---
title: "Highmark Health Options West Virginia ABA coverage: the intake guide."
url: "https://carelu.com/payers/highmark-health-options-west-virginia"
markdown_url: "https://carelu.com/payers/highmark-health-options-west-virginia.md"
state: WV (West Virginia)
payer: Highmark Health Options West Virginia (Mountain Health Trust)
kind: Medicaid managed care plan (MCO)
parent_program: West Virginia Medicaid (Mountain Health Trust)
description: "How Highmark Health Options West Virginia handles ABA for Mountain Health Trust members: the outpatient BH PA form, InterQual and BMS medical necessity, BMS Policy 519.23 eligibility, 60-day credentialing, 12-month filing."
last_reviewed: October 2026
---

# Highmark Health Options West Virginia ABA coverage: the intake guide.

_Payer Guide · Highmark Health Options · West Virginia · Last updated October 2026 · 14 primary sources_

> Highmark’s Medicaid MCO: ABA requested on its outpatient BH PA form (fax 1-855-412-7997); InterQual review; 12-month filing.

Highmark Health Options West Virginia (HHO WV) is Highmark’s Mountain Health Trust MCO and an independent Blue Cross Blue Shield licensee, separate from Highmark Blue Cross Blue Shield West Virginia’s commercial business. Its 2025 provider manual (updated 11/4/25) does not discuss ABA directly, but its Outpatient Behavioral Health Prior Authorization Request Form includes ABA therapy, and BMS Policy 519.23 sets the eligibility rules.

This plan administers the **West Virginia Medicaid (Mountain Health Trust)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [West Virginia Medicaid (BMS) guide](https://carelu.com/payers/west-virginia-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment:** Not published / unverified. Verify via: Highmark Health Options WV Prior Authorization Code Lookup (search 97151 and H0031) or Utilization Management, 1-844-325-6251. [3][1][4]
- **Prior auth for treatment**: Yes. HHO’s Outpatient Behavioral Health Prior Authorization Request Form has an "ABA Therapy" line (sessions and frequency); "Authorization is based on medical necessity" [2]
- **Autism diagnosis required?**: Yes. HHO publishes no ABA criteria of its own and applies "the Bureau for Medical Services definition of medical necessity," so BMS Policy 519.23 applies: primary ASD diagnosis before age 8, assessed within 24 months [1][4]

## At a glance

- **Covers ABA?:** Yes, as a Medicaid state-plan service (BMS Policy 519.23)
- **Prior auth:** Outpatient BH PA form, "ABA Therapy" line; fax 1-855-412-7997; UM 1-844-325-6251
- **Criteria:** InterQual, medical policy, and the BMS definition of medical necessity
- **Credentialing:** Written decision within 60 days of committee approval
- **Timely filing:** 12 months from date of service
- **Licensure:** None in WV; BACB certification governs

## Prior authorization and criteria

HHO WV’s Outpatient Behavioral Health Prior Authorization Request Form asks for the member, diagnosis (ICD-10), facility and provider NPIs, and under Mental Health Services an "ABA Therapy" request by number of sessions and frequency. The form says to fax it with supporting documentation to 1-855-412-7997 and that "Authorization is based on medical necessity"; questions go to Utilization Management at 1-844-325-6251. West Virginia law (W. Va. Code § 9-5-32) expects PA requests to go through an electronic portal, so ask whether HHO wants ABA submitted in its provider portal instead. HHO’s code lookup is now a search box on its provider site; the manual does not list ABA codes. [2][1][3][10][4]

HHO assesses medical necessity with ASAM criteria, InterQual criteria, and medical policy criteria together with "the Bureau for Medical Services definition of medical necessity." For ABA that means BMS Policy 519.23: ages 18 months through 20, ASD diagnosed before age 8, a diagnostic assessment from the past 24 months, an annual physician’s order, and no more than 40 hours a week. [2][1][3][10][4]

## Credentialing, claims and rates

Providers apply through CAQH, and after approval by the Highmark Quality and Credentialing committee or medical director "will receive written notification regarding their credentialing decision within 60 days." Original claims must be filed "within 12 months from the date of service"; corrected claims and requests for review within 120 days of the original remittance. HHO WV is payer of last resort when commercial or Medicare coverage exists, and clean claims are paid within 30 days of receipt, with 18% annual interest for in-network providers after that. Rates are contracted and unpublished; the BMS ABA fee schedule (97153 $9.90 per 15 minutes) is the public benchmark. [1][7]

## Intake gates

The questions that decide whether a family can start with Highmark Health Options West Virginia (Mountain Health Trust), and what they have to bring.

- **Age limit**: HHO publishes no ABA age rule, so the state rule applies. Ages 18 months through 20. Policy 519.23.1 makes ABA available to "Medicaid members ages 18 months through age 20 with a primary diagnosis of Autism Spectrum Disorder (ASD) prior to their eighth birthday" who are referred for diagnostic and treatment services identified during an EPSDT encounter. [1][4]
- **Diagnosis recency**: HHO publishes no rule of its own. Within 24 months. The PA request must include "the qualifying diagnostic assessment establishing the ASD diagnosis prior to age eight and completed within the previous 24 months" and "A comprehensive diagnostic assessment completed by a qualifying provider within the previous 24 months" (519.23.6). The first request must also document that the primary diagnosis "was rendered prior to the child’s eighth year of age" (519.23.2). [1][4]
- **Who may diagnose**: HHO publishes no list of its own. Policy 519.23.2 names the "qualified diagnostic provider": a licensed physician "such as a neurologist, pediatric neurologist, developmental pediatrician, psychiatrist, supervising psychologist, or a licensed psychologist, licensed independent social worker, licensed independent counselor." The glossary’s narrower definition of "Diagnostic Assessment" lists only physicians (neurologist, pediatric neurologist, developmental pediatrician, psychiatrist) and licensed psychologists, so a psychologist or physician diagnosis is the safe choice. [1][4]
- **Referral required?**: HHO publishes nothing different from the state. Yes. Members must be "referred for necessary diagnostic and treatment services identified during an Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) encounter" (519.23.1), and every PA request must include "The annual physician’s order for ABA Services" (519.23.6). [1][4]
- **Telehealth**: HHO publishes no ABA telehealth rule of its own, so the state rule applies. BMS lists every ABA code it pays except 97157 on its telehealth code list: Appendix A to Policy 519.17 (effective 1/1/2025) carries 97151, 97152, 97153, 97154, 97155, 97156 and 97158 with "provisional" status, meaning "temporarily approved for telehealth" and "subject to review." Policy 519.23 says telehealth "must align with" Policy 519.17, which requires real-time audio and video, POS 02 (or POS 10 when the member is at home, since January 1, 2022), written member consent, notes that record the telehealth mode, and HIPAA-compliant platforms. Two cautions: Policy 519.17’s list of distant-site practitioners does not name behavior analysts, and it requires interstate telehealth practitioners to register "with the appropriate board in West Virginia," a board that does not exist for BCBAs. Confirm with BMS or the MCO before building a remote program. [6][5][1]
- **Other insurance (who pays first)**: "HHO WV is the payer of last resort on claims for services provided to patients when any commercial or Medicare plan covers the patient." Bill the primary first and send HHO the original claim with the EOB within 12 months of the date of service (12 months from the Medicare remittance if Medicare is primary). [1][12]
- **Prior-auth decision time** _(plan-dependent)_: HHO’s manual does not publish an ABA decision clock. As a Medicaid MCO it is held to W. Va. Code § 9-5-32 (5 business days once a complete electronic request is received, 2 business days urgent) and to the federal managed-care ceiling of 7 calendar days for rating periods starting on or after January 1, 2026 (42 CFR 438.210(d)). [1][10][11]
  - Ask the plan: HHO WV UM, 1-844-325-6251: ask its standard and urgent turnaround for ABA requests.
- **Diagnostic tools required** _(licensed criteria)_: HHO reviews on InterQual, which is licensed and not public; neither HHO nor BMS names a diagnostic instrument. [1][4]
  - In licensed criteria: HHO WV UM, 1-844-325-6251: ask what diagnostic documentation InterQual review expects.

## Delivery and billing rules

Coverage decides whether Highmark Health Options West Virginia (Mountain Health Trust) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: HHO publishes no ABA supervision rule of its own, so the state rule applies. BMS sets no numeric supervision ratio. Policy 519.23.4 recognizes a BCBA (master’s or BCBA-D), a BCaBA "working under the supervision of a BCBA or who meets Behavior Analyst Certification Board supervisor requirements," and an RBT "working under the supervision of a BCBA or BCaBA who meets the Behavior Analyst Certification Board supervisor requirements," each only while BACB certification is "current and in good standing." The glossary adds that BCaBA "Competency and supervision must be verified annually and submitted to supervisor," and that BMS follows the BACB ethics code. Group skills training is limited to "four members to each staff person." [1][4]
- **Daily limits / MUEs**: HHO publishes no ABA unit cap of its own; Policy 519.23 caps 97151, 97152, 97153, 97154, 97155, 97156 and 97158 in combination at "a maximum of 40 hours per week and/or eight hours within a 24-hour period," with the service week running Sunday 12:00 am through Saturday 11:59 pm. The H0031 assessment is limited to "one per year per member." Group codes 97154 and 97158 may not exceed eight members. [1][4]
- **Concurrent billing (97153 + 97155)** _(plan-dependent)_: HHO publishes no ABA concurrent-billing rule; BMS Policy 519.23 requires that "only one staff person’s time is billed for any specific activity." [1][4]
  - Ask the plan: HHO WV Provider Services, 1-833-957-0020: ask whether 97153 and 97155 may be billed for the same minutes.
- **Place of service** _(plan-dependent)_: HHO publishes no ABA setting rule. Under state policy, services may be delivered in the member’s natural environment, educational services cannot be authorized, and school-administered services are outside managed care. [1][4][8]
  - Ask the plan: HHO WV UM, 1-844-325-6251: ask which POS codes it pays for ABA.
- **Bill as provider** _(plan-dependent)_: The PA form asks for both the servicing facility NPI and the servicing provider NPI; HHO publishes no rule on how RBT services are billed. BMS lets the BCBA or BCaBA bill RBT-delivered codes. [2][4]
  - Ask the plan: HHO WV Provider Services, 1-833-957-0020: confirm the rendering NPI on RBT lines.
- **Session-note signature** _(ask the plan)_: Not addressed in the HHO WV provider manual for ABA. [1]
  - Ask the plan: HHO WV Provider Services, 1-833-957-0020, or your provider agreement.

## What intake should collect for Highmark Health Options West Virginia (Mountain Health Trust)

- **Member ID:** Confirm HHO WV (Medicaid), not Highmark BCBS WV commercial.
- **Age at diagnosis + recent assessment:** ASD diagnosed before age 8; diagnostic assessment from the past 24 months (BMS Policy 519.23).
- **Annual physician’s order:** Required with ABA PA requests under the state policy.
- **Sessions and frequency requested:** The HHO form asks for ABA by sessions and frequency.
- **Other insurance:** Bill the primary first; HHO needs the EOB within 12 months of service.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Common questions

### Does Highmark Health Options West Virginia cover ABA?

Yes. ABA is a West Virginia Medicaid state-plan service under BMS Policy 519.23, and HHO’s outpatient behavioral health PA form includes ABA therapy.

### Is Highmark Health Options the same as Highmark Blue Cross Blue Shield West Virginia?

No. HHO WV is Highmark’s Medicaid MCO; Highmark BCBS West Virginia is the commercial plan, with its own prior-authorization list and the state autism mandate.

### What is HHO WV’s timely filing limit?

12 months from the date of service for original claims; corrected claims and review requests within 120 days of the original remittance.

## Primary sources

1. [Highmark Health Options West Virginia — 2025 Medicaid Provider Manual (updated 11/4/25)](https://providers.highmark.com/content/dam/highmark/en/providerresourcecenter/highmark-health-options/hho-wv/documents/pdfs/resources/provider-manual-and-newsletters/provider-manual/2025-HHOWV-ProviderManual.pdf)
2. [Highmark Health Options — Outpatient Behavioral Health Prior Authorization Request Form (ABA Therapy section)](https://providers.highmark.com/content/dam/highmark/en/providerresourcecenter/highmark-health-options/hho-wv/documents/pdfs/resources/forms-and-reference-material/OutpatientBehavioralHealthPrior%20Authorization%20Request%20Form_10112022.pdf)
3. [Highmark Health Options West Virginia — Prior Authorization Code Lookup](https://providers.highmark.com/hho-wv/resources/prior-authorization-code-lookup.html)
4. [BMS Provider Manual Chapter 519, Policy 519.23 — Applied Behavior Analysis (effective April 1, 2020; current posting)](https://bms.wv.gov/media/40119/download?inline)
5. [BMS Provider Manual Policy 519.17 — Telehealth Services (effective 1/1/2022)](https://bms.wv.gov/media/40772/download?inline)
6. [BMS Policy 519.17 Appendix A — Medicaid Telehealth Standard Codes (effective 1/1/2025)](https://bms.wv.gov/media/22096/download?inline)
7. [BMS — Applied Behavior Analysis Fee Schedule ("Contracts & Codes for: ABA - Medicaid")](https://bms.wv.gov/media/39954/download?inline)
8. [BMS Provider Manual Chapter 527 — Mountain Health Trust (Managed Care)](https://bms.wv.gov/media/40937/download?inline)
9. [BMS — Mountain Health Trust (Managed Care): the four MCOs](https://bms.wv.gov/members/mountain-health-trust-managed-care)
10. [W. Va. Code § 9-5-32 — Prior authorization (Bureau for Medical Services)](https://code.wvlegislature.gov/9-5-32/)
11. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-D/section-438.210)
12. [42 CFR 433.139 — Medicaid third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
13. [BACB — U.S. Licensure of Behavior Analysts (West Virginia not listed)](https://www.bacb.com/u-s-licensure-of-behavior-analysts/)
14. [Highmark Health Options WV — Provider Manual and Newsletters (quarterly provider newsletter archive)](https://providers.highmark.com/hho-wv/resources/provider-manual)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.