turnaround or check-run schedule.
No. In South Carolina Healthy Blue is offered by BlueChoice HealthPlan, an independent Blue licensee affiliated with BlueCross BlueShield of South Carolina.
Yes, for all covered autism services except diagnostic services. Ask the plan whether it treats the 97151 assessment as diagnostic.
Its manual names the SCDHHS Autism Provider Manual as the criteria for autism services.
365 days from the date of service; claims disputes within 90 days of the remittance.
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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