Highmark West Virginia Inc., doing business as Highmark Blue Cross Blue Shield, "serves the entire state of West Virginia" and runs on the multi-state Highmark Provider Manual shared with Pennsylvania, Delaware and New York. Since March 1, 2026, every ABA code has been on Highmark’s prior-authorization list, reviewed in-house by Highmark Behavioral Health.
Under that sits West Virginia’s autism mandate for fully insured group plans. Establish funding type and employer size on every benefits check: self-funded employer plans administered by Highmark answer to their own plan documents and ERISA, and small employers are exempt from the mandate. Highmark Health Options, Highmark’s Medicaid MCO, has its own guide.
Highmark announced on November 24, 2025 that "Effective March 1, 2026, 19 behavioral health codes will be added to the prior authorization list," including applied behavior analysis (97151 through 97158 among them). The current List of Procedures/DME Requiring Authorization (effective 10/01/2026), which applies "For PA, WV, DE & NY Members," lists 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T and 0373T under the UM program "Highmark Behavioral Health," with the caveat that "Some authorization requirements vary by member plan." The provider manual names "Applied Behavioral Analysis (ABA) for Autism" among the outpatient services that require prior authorization for most Highmark products, notes the March 1 requirements "do not currently apply to the Federal Employee Program (FEP) and Medicare," and says Highmark Behavioral Health renders a routine decision "within two business days from the receipt of the request." Peer-to-peer requests go to 866-634-6468.[2][1][3]
West Virginia’s autism mandate is written into each insurance article separately, with matching text: W. Va. Code § 33-16-3v (group accident and sickness insurers), § 33-24-7k (hospital, medical and health service corporations) and § 33-25A-8j (HMOs), all from HB 2693 (2011) as amended by HB 4260 (2012), plus a parallel paragraph for PEIA in § 5-16-7. Each applies to a "policy of group accident and sickness insurance" issued or renewed on or after January 1, 2012, and requires "coverage for diagnosis, evaluation and treatment of autism spectrum disorder in individuals ages eighteen months to eighteen years." Three gates follow. The child "must be diagnosed with autism spectrum disorder at age eight or younger." Treatment must be "medically necessary and ordered or prescribed by a licensed physician or licensed psychologist and in accordance with a treatment plan developed from a comprehensive evaluation by a certified behavior analyst." And ABA "shall be provided or supervised by a certified behavior analyst," defined as someone "certified by the Behavior Analyst Certification Board or certified by a similar nationally recognized organization." The insurer statutes let ABA be capped: "not to exceed $30,000 per individual, for three consecutive years from the date treatment commences," then "not to exceed $2,000 per month, until the individual reaches eighteen years of age." The PEIA paragraph carries the same age, diagnosis and supervision terms but no dollar cap. To keep treatment going, the analyst must "file progress reports … semiannually," and the plan must receive objective evidence or "a clinically supportable statement of expectation" that the child is improving, has not reached maximum improvement, and can reach the anticipated improvement in a reasonable time. Exemptions: "small employers" (25 or fewer eligible employees), cost-containment once the mandate raises total costs by 1% for a plan year, and any part that exceeds the ACA essential health benefits. The mandate does not reach self-funded ERISA plans, and nothing in it requires payment for services by public school personnel or replaces IDEA obligations. The WVCHIP autism section (§ 5-16B-6e) was repealed in 2022; WVCHIP now covers ABA on Medicaid’s terms.[4][5][6][7][19][20]
West Virginia does not license behavior analysts. The BACB’s state licensure table (2026) lists no West Virginia law or board, and the articles of Chapter 30 of the West Virginia Code (Professions and Occupations) include none for behavior analysts; the psychologists’ article (30-21) does not mention them. The working credential is therefore BACB certification, which both the commercial mandate ("certified behavior analyst") and Medicaid Policy 519.23 ("certification by the Behavior Analyst Certification Board is current and in good standing") require. For an out-of-state BCBA, that means there is no West Virginia license to obtain, but each payer still credentials and enrolls you: Medicaid requires enrollment through the BMS fiscal agent (Chapter 300), and BMS’s telehealth policy expects interstate practitioners to register "with the appropriate board in West Virginia" and enroll "as an Interstate Provider," a step that has no obvious board for a BCBA, so get BMS’s answer in writing. On commercial telehealth, § 33-57-1 defines the covered "health care practitioner" as someone licensed under Chapter 30, which an unlicensed BCBA is not, so the carrier’s own telehealth policy decides. On rates: commercial ABA rates are negotiated and unpublished. The public benchmark is the West Virginia Medicaid ABA fee schedule, which is very low (97153 $9.90 and 97155 $29.14 per 15-minute unit).[11][12][21][22][10][14]
Unless your contract sets a different limit, "claims must be received within 365 days of the last date of service in Delaware, Pennsylvania, and West Virginia." When Highmark is secondary, the same limit runs from the primary payer’s finalized date, with the EOB attached, and corrected claims must arrive within 15 months (455 days) of the original claim’s finalization (effective September 1, 2026). West Virginia’s prompt-pay law, W. Va. Code § 33-45-2, requires an insurer to "either pay or deny a clean claim within 40 days of receipt of the claim if submitted manually and within 30 days of receipt of the claim if submitted electronically," to ask for any missing information within 30 days of receipt, and to pay interest at 10 percent a year on claims paid after the 40-day period.[3][9]
Highmark’s provider manual (Chapter 2, Unit 6) says a Highmark participating provider "may render services to patients who are members of other Blue Plans traveling to or living in" West Virginia, and the claim goes to the local plan: the provider "files a claim locally," the local plan forwards it, the home plan adjudicates it "according to the member’s benefits and the provider’s arrangement" with the local plan, and the local plan pays the provider. In West Virginia, Highmark’s indemnity, PPO and POS networks support BlueCard. Verify an out-of-area member’s eligibility through Availity or 800-676-BLUE (2583).[3]
Outpatient authorization is the member’s side of the street: "your out-of-area Blue Plan patients are responsible for obtaining precertification/preauthorization from their Blue Plan when required for outpatient services. However, you may contact the member’s Blue Plan for authorization on behalf of the member," including through Electronic Provider Access. In the other direction, Highmark’s own prior-authorization requirements "include those services provided by out-of-area providers participating with their local Blue Plan," and "Claims for services on the prior authorization list received without authorization will be denied." So an out-of-state agency treating a Highmark West Virginia member needs Highmark’s ABA authorization, requested through its local plan’s portal. Blue Plan Medicaid members are "not officially part of the BlueCard Program."[3]
Highmark published new commercial rates for technician-delivered 97153 effective October 16, 2026, "across applicable Commercial products in Delaware (DE), Pennsylvania (PA), and West Virginia (WV)." The West Virginia PPO rate is $14.53 in an office and $13.78 outside an office (the notice’s table lists rates by state, product and place of service). Highmark says the change follows a review that found 97153 reimbursement "in several markets exceeded prevailing reimbursement relationships" between technician and clinician services, and that it does not change member benefits, medical necessity criteria, authorization requirements, coverage policies or documentation expectations. Rates for other codes are in your participation agreement.[23]
The questions that decide whether a family can start with Highmark Blue Cross Blue Shield West Virginia, and what they have to bring. Each maps onto something intake should ask on the first call.
Highmark requires prior authorization, not a referral, for ABA. Highmark publishes no ABA order form or validity period. Its CMS-1500 instructions use box 17 only when a referring, ordering or supervising provider is involved (one name, in that priority order, with qualifier DN, DK or DQ, and the NPI in 17b); the manual sets no ABA-specific referring-provider requirement. For a fully insured West Virginia group plan, the mandate requires treatment "ordered or prescribed by a licensed physician or licensed psychologist" and "in accordance with a treatment plan developed from a comprehensive evaluation by a certified behavior analyst," with semiannual progress reports from the analyst. Self-funded ERISA plans sit outside the statute.[1][4][3]
Highmark’s West Virginia ABA policy was not retrievable. For fully insured West Virginia group plans, the mandate covers ages 18 months to 18 years, requires an ASD diagnosis "at age eight or younger," and lets the insurer cap ABA at $30,000 a year for three consecutive years from the start of treatment and $2,000 a month after that until age 18 (W. Va. Code §§ 33-16-3v, 33-24-7k, 33-25A-8j). Employers with 25 or fewer eligible employees are exempt, and self-funded ERISA plans are outside the statute, so plan funding and size decide whether that binds.[4][5][6]
Ask the plan: Live benefits verification in Availity: establish funding type, employer size and the plan’s age terms.
Highmark lets participating behavioral health providers deliver "virtual" visits when the service falls within the provider’s scope and follows Highmark’s service and security guidelines; it publishes no ABA telehealth code list in the sources read. For a West Virginia-regulated policy, W. Va. Code § 33-57-1 requires coverage of "health care services provided through telehealth services if those same services are covered through face-to-face consultation," bars excluding a service "solely because the service is provided through telehealth services," and counts the patient’s home as an originating site. The statute defines the practitioner as someone licensed under Chapter 30, and West Virginia does not license behavior analysts, so it is unclear whether it reaches BCBA-delivered ABA. Self-funded employer plans are outside it.[3][10]
Ask the plan: Highmark Provider Manual Chapter 2, Unit 5 (Telemedicine Services) via Availity, or Highmark Behavioral Health.
Highmark Behavioral Health renders a routine decision "within two business days from the receipt of the request." Depends on how the plan is funded. West Virginia-regulated plans fall under W. Va. Code § 33-24-7s and its twins (§ 33-16-3dd for insurers, § 33-25A-8s for HMOs), for plans beginning on or after January 1, 2024. Requests go through the carrier’s electronic portal, and once "all of the information as required is provided," the carrier "shall respond … within five business days," or "within two business days" for urgent care. If a request is incomplete, the carrier must identify every deficiency and return it within two business days; you then have three business days to supply the information, and the carrier decides within two business days after that (miss the three days and the request is denied and must be resubmitted). A peer-to-peer must finish within five business days of being requested, and a PA appeal within ten business days. An approved PA "is carried over to all other managed care organizations, health insurers, and the Public Employees Insurance Agency for three months if the services are provided within the state," and a practitioner with a 90% approval rate over six months (and at least 30 procedures a year) earns a six-month gold-card exemption. 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.[3][8][24][25][13]
Ask the plan: At benefits verification ask whether the plan is fully insured (West Virginia-regulated) or self-funded (ERISA).
When Highmark is secondary, claims need the primary EOB and are due within the same timely-filing window counted from the primary’s finalized date. West Virginia regulates coordination of benefits by insurance rule (114 CSR 28), which we could not open this run, so we do not restate its birthday rule here; get the member’s order of benefits from both plans. When the child also has West Virginia Medicaid, the commercial plan pays first: Medicaid is "always the payer of last resort," and "All requirements of the third-party insurance plan must be met before Medicaid will reimburse including use of in-network providers" (BMS Chapter 100), consistent with 42 CFR 433.139. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[3][15][26][16][17]
Ask the plan: Ask Highmark and any other carrier for the member’s order of benefits.
Not stated in the Highmark sources read. The West Virginia mandate requires the diagnosis at age 8 or younger.[4]
Blocked on: Highmark Behavioral Health, 800-258-9808.
Not stated in the Highmark sources read. The mandate requires treatment ordered or prescribed by a licensed physician or licensed psychologist.[4]
Blocked on: Highmark Behavioral Health, 800-258-9808.
Not stated in the Highmark sources read.[3]
Blocked on: Highmark Behavioral Health, 800-258-9808, or the West Virginia ABA medical policy.
Coverage decides whether Highmark Blue Cross Blue Shield West Virginia 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.
Highmark publishes no ABA hour cap in the sources read; authorized units are set per request. On mandated West Virginia plans, the dollar cap ($30,000 a year for three years, then $2,000 a month) is the binding statutory limit.[1][4]
Ask the plan: Highmark Behavioral Health, 800-258-9808, and the member’s benefit summary.
Highmark’s West Virginia ABA medical policy, where supervision rules would sit, was not retrievable this run. The West Virginia mandate requires ABA "provided or supervised by a certified behavior analyst."[4]
Blocked on: Highmark’s West Virginia autism/ABA medical policy (V-37 series) via Availity, or Highmark Behavioral Health, 800-258-9808.
Not found in the Highmark sources read.[3]
Blocked on: Highmark’s ABA medical/reimbursement policy via Availity, or Provider Services.
Not found in the Highmark sources read.[3]
Blocked on: Highmark Provider Manual medical-records section (Availity) or Provider Services.
Yes. Since March 1, 2026, all ABA codes (97151–97158, 0362T, 0373T) are on Highmark’s prior-authorization list for West Virginia members, reviewed by Highmark Behavioral Health; requirements can vary by plan, and FEP and Medicare are excluded.
365 days from the last date of service unless your contract says otherwise; corrected claims within 15 months of the original claim’s finalization.
Only if it is a fully insured group plan from an employer with more than 25 eligible employees. It covers ages 18 months to 18 when diagnosed by age 8, and lets ABA be capped at $30,000 a year for three years, then $2,000 a month.
Yes, if it is in its own local Blue plan’s network: it files the claim with that local plan. But Highmark’s prior-authorization list still applies to its members treated by out-of-area providers, and claims without the required authorization are denied, so request Highmark’s ABA authorization through your local plan’s portal before starting.
Yes. From October 16, 2026 Highmark’s West Virginia PPO rate for 97153 is $14.53 in an office and $13.78 outside an office, under its August 17, 2026 notice. Authorization, medical necessity and documentation rules do not change.
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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