Horizon BCBSNJ is New Jersey's Blue plan. For its commercial members ABA runs on two of its own documents: Medical Policy 165, which sets the clinical and documentation criteria (revised effective December 1, 2026), and an ABA reimbursement policy that requires prior authorization for every ABA code and caps daily units. New Jersey's autism mandate sits underneath for fully insured plans and for self-funded groups that opted in. Horizon's Medicaid plan, Horizon NJ Health, follows NJ FamilyCare rules and has its own guide.
Requests go through the Utilization Management Request Tool in Availity Essentials. Form 40001 (ABA Supplemental Information) goes with it, plus proof of the autism diagnosis by a QHP (initial requests), current symptoms, the treatment plan, the functional assessment tool and, for concurrent requests, a progress summary. The form asks for hours per week by setting and units per code, and for concurrent reviews it asks you to explain any period where units requested were more than units used. Medical Policy 165 lists what the treatment plan must contain: measurable goals with baselines, frequency and duration, caregiver goals and participation, coordination with other providers and educators, the member's school supports and "verification of a current Individualized Education Program (IEP)," discharge and fading plans, a norm-referenced baseline (PDDBI, Vineland or ABAS), and the BCBA's signature. Treatment plans are revised every 6 months. Horizon's ABA Provider Report Guidelines give the outline for the assessment report and the progress report; progress reports are due "at minimum, two weeks prior to, and no more than 30 days, to the authorization end date," with graphed data per goal.[5][1][6]
Until November 30, 2026, no. The current Medical Policy 165 says authorized ABA hours "will be for time of treatment outside of the school setting (i.e., home or office setting). The school is responsible for ABA provided by an aide throughout the school day." Services the school district supplies are excluded, and ABA that is part of an NJ Early Intervention service plan or a school IEP "is not eligible for coverage by Horizon BCBSNJ" (form 40001 repeats this).[1][2][5]
From December 1, 2026, the revised policy opens a narrow door. ABA during "core instructional periods" is generally not medically necessary when it mainly supports classroom instruction or academics. ABA in school "may be considered medically necessary during non-instructional periods, including lunch, recess, transitions, and other natural social environments," when it targets clinically significant deficits in social communication, emotional regulation, adaptive functioning, safety or peer interaction and does not duplicate IEP supports. Every requested location, school included, needs a clinical rationale with the request. Services supplied by the school district stay excluded.[1][2][5]
Not as a routine path. The ABA reimbursement policy says "All ABA codes require prior authorization" and "Any request without prior authorization will prompt a denial of claims and require medical necessity review upon receipt of medical records." So services delivered without authorization are reviewed after the fact (a post-service medical-necessity review) only once the claim is denied and records are sent; payment is not assured. For telehealth, approval "must be obtained prior to rendering the services."[3][4][11]
New Jersey law protects you in two cases on fully insured plans. Under the Ensuring Transparency in Prior Authorization Act, a payer may not deny a claim for lack of prior authorization if you asked before the service and the payer did not answer within the legal deadline. And if a child changes plans, the new payer "shall accept the authorization" issued by the old one, based on the new plan's benefits. Self-funded plans are outside the Act.[3][4][11]
Medical Policy 165 starts from the mandate: P.L. 2009, c.115 requires policies issued or renewed on or after February 9, 2010 to cover "medically necessary behavioral interventions based on the principles of applied behavior analysis and related structural behavioral programs as prescribed by a treatment plan." Horizon applies the mandate and its own criteria to fully insured plans and to self-funded plans that opted to follow the mandate; for self-funded plans that did not, the same medical-necessity criteria apply but "Contract exclusions and/or limitations related to Applied Behavior Analysis(ABA) will determine the available benefit." The statute's $36,000 yearly ABA cap is mostly unusable on group plans: DOBI Bulletin 10-02 says the cap on a condition "classified in New Jersey law as a mental illness conflicts with federal provisions prohibiting such limits" under the federal parity law (MHPAEA). The individual and small-employer health benefits boards extended ABA coverage to adults with autism (amendments adopted in November 2014, effective January 2015).[1][9][10]
Horizon publishes no ABA rate table. Its reimbursement policies make payment subject to "The terms of any applicable provider participation agreement," and the telemedicine policy says participating providers are paid "at the same rate as that of the existing Professional Agreement Allowances." Participating providers may not bill the member beyond cost-sharing ("there shall be no member liability"); a non-participating provider's member "may be up to the provider's charge." Get rates from your Horizon agreement or Horizon network relations (BHNetworkRelations@HorizonBlue.com). For a public benchmark, see the NJ FamilyCare fee-for-service rates in the New Jersey Medicaid guide.[3][4][8]
Horizon Behavioral Health runs ABA utilization and care management for commercial members: 1-800-626-2212, or 1-800-991-5579 for the State Health Benefits Program (SHBP) and School Employees' Health Benefits Program (SEHBP). Horizon also runs an autism care management program. Clinical questions about the policy go to the Medical Policy department (medpol_ask@horizonblue.com, linked from the policy); network questions to BHNetworkRelations@HorizonBlue.com.[7][2][8]
The questions that decide whether a family can start with Horizon Blue Cross Blue Shield of New Jersey, and what they have to bring. Each maps onto something intake should ask on the first call.
A soft window, not a fixed number. The current policy asks for "a signed, recent diagnosis of Autism Spectrum Disorder (ASD) (e.g., within the last few years) including level of severity" under DSM-5; the December 1, 2026 revision reads "A signed, current (e.g., within the past several years) diagnosis … including DSM‑5‑TR severity level." The adaptive measure has its own clock: a standardized instrument of behavior and adaptive functioning is required as a baseline and repeated "no more frequently than every 6 months in support of the treatment plan unless Horizon and the treating physician agree that a more frequent review is necessary." So an old diagnostic report without a severity level is the thing most likely to be sent back.[1][2]
A named list. The medical policy defines the Qualified Health Professional who makes the diagnosis as "a Pediatrician, Advanced Practice Nurses (APNs), Pediatric Neurologist, Child Psychiatrist or Psychologist," and the reimbursement policy repeats it for claims: the ASD code must be "diagnosed by a Qualified Health Professional (QHP) such as a Pediatrician, Pediatric Neurologist, Advanced Practice Nurses (APNs), Child Psychiatrist or Psychologist with Autism Services within their scope of practice." A BCBA writes the treatment plan but is not on the diagnosing list. For initial requests, form 40001 asks for "Proof of autism diagnosis by a Qualified Health Professional."[1][3][5]
Two layers. Diagnosis: the policy wants the ASD diagnosis "made through extended observation and the use of standardized criteria (e.g., DSM-5-TR) or standardized diagnostic tools (e.g., Autism Diagnostic Interview, Revised (ADI-R)'; Autism Diagnostic Observation Schedule, Second Edition (ADOS-2)" — the ADI-R and ADOS-2 are examples, not a mandate, in the current version. The December 1, 2026 revision tightens this to "Diagnostic evaluation performed using extended observation and a standardized tool." If the diagnosis includes intellectual disability, a psychologist's report with standardized intelligence testing is required. Treatment: a "standardized, norm referenced baseline assessment of behavioral and adaptive functioning (e.g., PDDBI, Vineland, ABAS)" plus a functional assessment "using validated behavioral analysis tools," with test scores. Form 40001 asks for the last standardized assessment and any curriculum assessment (ABLLS, AFLS, PEAK, VB-MAPP) with dates and scores.[1][2][5]
Covered as telemedicine, with prior approval. Horizon's Telemedicine and Telehealth Services reimbursement policy (revised 12/18/2025) lists 97151–97158 among its telemedicine codes and pays real-time audio-video services billed with modifier 95 or GT, POS 10 when the member is at home and POS 02 when the member is in an office or facility; "Any service requiring a medical necessity for a face-to-face visit also requires a medical necessity approval for services provided through telemedicine channels. Request and approval of the medical necessity must be obtained prior to rendering the services." Participating providers are paid "at the same rate as that of the existing Professional Agreement Allowances." The ABA medical policy adds that telehealth services are "held to the same medical necessity criteria as in-person care" and that "Clinical justification for services rendered via telehealth must be included within the treatment plan"; the December 2026 revision makes telehealth one of the treatment locations that needs a submitted clinical rationale. So 97151 assessment and 97155 supervision by telehealth are payable when authorized for telehealth. N.J.S.A. 26:2S-29 (P.L.2021, c.310) requires a carrier to cover telehealth on the same basis as in person.[4][1][15]
Horizon's medical policy sets no upper age for commercial members. Its criteria apply to "fully insured plans and … self-funded plans that have opted to follow the New Jersey Autism and Developmental Disabilities Mandate," and the revision effective December 1, 2026 adds guidance on care models "for adults with ASD" and age-banded intensity thresholds: average weekly requests exceeding "33 hours for members under 6 years old," "27 hours for members between 7-12 years old" or "28 hours for members over 12 years old" need clear clinical rationale (those are the policy's own bands, which do not state a threshold for age 6). The age cap that does exist is the legal layer: the mandate (P.L. 2009, c.115) reaches ABA for individuals under 21, and the individual and small-employer (IHC/SEH) boards extended ABA to adults with autism in amendments adopted in November 2014. A self-funded plan that did not opt in follows its own plan document. Horizon's Medicaid line (Horizon NJ Health) is a separate guide with an under-21 limit.[1][2][10]
Ask the plan: Horizon Behavioral Health (1-800-626-2212; SHBP/SEHBP 1-800-991-5579): ask whether the plan is fully insured, a self-funded group that opted into the NJ mandate, or a self-funded group that did not, and whether the plan document has an ABA age limit.
Depends on how the plan is funded; Horizon publishes no ABA-specific clock. Fully insured New Jersey plans follow the Ensuring Transparency in Prior Authorization Act (in force January 1, 2025): for services such as ABA the payer must answer "no later than 12 days if the request is submitted in paper, or nine days if submitted through an electronic portal provided by the payer," and urgent-care claims no later than 72 hours after receipt; if the provider does not answer a request for more information within 72 hours the request is "deemed withdrawn"; a prior authorization for a chronic or long-term condition "shall remain valid for 180 days" unless a shorter period is needed with notice to the provider. If the payer misses its deadline, the claim "shall not be denied on the basis of a failure to secure prior or concurrent authorization." Self-funded (ERISA) plans follow the federal claims rule: pre-service decisions "not later than 15 days after receipt," one 15-day extension, urgent within 72 hours.[11][12][13]
Ask the plan: Benefits verification: fully insured NJ policy (ETPAA 9/12-day clock, 180-day authorizations) vs. self-funded ERISA plan (15 days / 72 hours).
For a child on two parents' plans, New Jersey's coordination-of-benefits rule for fully insured group contracts puts first "the plan of the parent whose birthday falls earlier in a year"; "birthday" means month and day only, and if both parents share a birthday the plan that covered the parent longer pays first. Self-funded plans set their order in the plan document. Note that Horizon's ABA reimbursement policy and its telemedicine policy both list Coordination of Benefits as out of scope, so when Horizon is secondary, ask how ABA claims and authorizations are handled.[14][3]
Ask the plan: Benefits verification with both plans: which is primary for the child, and whether Horizon requires its own ABA authorization when it is secondary.
Not published. Horizon's ABA medical policy, reimbursement policy and form 40001 require a QHP diagnosis, a BCBA-signed treatment plan ("Signature of the ordering health care provider (i.e., BCBA)") and prior authorization, but state no PCP referral or physician order. Whether an HMO-type plan adds a referral is a plan-document question.[1][5]
Ask the plan: Horizon Behavioral Health (1-800-626-2212) or the member's plan document: ask whether the member's product requires a PCP referral for behavioral health.
Coverage decides whether Horizon Blue Cross Blue Shield of New Jersey 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.
Horizon follows the DOBI position quoted in its medical policy: ABA is eligible for benefits "if administered directly by or under the direct supervision of an individual who is credentialed by the national Behavior Analyst Certification Board as either: A Board Certified Behavior Analyst - Doctoral (BCBA-D); Or a Board Certified Behavior Analyst (BCBA)." Form 40001 describes 97153 as treatment "administered by technician under the direction of BCBA, receiving 1 hour of supervision for every 5 to 10 hours of direct treatment." Session documentation must name everyone working with the member and their designation ("BCBA, BcaBA, RBT, etc."). No published rule requires the RBT credential by name.[1][5]
Published. Horizon's ABA reimbursement policy "shall apply the maximum daily allowable units" per 15-minute code: 97151 32, 97152 16, 97153 32, 97154 18, 97155 24, 97156 16, 97157 16, 97158 16, 0362T 16, 0373T 32. Billing above what was authorized "will not be considered for reimbursement," units billed above the daily limits trigger medical-necessity review, and moving the same service to another code to get around the limit "will be denied and/or subject to medical necessity review."[3]
School is the restriction. Until November 30, 2026 the medical policy says "ABA hours provided per this policy will be for time of treatment outside of the school setting (i.e., home or office setting). The school is responsible for ABA provided by an aide throughout the school day," and "Services supplied by the member's school district are excluded"; ABA delivered under an NJ Early Intervention plan or a school IEP "is not eligible for coverage by Horizon BCBSNJ." From December 1, 2026 the revised policy allows some school-based ABA: "ABA services delivered during core instructional periods are generally not medically necessary when the requested intervention primarily supports educational participation, classroom instruction, or academic performance. School-based ABA services may be considered medically necessary during non-instructional periods, including lunch, recess, transitions, and other natural social environments," when they target clinically significant deficits and are "not duplicative of supports provided under the member's IEP." Any requested location (center, home, school, community, telehealth) needs a clinical rationale. Form 40001 asks for hours per week by setting: member's home, facility/clinic, or other. Telehealth bills POS 10 (home) or 02.[1][2][5][4]
The behavior analyst. Horizon "shall only consider applied behavior analysis services for reimbursement when submitted by a Board Certified Behavior Analyst (BCBA®/BCBA-D®) or Licensed Behavioral Analyst," and will not pay ABA claims "submitted by a specialty other than" those. Form 40001 asks for the BCBA certification number, NJ LBA license number, the BCBA's NPI and the group TIN/NPI, and says the practitioner information "should match the information that will be submitted on claims." Technicians are not billed under their own NPI.[3][5]
Not stated as a rule. Form 40001 says 97155 "May be used for Direction of Technician (Supervision) face-to-face with one member," and the medical policy requires session records to show "what treatments were performed concurrent/overlapping and whether intervention was with member, caregiver(s), or both." Neither document says in terms whether 97155 and 97153 pay for the same minutes.[5][1]
Ask the plan: Horizon Behavioral Health provider line (1-800-626-2212): ask whether 97155 pays alongside 97153 when the BCBA directs the technician face-to-face.
Horizon sets note content, not a session-note signer or deadline. The medical policy wants narrative session notes tied to treatment-plan goals, start/stop times (breaks and snacks not billable), who worked with the member and their credential, prompt level, and data per opportunity; session data summaries are "submitted upon request on a case-by-case basis." The treatment plan must carry the "Signature of the ordering health care provider (i.e., BCBA)," and both the assessment report and the progress report end with the "Signature, title, and credential of the author of the report as well as the supervising BCBA, if different than the author."[1][6]
Ask the plan: Your Horizon participation agreement and Horizon's record-keeping standards: ask who must sign each session note and by when.
Yes, for autism spectrum disorder, under Horizon Medical Policy 165 and the New Jersey autism mandate for fully insured plans and self-funded groups that opted in. Every ABA code needs prior authorization.
Yes. Until November 30, 2026, Horizon pays ABA only outside the school setting; the school is responsible for ABA during the school day, and IEP or Early Intervention services are not covered. From December 1, 2026, school-based ABA may be approved during non-instructional periods (lunch, recess, transitions) if it is not duplicative of the IEP and you justify the setting. ABA during core instruction is generally not medically necessary.
Not routinely. Its ABA reimbursement policy says a service without prior authorization gets a claim denial and then a medical-necessity review once records arrive. On fully insured plans, NJ law bars a no-authorization denial if Horizon missed its decision deadline, and a new payer must honor an existing authorization when a child switches plans.
Yes, when authorized. Horizon's telemedicine policy lists 97151–97158; bill modifier 95 or GT with POS 10 (home) or 02, get medical-necessity approval before the service, and explain the telehealth use in the treatment plan.
Not by name in its published policies. ABA must be delivered by or under the direct supervision of a BCBA or BCBA-D, and the BCBA or NJ Licensed Behavior Analyst bills the claim. Form 40001 expects 1 hour of supervision for every 5 to 10 hours of technician treatment.
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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