Highmark Western and Northeastern New York Inc. — the plan formerly branded HealthNow New York / BlueCross BlueShield of Western New York, now operating as "Highmark Blue Cross Blue Shield of Western New York" since the 2021 Highmark affiliation — runs NY Medicaid Managed Care, HARP, and Child Health Plus across eight Western New York counties (Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, and Wyoming), covering 45,881 members per the state's July 2026 enrollment report. Unlike several plans in this directory, Highmark WNY names its ABA rules with unusual specificity — a stated dollar cap, an explicit prior-authorization requirement, and named telehealth codes — through a longstanding delegation to Wellpoint Partnership Plan, LLC (formerly Amerigroup Partnership Plan), which the plan's own Provider Manual says has managed its Medicaid behavioral health since 2016.
Highmark WNY's Medicaid/CHPlus Provider Manual states its Autism Spectrum Disorder section plainly: "The maximum applied behavioral health analysis benefit is $45,000 per calendar year" — a specific dollar figure this guide has not found published this precisely by any other upstate NY Medicaid plan. The manual's Behavioral Health prior-authorization table confirms ABA requires authorization across the board: "Applied behavior analysis (ABA) services — Covered effective 1/1/2023: requires authorization" for MMC and SSI, and "Covered: requires authorization" for HARP and CHPlus alike. Psychological and neuropsychological testing used to establish or support the ASD diagnosis is separately listed as requiring authorization based on medical necessity criteria.[1][6]
Re-checked September 27, 2026 against the current manual (copyright March 2026): the $45,000 sentence is still there, unchanged, as the closing line of the section headed "Autism Spectrum Disorder (ASD) Screening, Diagnosis and Treatment: Medicaid Managed Care, HARP & CHPlus." Two things to know before you plan around it. The state's own ABA Policy Manual sets no annual dollar or hour maximum for NY Medicaid ABA, for fee-for-service or managed care. And the ASD section the cap sits in is written in the vocabulary of New York's commercial autism mandate (ASD "diagnosed by a licensed physician or psychologist"; "therapeutic care, even if deemed habilitative or nonrestorative"; assistive communication devices) rather than the Medicaid ABA benefit. Nothing we can read says whether Highmark actually applies the cap to under-21 Medicaid members, so ask Highmark's precertification line in writing before treating it as a hard ceiling, and escalate any cap-based denial for a Medicaid child.[1][6]
Highmark WNY publishes a standalone "Request for Authorization: Autism Spectrum Disorder Testing" form (Feb 2026) covering the psych/neuropsych testing codes used to diagnose ASD (96130, 96131, 96136–96139), requiring clinical history, validated screener results (ASRS, SCQ, SRS, M-CHAT, CARS, GARS, GADS), and DSM-5/ICD-10 codes — and it explicitly asks "Is this a request to access ABA services?" as a checkbox, tying the testing authorization directly to the ABA pathway. Submit via Availity Essentials or fax to 844-452-8073, before rendering services. On delegation: the Provider Manual states repeatedly, with a dedicated contact inbox (WNYBehavioralHealthTeam@wellpoint.com), that Wellpoint Partnership Plan, LLC has administered the plan's Medicaid Managed Care, HARP, and CHPlus behavioral health since 2016 — but the same manual's vendor-disclosure footer also names Carelon Behavioral Health IPA Strategies, LLC as performing utilization review "on behalf of the health plan," without clarifying which lines of business that covers. The Wellpoint citations are far more numerous and Medicaid-specific; treat Wellpoint as the operative BH/ABA delegate, but confirm directly with Provider Services before assuming it over Carelon on any given case.[2][1][6]
What a reauthorization must show. Highmark Western and Northeastern New York publishes no reauthorization packet or progress-data rule of its own in the documents we checked, so the state’s floor is the reference: the eMedNY ABA manual requires the treatment plan to be updated “at least every 6 months or as needed” with “updated goals and data,” each goal carrying “baseline data reported in objective terms” and “current data expressed by the same data collection method as the baseline data so that progress can be measured.” The state does not require graphs; ask the plan whether it wants graphed data before the first concurrent review.[2][1][6]
A Highmark WNY provider bulletin (originally issued June 2020 for COVID-19, republished January 2022) names the exact ABA telehealth codes it recognizes: "Highmark BCBSWNY would recognize ABA therapy for functional behavior assessment (FBA) (97151), adaptive behavioral treatment by protocol or protocol modification (97153, 97155), and telehealth caregiver training (97156, 97157) visits within the member's benefits, with POS 02 and modifier 95 or GT." The same bulletin is explicit that telephonic-only (audio-only) delivery does not qualify — ABA requires audio-plus-video telehealth. Because this bulletin was written for the COVID period and no newer document was found superseding it, confirm with Provider Services that this telehealth guidance is still the operative policy before relying on it for a current authorization.[3]
Timely filing is 120 days from the date of service (or per the provider agreement); corrected claims must be submitted within 90 days of the Explanation of Payment. Claims route through Availity Essentials, Highmark's exclusive EDI clearinghouse partner (payer ID 00246), or by paper to New York Claims, P.O. Box 61010, Virginia Beach, VA 23466-1010. Medical appeals of an adverse determination must be filed within 60 calendar days of the notice-of-action date, and payment disputes within 45 calendar days of the Explanation of Payment.[1][4]
Highmark Western and Northeastern New York sets its own filing limit in its provider agreement and manual; New York law sets the floor. Ins. Law § 3224-a, which covers New York insurers, Article 43 corporations and Article 44 HMOs, requires claims to be submitted within 120 days of the date of service unless the contract is more favorable to the provider — and for Medicaid managed care contracts lets the parties agree on a different period "but in no event less than ninety days." Undisputed claims must be paid within 30 days of receipt when submitted electronically and 45 days on paper, with interest at the greater of the corporate-tax rate or 12% per annum when paid late.[11][12][1][8][9][6]
Electronic Visit Verification does not reach ABA: the Department of Health’s EVV list for fee-for-service and managed care Medicaid covers personal care and home health care codes (CDPAP, home care, HCBS habilitation and respite) and no ABA code (97151–97158).[11][12][1][8][9][6]
Highmark’s own clocks, from its Medicaid/CHP provider manual: claims within 120 days of the date of service; “In the case of other insurance, submit the claim within 120 days of receiving a response from the third-party payer”; corrected claims “within 90 days of the date of the EOP.” Payment: Highmark adjudicates clean electronic claims within 30 days and clean paper claims within 45 calendar days of receipt, with interest if late; providers review “the weekly Explanation of Payment (EOP),” and a biweekly mailed EOP covers claims adjudicated during “the previous check week cycle.” Check status if a claim has not appeared on an EOP within 30 business days. No submission cut-off is published.[11][12][1][8][9][6]
For Medicaid managed care specifically, the state’s model contract adds a payment rule: the plan “shall make payments to Participating Providers and to Non-Participating Providers, as applicable, for items and services covered under this Agreement on a timely basis, consistent with the claims payment procedures described in SIL § 3224-a,” and must comply with 42 CFR 447.45(d)(5) and (6).[11][12][1][8][9][6]
Code set: Highmark Western and Northeastern New York publishes no ABA code list of its own in the documents we checked (its Medicaid/CHP provider manual; its COVID-era telehealth bulletin names only 97151, 97153, 97155, 97156 and 97157), so the state’s applies: New York Medicaid’s ABA fee schedule (effective October 1, 2026) and the eMedNY manual’s billing table carry only CPT 97151–97158 — no 0362T or 0373T and no HCPCS H-code (H0031, H0032, H2019, H2014). Bill ABA on the CPT codes; confirm the plan’s fee schedule before billing anything else.[11][12][1][8][9][6]
Highmark’s provider manual (Chapter 2, Unit 6) covers members of another Blue plan’s Medicaid product treated in Highmark’s area, which includes New York. Eligibility and prior authorization use the same tools as BlueCard: BlueExchange, BlueCard Eligibility at 800-676-BLUE (2583), and Electronic Provider Access for pre-service review. Claims still go to Highmark as the local plan. But "Medicaid is not officially part of the BlueCard Program since there is no network reciprocity, and the locally negotiated rates do not apply to Medicaid claims": payment is limited to the Medicaid allowed amount set in the member’s home state, and the out-of-area care "generally ... requires authorization." Blue Medicaid ID cards carry no suitcase logo and must say on the back that out-of-area benefits are limited.[7]
The questions that decide whether a family can start with Highmark Western and Northeastern New York (NY Medicaid), and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the New York Medicaid rule: ABA is covered for members “under 21 years of age with a diagnosis of Autism Spectrum Disorder (ASD) as defined by… (DSM-5) and/or Rett Syndrome.” No minimum age and no adult pathway — the 21st birthday is a hard cliff. Highmark WNY publishes no age rule of its own; its Provider Manual lists ABA as covered effective 1/1/2023 across MMC, SSI, HARP and CHPlus, subject to authorization and to a stated $45,000-per-calendar-year benefit maximum.[6][1]
Follows the New York Medicaid rule — the two-year referral is the clock and no maximum age is set on the diagnostic evaluation. Highmark WNY publishes no recency rule of its own; what it does gate is the workup, through a standalone ASD testing authorization that must be filed before the diagnostic services are rendered.[6][2]
Follows the New York Medicaid rule: the diagnosis and referral must come from a NYS-licensed, NYS Medicaid-enrolled physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner or physician assistant, following DSM-5 criteria and NYSDOH’s Clinical Practice Guideline on ASD. LBAs and CBAAs sit outside that list — they may not diagnose and may not self-refer. Highmark WNY’s ASD Testing authorization form covers the psychological and neuropsychological testing codes used to diagnose ASD (96130, 96131, 96136–96139) and asks for clinical history and DSM-5/ICD-10 codes, but names no diagnosing credential beyond the state’s referral list.[6][2]
The most explicit screener list of any New York Medicaid plan, though it sits on the testing-authorization form rather than in a clinical policy. The “Request for Authorization: Autism Spectrum Disorder Testing” form (Feb 2026) requires clinical history, DSM-5/ICD-10 codes and validated screener results — ASRS, SCQ, SRS, M-CHAT, CARS, GARS and GADS — and explicitly asks “Is this a request to access ABA services?” as a checkbox, tying the testing authorization directly to the ABA pathway. The state baseline underneath requires only the DSM-5 Diagnostic Checklist with the referral.[2][6]
Follows the New York Medicaid rule: the member “must be referred for ABA services by a NYS-licensed and NYS Medicaid-enrolled physician, psychologist, psychiatric nurse practitioner, pediatric nurse practitioner, or physician assistant,” the referral is “valid for no more than two years,” and it must carry age, the ASD/Rett diagnosis, date of initial diagnosis, co-morbid diagnoses, symptom severity level, a statement the patient needs ABA, and the DSM-5 Diagnostic Checklist. Highmark WNY adds two of its own gates. First, the diagnostic workup: file the ASD Testing authorization via Availity Essentials or fax to 844-452-8073 before rendering services. Second, treatment: the Provider Manual’s behavioral-health PA table reads “Applied behavior analysis (ABA) services — Covered effective 1/1/2023: requires authorization” for MMC and SSI, and “Covered: requires authorization” for HARP and CHPlus. Behavioral health has been delegated to Wellpoint Partnership Plan, LLC since 2016 (WNYBehavioralHealthTeam@wellpoint.com), though the same manual’s vendor footer also names Carelon Behavioral Health IPA Strategies without clarifying scope.[6][1][2]
Ask the plan: Highmark WNY Provider Services — confirm whether Wellpoint Partnership Plan or Carelon is the operative BH/ABA reviewer for the case before submitting.
ABA requires authorization (effective January 1, 2023). “In the case of a standard or non-expedited request, a decision and notification will be made within three business days of receipt of the necessary information but no later than 14 calendar days after the receipt of the request”; expedited requests no later than 72 hours after receipt; a continued-services (concurrent) request within one business day of the necessary information, no more than 14 calendar days. “An extension will extend the review turnaround time by 14 calendar days.” Highmark’s submission rule: “Precertification requests must be submitted, at a minimum, within 72 hours prior to the scheduled service/procedure,” or they are administratively denied. Federal rules cap standard decisions at 7 calendar days for plan rating periods starting on or after January 1, 2026, tighter than the manual’s 14. No ABA reauth lead time is published (the manual’s 14-day pre-expiry rule is for children’s HCBS, not ABA).[1][13]
“We and our providers agree the Medicaid program will be the payer of last resort when third-party resources are available.” When Highmark knows of other coverage it rejects the claim and redirects you to bill that carrier; when it learns later, it recovers after payment. Bill the other plan first, then Highmark: “In the case of other insurance, submit the claim within 120 days of receiving a response from the third-party payer.” The manual does not say whether Highmark’s ABA authorization is still required when it is secondary — confirm on Highmark’s precertification line (1-866-231-0847) before starting on the primary plan’s approval alone.[1]
Highmark WNY names the codes, but the only guidance found is a COVID-era bulletin. Originally issued June 2020 and republished January 2022, it states that “Highmark BCBSWNY would recognize ABA therapy for functional behavior assessment (FBA) (97151), adaptive behavioral treatment by protocol or protocol modification (97153, 97155), and telehealth caregiver training (97156, 97157) visits within the member’s benefits, with POS 02 and modifier 95 or GT,” and is explicit that telephonic-only (audio-only) delivery does not qualify — ABA requires audio plus video. On the authorization, the same bulletin says telehealth does not need its own approval: “If an ABA provider is not requesting changes to existing authorized codes or units, they can continue to use the authorization they have on file. No further action is required by the provider”; changes to codes or units need a new treatment request form with the current authorization reference number. No newer document superseding it was located.[3]
Ask the plan: Highmark WNY Provider Services — confirm the COVID-era telehealth bulletin is still operative before billing 97151/97153/97155/97156/97157 via telehealth.
Coverage decides whether Highmark Western and Northeastern New York (NY Medicaid) 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.
Follows the New York Medicaid rule, which the state applies to FFS and managed care alike: “an LBA can supervise no more than six CBAAs/unlicensed individuals at a time,” “LBAs are required to supervise unlicensed individuals for a minimum of five percent of the hours the unlicensed individual spends providing behavior analysis services each calendar month,” and “supervision must include at least two face-to-face, real-time contacts per month” with the LBA observing service delivery in at least one. Supervision may run over synchronous audio-and-video where on-site is impractical. 97155 counts toward the 5% “only when the LBA joins the patient and the unlicensed individual during a treatment session to direct the unlicensed individual/technician in implementing a new or modified treatment protocol.” CBAAs need direct supervision, and the supervisor “should assess each patient’s/client’s progress at least every 6 months… and review and sign treatment notes and reports prepared by the CBAA supervisee.” Highmark WNY publishes no supervision ratio of its own; its Provider Manual addresses authorization and benefit limits rather than staffing structure, so the state rule is the operative one.[6][1]
No per-day unit ceiling, but the only stated dollar cap among New York’s Medicaid plans: “the maximum applied behavioral health analysis benefit is $45,000 per calendar year,” stated directly in the Provider Manual’s Autism Spectrum Disorder section (still present in the March 2026 manual, re-checked 2026-09-27). The state ABA manual sets no annual maximum for FFS or managed care, and the manual does not say whether the cap is enforced for under-21 Medicaid members — confirm with Highmark in writing, and track spend-to-date against the treatment plan’s intensity rather than discovering it mid-year. On claims: timely filing is 120 days from the date of service or per the provider agreement, corrected claims within 90 days of the Explanation of Payment, appeals within 60 calendar days of the notice-of-action date and payment disputes within 45.[1][6]
Follows the New York Medicaid rule: the LBA supervisor must “review and sign treatment notes and reports prepared by the CBAA supervisee,” and documentation of supervision itself “should be recorded in the patient file.” Clinical documentation must carry the treatment plan with assessment and goals, the goal data, total hours of service per week by who delivered them, and the location(s) of services. Records are kept “for a minimum of six years and, for minors, until the patient turns 22 years of age.” Highmark WNY publishes no additional session-note signature rule for ABA.[6][1]
Follows the New York Medicaid rule: “LBAs and CBAAs may work in any legally authorized setting. Examples of such settings include private practice, settings where patients/clients reside full-time or part-time, clinics, hospitals, residences, and community settings” — but “NYS Medicaid does not reimburse for ABA services in a school setting.” The treatment plan must record the location(s) of services. Highmark WNY publishes no separate setting rule for ABA; the state’s school bar is the operative constraint, and the plan’s own telehealth bulletin adds POS 02 with modifier 95 or GT for the codes it recognizes remotely.[6][3]
Ask the plan: Highmark WNY Provider Services for any plan-specific setting restriction.
Not published. The Provider Manual’s ASD section states the benefit cap and the PA requirement rather than claim edits, and the state manual is silent on 97153 with 97155.[1][6]
Ask the plan: Highmark WNY Provider Services, or the delegated behavioral-health team at WNYBehavioralHealthTeam@wellpoint.com — confirm in writing before billing the overlap.
Not published as a claim convention — the Provider Manual sets the authorization and benefit rules rather than a rendering-versus-supervising NPI rule. At the fee-for-service layer New York is explicit: LBAs bill “using the LBA’s National Provider Identification (NPI) number for the ‘Billing’ provider and/or ‘Supervising’ provider,” with “the NPI number of the CBAA that provided the ABA service… reported as the ‘Rendering’ provider on each claim”; for unlicensed aides and LBA limited-permit holders the supervising LBA’s NPI fills all three roles. CBAAs cannot bill directly and enroll as OPRA providers. Claims route through Availity Essentials, Highmark’s exclusive EDI clearinghouse partner (payer ID 00246), or by paper to New York Claims, P.O. Box 61010, Virginia Beach, VA 23466-1010.[1][6]
Ask the plan: Highmark WNY Provider Services — confirm the rendering/supervising NPI convention and any modifier requirement for CBAA- and technician-delivered units.
Yes — for NY Medicaid Managed Care, HARP, and Child Health Plus members under 21 with ASD/Rett, effective 1/1/2023, subject to a stated $45,000-per-calendar-year benefit maximum and prior authorization.
Yes — a standalone Autism Spectrum Disorder Testing authorization form gates the diagnostic workup and explicitly asks whether the request is meant to access ABA services, submitted via Availity Essentials or fax before services are rendered.
Wellpoint Partnership Plan, LLC (formerly Amerigroup Partnership Plan) has managed the plan's Medicaid Managed Care, HARP, and CHPlus behavioral health since 2016, per the Provider Manual — though the same manual also references Carelon Behavioral Health in a vendor-disclosure footer without clarifying scope. Confirm with Provider Services which applies to your case.
No — the Medicaid Managed Care/HARP/CHPlus product is limited to eight Western New York counties (Allegany, Cattaraugus, Chautauqua, Erie, Genesee, Niagara, Orleans, Wyoming), despite the plan's legal name including "Northeastern New York."
Six at a time. New York Medicaid, which applies the rule to fee-for-service and managed care alike, says an LBA "can supervise no more than six CBAAs/unlicensed individuals at a time," must supervise each for at least 5% of their monthly service hours, and must hold at least two face-to-face real-time contacts a month, observing service delivery in one. In New York the supervisor must be a NYSED-licensed behavior analyst; BCBA certification alone is not a license.
Your contract sets it, but New York Ins. Law § 3224-a bars a Medicaid managed care contract from setting less than 90 days from the date of service (120 days is the default without a contract term). Clean electronic claims must be paid within 30 days, paper within 45.
Not on anything Highmark Western and Northeastern New York publishes. It posts no ABA code list of its own, and the New York Medicaid ABA fee schedule it builds on lists only CPT 97151–97158, with no H-codes and no 0362T/0373T. Bill ABA on the CPT codes.
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.
Carelu collects all of this automatically.
Every ID, document, and detail this payer requires — gathered conversationally the moment a family reaches out, with insurance verified before your team touches the file.
Get a Demo