Highmark Health Options is the Medicaid MCO affiliated with Highmark Blue Cross Blue Shield Delaware, and one of the three Diamond State Health Plan plans. Its Medical Policy MP-1045 covers behavioral health treatment for ASD "pursuant to EPSDT," and its 2025 provider manual takes ABA out of the 30-unit yearly cap on outpatient behavioral health for members under 18.
MP-1045 (last revised October 26, 2022) says "HHO covers behavioral health services to treat autism spectrum disorders, pursuant to EPSDT," and for ABA "A prior authorization is required for members under the age of 18." It restates the Delaware mandate’s coverage to age 21 and its ban on "any limitations on number or location of visits by ABA providers." Treatment must be "prescribed or ordered for an individual diagnosed with" ASD "by a licensed physician or licensed psychologist who determines the care to be medically necessary." Providers must meet the DHSS certification regulation: "ABA providers must obtain national certification as a Board-Certified Behavior Analyst (BCBA) or Board-Certified Behavior Analyst – D (BCBA-D)," and behavioral technicians working under them must meet its criteria. The treatment plan must include ABA where applicable, and the plan "reserves the right to review the treatment plan once every 12 months." Codes 97151–97153, 97155 and 97156 are listed. Covered diagnoses are F84.0, F84.3, F84.5, F84.8 and F84.9. Payment follows the provider’s contract.[1][3]
The 2025 provider manual limits outpatient behavioral health for members 17 and younger to "30 units (a unit is defined as one hour of service) per calendar year," with the Division of Prevention and Behavioral Health Services managing care beyond that. It then lists services covered when medically necessary that it "will not count … against the 30 units," including "Applied behavioral analysis (ABA)." Highmark Health Options "requires precertification for all inpatient and outpatient BH services"; fax the Request for Authorization form or call the BH team, with the treatment plan. Initial claims are due within "120 calendar days from the date of service." Corrected claims or review requests are due within 180 days of the initial remittance, and COB claims within 60 days of the primary carrier’s adjudication. Providers have 60 calendar days from a Notice of Adverse Benefit Determination to appeal a denied authorization, and 180 days from a post-service claim denial.[2]
The questions that decide whether a family can start with Highmark Health Options, and what they have to bring. Each maps onto something intake should ask on the first call.
Under 21: MP-1045 says "The Delaware law mandates coverage to age 21," and the state plan covers ASD services under 21. The policy states the PA requirement for members under 18.[1][4]
Yes. Treatment must be "prescribed or ordered" by a licensed physician or licensed psychologist who determines it is medically necessary (MP-1045), on top of the state plan’s prior medical/physical evaluation.[1][4]
Highmark Health Options publishes no ABA telehealth rule, so the state rule applies: DMAP covers covered services by telehealth with "The same procedure codes and rates," POS 02, the member’s home as an approved originating site (no originating-site fee), and enrolled providers at both ends. MCO-credentialed providers follow the plan’s billing procedures.[5][2]
Highmark Health Options, "like Delaware’s DMMA, is the payer of last resort." Bill the primary carrier first; "All COB claims must be received within 60 calendar days from primary carrier’s adjudication date."[2][8]
The 2025 manual publishes no standard decision timeframe for behavioral health precertification. The federal ceiling applies: for rating periods starting on or after January 1, 2026, standard decisions "may not exceed 7 calendar days," expedited ones 72 hours.[2][7]
Ask the plan: Highmark Health Options behavioral health team: ask its current turnaround for ABA precertification and reauthorization lead time.
Not stated by the plan or the state.[1]
Ask the plan: Highmark Health Options behavioral health UM: ask how recent the diagnostic evaluation must be.
MP-1045 requires treatment prescribed or ordered by a licensed physician or licensed psychologist; it does not separately name who may make the diagnosis.[1]
Ask the plan: Highmark Health Options behavioral health UM.
No diagnostic instrument is named in MP-1045.[1]
Ask the plan: Highmark Health Options behavioral health UM: ask which documentation it expects with the first request.
Coverage decides whether Highmark Health Options 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.
MP-1045 adopts the DHSS provider regulation: ABA by a BCBA or BCBA-D, with behavioral technicians working under their supervision who meet its criteria. That regulation (16 Del. Admin. Code 2102) sets BCBA supervision at "not … less than 1.5:10 per week," and at least 1 hour a week when fewer than 10 hours of ABA are delivered.[1][3]
No daily unit cap. MP-1045 restates the Delaware law’s ban on "any limitations on number or location of visits by ABA providers," and the 2025 manual keeps ABA outside the under-18 30-unit cap. Hours are set by precertification.[1][2]
MP-1045: ASD treatment "is typically an outpatient procedure," eligible as inpatient only in special circumstances such as a comorbid condition needing monitoring. The policy also notes the Delaware law bars limits on the location of ABA visits.[1]
Not addressed in MP-1045 or the provider manual.[1][2]
Ask the plan: Highmark Health Options Provider Services or your provider agreement.
MP-1045 requires the medical record to document the medical necessity criteria, subject to audit, but sets no session-note signature rule.[1]
Ask the plan: Highmark Health Options Provider Services or the documentation terms of your provider agreement.
Yes. Medical Policy MP-1045 covers behavioral health treatment for ASD under EPSDT, including ABA, and the Delaware coverage runs to age 21.
No. The 2025 provider manual lists ABA among services it will not count against the 30 units.
Yes. It precertifies all inpatient and outpatient behavioral health, and MP-1045 requires PA for ABA for members under 18.
120 calendar days from the date of service for initial claims; COB claims within 60 days of the primary carrier’s adjudication.
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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