Highmark is the Blue plan for most of Pennsylvania. It is Highmark Blue Cross Blue Shield in 29 western and 13 northeastern counties, and Highmark Blue Shield in the 21 central counties. In central PA, Capital Blue Cross is the Blue Cross plan for the same counties. In southeastern PA, Highmark Blue Shield works with a separate plan under a joint operating agreement. For ABA, three documents do most of the work: Medical Policy V-37 (autism spectrum disorders), the prior authorization list (every ABA code since March 1, 2026), and Pennsylvania’s Act 62 autism mandate for the plans it covers.
Highmark’s Pennsylvania commercial policy V-37-044 (effective August 4, 2025) covers ABA when every criterion is met. The child has a DSM-5 ASD diagnosis. A qualified behavior analyst used a standardized assessment to find impairment in social communication and interaction, restricted or repetitive behavior, or activities of daily living. A state-licensed physician (MD/DO) or an independently licensed psychologist wrote an individualized treatment plan with measurable goals and outcomes. The services are delivered by a BCBA, a licensed behavior analyst, a BCaBA supervised by a BCBA, an RBT supervised by a BCBA or BCaBA, or an equivalent licensed or certified professional.[1]
Covered interventions include functional behavioral analysis, one-on-one and group sessions, and team conferences. Parent or caregiver training is covered when it ties to treatment goals and a BCBA, LBA or equivalent licensed professional delivers it. ABA cannot replace what the setting is responsible for (for example, a classroom aide or respite). Services that are only respite or custodial are not covered. The policy applies to “all commercial lines of insured business and, if elected, ASO”, so a self-funded employer chooses whether it applies.[1]
Highmark announced in November 2025 that it would add 19 behavioral health codes to its prior authorization list on March 1, 2026. These include all ten ABA codes: 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T and 0373T. The list effective 09/01/2026 carries them, plus H0032 and H2019, under “Applied Behavioral Analysis”, with “Highmark Behavioral Health” as the UM program. No ABA code is marked Gold Card Eligible. Submit through Availity Essentials (fax is the backup). Highmark Healthy Kids (CHIP) requests must be submitted electronically through Availity. The list says requirements vary by member plan: check the card number, Availity eligibility, or BlueExchange for out-of-area members.[3][2][4]
V-37 repeats Act 62 almost word for word. The mandate applies to group contracts issued or renewed on or after July 1, 2009 for fully insured employers with 51 or more employees, and to CHIP. The treatment plan must come from a physician or psychologist after a comprehensive evaluation. Highmark may review it once every six months under its utilization review rules, or on another schedule agreed with the plan author. The provider must keep the autism assessment and treatment plan on file. Copays, deductibles and coinsurance apply. Act 62 also holds a diagnostic assessment valid for 12 months and requires insurers to accept MA-enrolled autism service providers in their service area as participating providers. The Insurance Department’s 2026 notice sets the statutory cap at $51,908 for 2026 renewals ($53,310 for 2027). It expects the cap to have no impact on coverage, because autism is treated as a mental health condition under federal parity.[1][9][10][12]
Highmark’s eligible-provider policy (Z-27-037, effective October 13, 2025) lists “Behavior health rehabilitation agency providers (solely for the diagnosis or treatment of autism spectrum disorders)” and “Behavior specialist” among eligible professional providers. Highmark also pays for services by state-licensed or state-certified practitioners employed and supervised by an eligible provider.[5][6][1]
Telehealth: V-37 allows ABA in person, by secure real-time video and audio, or both. Reimbursement policy RP-046 (version effective September 1, 2026) pays telehealth at parity with in-person care, subject to plan terms. It requires POS 02 (outside the home) or POS 10 (in the home).[5][6][1]
Documentation: V-37 requires a parent or caregiver signature for each rendered service, the rendering provider’s name, signature and credential, start and end times that support the units billed, and the setting.[5][6][1]
Commercial ABA rates are negotiated in the provider agreement, and Highmark’s fee schedules are behind the Availity login. The exception is CPT 97153. On August 17, 2026 Highmark announced new 97153 reimbursement for applicable commercial products, effective October 16, 2026. For PA PPO it is $16.59 in the office and $15.73 outside the office (97153 is a 15-minute code). Highmark says the change does not alter eligibility, medical necessity criteria, authorization requirements or documentation expectations. Rates for the other ABA codes, and for products other than PPO, are not published.[7]
A Highmark Wholecare card is a Medicaid (HealthChoices) physical-health plan, not Highmark commercial coverage. Wholecare’s member handbook says behavioral health services “are provided through behavioral health managed care organizations (BH-MCOs)”, assigned by county. In Pennsylvania Medicaid, ABA is part of Intensive Behavioral Health Services (IBHS), so a Wholecare child’s ABA goes through the county BH-MCO, not Highmark. When a child has Highmark commercial coverage plus Medicaid (often PH-95), Highmark pays first and Medicaid pays second.[8][16][17]
Pennsylvania has no behavior-analyst license, and the BACB licensure table has no Pennsylvania entry. Under Act 62 § 635.2(g), the State Board of Medicine licenses Behavior Specialists (49 Pa. Code §§ 18.521–18.527), and Highmark’s Z-27 lists “Behavior specialist” as an eligible provider. Highmark’s V-37 separately accepts BCBAs, BCaBAs and RBTs under supervision. Confirm which credential your contract credentials as the rendering provider.[14][18][15][5]
The questions that decide whether a family can start with Highmark Blue Cross Blue Shield in Pennsylvania, and what they have to bring. Each maps onto something intake should ask on the first call.
No instrument is named for the diagnosis. V-37 requires that “a qualified behavior analyst used a standardized assessment” to find impairment in social communication and interaction, restricted or repetitive behavior, or activities of daily living. It names no specific tool.[1]
Highmark’s ABA documents require no PCP referral. What they require is an individualized treatment plan developed by a state-licensed physician (MD/DO) or an independently licensed psychologist (V-37), plus prior authorization for every ABA code. Act 62 adds that treatment must be prescribed, ordered or provided by a licensed physician, PA, psychologist, LCSW or CRNP, or provided by (or under the direction of) an autism service provider.[1][2][9]
Allowed. V-37 lets ABA be delivered in person, “via secure real-time video and audio telehealth/virtual modalities”, or a mix of both. RP-046 (version effective September 1, 2026) pays medically appropriate network telehealth at parity with in-person care, subject to plan terms. Bill POS 02 for services outside the patient’s home and POS 10 for services in the home. Outpatient facility claims also need modifier GT, 93 or 95. RP-046 limits telehealth coverage to interactions “between a licensed clinician and a member/patient” and does not list ABA codes one by one.[1][6]
V-37 sets no age limit for ABA. Act 62 requires coverage for members under 21 on plans it reaches: fully insured groups of 51 or more issued or renewed on or after July 1, 2009, and CHIP. V-37 says services beyond traditional medical management are covered for groups, CHIP and Adult Basic members “whose coverage is impacted by the ASD mandate under Act 62; or in accordance with the member’s benefit contract”. So for anyone 21 or older, and for self-funded, individual and small-group plans, the benefit contract decides.[1][9]
Ask the plan: Availity eligibility and benefits on the member ID. Establish fully insured vs. ASO and group size, then read the plan’s ABA/autism benefit and any age term.
V-37 sets no expiry date on the diagnosis. On Act 62 plans, “the results of a diagnostic assessment of autism spectrum disorder shall be valid for a period of twelve (12) months, unless a licensed physician or licensed psychologist determines an earlier assessment is necessary.” Self-funded and other non-mandate plans have no published rule.[9][1]
Ask the plan: Highmark Behavioral Health, when you submit the Availity request: ask whether an older evaluation is accepted on this plan, especially on self-funded groups.
V-37 requires a confirmed DSM-5 ASD diagnosis but does not say who must make it. On Act 62 plans, the “diagnostic assessment” is one performed by a licensed physician, licensed physician assistant, licensed psychologist or certified registered nurse practitioner. The treatment plan must come from a state-licensed MD/DO or an independently licensed psychologist.[1][9]
Ask the plan: For non-mandate (self-funded, individual, small-group) plans, ask Highmark Behavioral Health at authorization whether a diagnosis from another type of provider is accepted.
Depends on how the plan is funded. Fully insured plans follow Act 146 (Insurance Company Law § 2155): urgent requests for care not yet started within 72 hours, ongoing urgent care within 24 hours when requested at least 24 hours before it would be reduced or ended, and other requests “within 15 days”. The clock can extend when the insurer promptly flags missing information, and the provider gets at least 45 days to respond. Self-funded ERISA plans follow 29 CFR 2560.503-1: pre-service decisions within 15 days plus one 15-day extension, urgent within 72 hours. Highmark said in November 2025 that its average turnaround for urgent and non-urgent requests had dropped from about five days to about one day. That is an average, not a deadline.[13][19][3]
Ask the plan: At benefits verification, ask whether the plan is fully insured (PA-regulated) or self-funded (ERISA). Then confirm in Availity when the reauthorization request is due before the current authorization ends.
Two parents’ plans: no Pennsylvania regulation fixing the birthday rule was found, and no Highmark coordination-of-benefits document was read, so ask Highmark which plan is primary. Medicaid: if the child also has Medical Assistance (often PH-95, which ignores parental income), Highmark pays first. Pennsylvania requires other insurance, naming Blue Cross/Blue Shield, to be used before MA is billed (55 Pa. Code § 1101.64), and providers must bill private insurance before MA for ASD assessment and treatment. MA pays IBHS only when no third party pays (§ 1155.31(e)). Get Highmark’s authorization anyway, because the secondary claim needs Highmark’s decision. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)). CHAMPVA is the last payer (38 CFR 17.270).[17][20][21][22][23][24][25]
Ask the plan: Ask Highmark at benefits verification for the member’s coordination-of-benefits order (including whether a self-funded plan uses the birthday rule), and record every other coverage the child has.
Coverage decides whether Highmark Blue Cross Blue Shield in Pennsylvania 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.
BCaBAs must be supervised by a BCBA. RBTs must be supervised by a BCBA or BCaBA. Other licensed or certified professionals trained in ABA must be independently licensed or “supervised appropriately if required”. Parent training must be delivered by a BCBA, LBA or equivalent independently licensed professional. Highmark publishes no numeric supervision ratio or minimum hours.[1]
V-37’s documentation rules require, for each date of service: “a parent or caregiver’s signature for each rendered service”, the rendering provider’s name, signature and credential, the service or code with a written summary (behaviors with measured outcomes, redirections, goal changes, progress), start and end times that support the units billed, and the setting. The record must be available to Highmark on request. V-37 sets no deadline for signing.[1]
Home, clinic, or community settings, in person or by telehealth. School only when all three hold: the child has significant behavioral or other challenges that interfere with school performance; direct services in school are entirely ABA; and the activities are not primarily educational or vocational. ABA may not replace a classroom aide, 1:1 teacher, tutor, vocational coach or respite. Services outside a standard setting are subject to medical necessity review. For telehealth, bill POS 02 (outside home) or 10 (home) per RP-046.[1][6]
Z-27-037 makes “Behavior health rehabilitation agency providers (solely for the diagnosis or treatment of autism spectrum disorders)”, behavior specialists, psychologists and physicians eligible professional providers. It also pays for services by “state licensed or state certified health care practitioners, who are employed and supervised by eligible professional providers”. RBTs and BCBAs hold national certification, not a PA state license, and Highmark publishes no ABA-specific rule on whose NPI goes in the rendering field. That depends on how your contract credentialed the practice.[5][1]
Ask the plan: Highmark Provider Services or your provider agreement / credentialing letter. Confirm whether the agency, the supervising BCBA or behavior specialist, or the technician goes in the rendering-provider field.
Not addressed. Neither V-37 nor the reimbursement policies read (RP-046) say whether 97153 and 97155 may be billed for the same clock time.[1]
Ask the plan: Highmark Provider Services, or the provider agreement: get a written answer on concurrent 97153/97155 billing.
No per-day ABA unit ceiling is published in V-37. Highmark keeps its Medically Unlikely Edit (MUE) update schedule and fee schedules behind the Availity login, so any daily unit edits could not be read. Authorized units come from the Highmark Behavioral Health authorization.[1][3]
Blocked on: Highmark Provider Resource Center, “Medically Unlikely Edit (MUE) Update Schedule” (Availity login required), and the unit counts on each ABA authorization.
Yes, for a DSM-5 autism diagnosis under Medical Policy V-37. Fully insured large-group plans (51+ employees) and CHIP must cover it under Act 62 for members under 21. Self-funded, individual and small-group plans cover it per the benefit contract, and self-funded groups choose whether V-37 applies.
Yes. Since March 1, 2026, all ABA codes (97151–97158, 0362T, 0373T) are on Highmark’s prior authorization list, managed by Highmark Behavioral Health. That includes the assessment. Submit through Availity.
No. Highmark Wholecare is a Medicaid physical-health plan. Its handbook says behavioral health services come through the county BH-MCO, which manages ABA (IBHS) for Medicaid children in Pennsylvania.
Commercial ABA rates are negotiated. One exception is published: from October 16, 2026, CPT 97153 for PA PPO pays $16.59 in the office and $15.73 outside the office. Other codes and products are set by your contract.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 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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