Horizon NJ Health — the Horizon BCBSNJ Medicaid plan — is the largest NJ FamilyCare MCO and the one with the most built-out ABA machinery: its own medical policy, MCG-based utilization review, and a documented assessment fast-track. It manages ABA across Core Medicaid, DDD, MLTSS, and FIDE-SNP populations. Horizon uses the state's code set and daily unit table, but layers a meaningfully stricter process on top than the state baseline — and has announced further policy revisions taking effect through 2026.
The front door is the ABA Authorization Request Form submitted through NaviNet's UM Request Tool, with an ASD diagnosis script from a QHP attached. The assessment step is fast-tracked: once Horizon confirms eligibility, diagnosis, and the script, it issues an assessment authorization of 32 units of 97151 valid for 30 days — no full clinical review at that stage. Treatment is where the review lives: the post-assessment ABA Request Form goes back through NaviNet, a UM clinician reviews against MCG criteria, requests are reviewed within 14 days of receipt, and approved cases get 6-month authorizations. Two hard edges: Horizon enforces the state's daily MUE unit limits ("shall not consider for reimbursement units exceeding the daily maximum as clinically authorized"), and claims above authorized units are not reimbursed — so the authorization, not the treatment plan, is the billing ceiling.[1][6]
Both 2026 Horizon announcements have now been read in full, and only one of them reaches this plan. H0032 is retired for ABA: "Effective July 15, 2026, HCPCS code H0032 will no longer be used to represent Applied Behavioral Analysis (ABA) services on authorizations or claims," and the notice says in terms that "This change applies to members enrolled in Horizon NJ Health NJ FamilyCare (Medicaid) and Horizon NJ TotalCare (HMO D-SNP) plans." Bill 97151–97158 and 0362T/0373T instead. The transition is soft: Horizon "will continue to honor authorizations created up through July 14, 2026 that include H0032" and keeps paying H0032 on claims for authorized services rendered between July 15, 2026 and January 14, 2027 — so any H0032 line still in flight must be re-coded before January 15, 2027. Horizon also states it is "not changing authorization requirements for ABA treatment hours." The January 1, 2026 ABA medical-policy revision (revised documentation standards for prior authorization and pre- and post-service medical-necessity reviews) is a different matter: it is scoped to "members enrolled in Horizon commercial plans and members enrolled in Administrative Services Only (ASO) group employer plans" that follow the New Jersey autism mandate, so it does not govern NJ FamilyCare members on this plan.[2][3]
Horizon publishes real ABA escalation contacts: ABA UM escalations go to Erin McNeill (732-256-6336, erin_mcneill@horizonblue.com), the behavioral Medicaid inbox is BHMedicaid_@horizonblue.com, and member services runs at 1-800-682-9091; claims use payor ID 22326. On rates: Horizon publishes no ABA fee schedule — it aligned behavioral-health fees to the DMAHS rate increase for claims on or after March 1, 2024, but the specific ABA amounts are unverified, so treat your participating-provider agreement as the source of truth.[5]
Yes, within a short window. Horizon NJ Health's provider manual (section 11.4.2, Retrospective Review) says Horizon "will accept the clinical review … for prior authorizations including outpatient medical and behavioral health within six business days," and lists "ABA services" among the behavioral health services this covers. Submit it in the Utilization Management Request Tool on Availity Essentials, choosing "Post Service" as the Event Classification; "Horizon NJ Health has up to 30 days to review retrospective requests." Beyond that, "In extenuating circumstances related to eligibility verification/exhaustion of primary benefit, such inquiries will be reviewed on a case-by-case basis and require supporting documentation."[10]
Yes, taxonomy is required. Horizon NJ Health’s manual (approved July 14, 2026): “Taxonomy codes must be provided on all claims,” and “WITHOUT THIS CODE CLAIMS PAYMENT WILL BE DENIED.” On a CMS-1500 the code goes “in the shaded portion of box 24j for the rendering level and in box 33b preceded with the “ZZ” qualifier for the billing level,” and “Claims that do not contain these codes cannot be processed.” On an 837P it goes in segment PRV03, loop 2000A for the billing level and loop 2420A for the rendering level. The manual also asks you to register your NPI with your taxonomy and tax ID.[10][11]
Filing and payment. Horizon NJ Health “must receive all claims within 180 calendar days from the initial date when services were rendered,” and it “shall pay all clean claims from hospitals, physicians and other health care professionals within 30 days of the date of receipt of EDI claims and within 40 days for paper claims.” The state contract holds MCOs to a faster standard for behavioral health claims, ABA included: 90% of electronic clean claims processed within 15 days and 90% of paper clean claims within 30 days. Claim appeals go on the DOBI Health Care Provider Application to Appeal a Claims Determination and “must be received by Horizon NJ Health within 90 calendar days following receipt by the physician, facility or health care professional of the payer’s claim determination.” Corrected claims (frequency code 7, with the original claim number): “Both paper and electronic claims must be submitted within 365 calendar days from the initial date of service.” A rejected claim never entered the system, so it must be resubmitted clean within the original 180 days. When another insurer pays first, “the claim must be received by Horizon NJ Health within 60 days from the date on the other carrier’s correspondence.” The manual counts the payment clock from “the date Horizon NJ Health receives the claim, as indicated by its date stamp on the claim” to “the date of the check or other form of payment”; it publishes no check-run day and no weekly submission cutoff, so a claim counts from the day it arrives. EVV: the manual applies DMAHS’s EVV reporting to personal care assistance services and gives no EVV step for ABA.[10][11]
CPT 97151–97158 and the Category III codes 0362T and 0373T only. Horizon NJ Health’s ABA reimbursement policy lists those ten codes, and its history entry for March 26, 2026 reads: “Removed H0032 from policy effective 07/15/2026.” Its provider manual says the same: “ABA services should be billed using the following HIPAA compliant HCPCS codes,” followed by 97151 through 0373T. H0031 does not appear in either document as an ABA code. The state sets the same list: the NJ FamilyCare managed care contract’s ABA service description names 97151–97158, 0362T and 0373T as the “HIPAA Compliant Billing Codes.” The only H0032 left is the transition: H0032 lines on authorizations created through July 14, 2026 are paid for services through January 14, 2027.[13][10][11][3]
The questions that decide whether a family can start with Horizon NJ Health, and what they have to bring. Each maps onto something intake should ask on the first call.
Two published numbers, and they differ in precision rather than in substance. The founding DMAHS newsletter sets the benefit for "any Medicaid eligible child, under the age of 21, who has been diagnosed with ASD as defined by ICD 10 diagnoses F84.0 through F84.9 by a qualified healthcare provider," delivered under EPSDT, which reaches "individuals under the age of twenty-one." Optum's New Jersey Medicaid entry adds the floor as well as the ceiling: "ABA services shall be made available to children 18 months to 21 years of age based on medical necessity," and its NJ FamilyCare provider orientation repeats it — "Must be 18 months – 21 years old," including in the specialized FamilyCare carve-out. No hour caps are attached to the age band. Horizon manages ABA across Core Medicaid, DDD, MLTSS and FIDE-SNP populations, so note which segment the member sits in alongside age.[6][7]
New Jersey names them twice, and the second list is narrower than the first. The newsletter's general test: "The need for ABA services must be determined by a qualified healthcare professional (QHP) capable of making a diagnosis of autism. QHPs include licensed health care professionals, who are qualified by education, training, or licensure/regulation (when applicable) to perform a professional service within his/her scope of practice." The enumerated list of acceptable QHPs "for the diagnosis and treatment planning for adaptive behavior services" is then: Physicians; Psychologists, which "Requires an active board certified behavior analyst (BCBA) certification in good standing and a qualifying doctoral-level degree (BCBA-D)"; and BCBAs, who appear for treatment planning rather than diagnosis. Optum's NJ entry restates the split: the diagnosis comes from "a physician or psychologist," and "It is not uncommon for one QHP to make the diagnosis (such as a physician) and a separate QHP (such as a BCBA) to develop and supervise the treatment plan."[6][1]
None required — and New Jersey is one of the few states that says so in terms. Optum's NJ Medicaid entry: "A comprehensive diagnostic evaluation is not required to access ABA services," with "ABA services … available to any child diagnosed with autism spectrum disorder as defined by ICD-10 diagnoses F84.0 through F84.9." The DMAHS newsletter names no instrument either. That makes this the friendliest diagnostic bar of the three states on this page — intake should not queue a New Jersey family for an ADOS-2 before starting the authorization. Horizon NJ Health publishes no deviation from this, and its own material was checked for one.[7][6]
The state sets no referral requirement, and Horizon turns the diagnosis itself into the trigger document: the ABA Authorization Request Form goes through NaviNet's UM Request Tool "with an ASD diagnosis script from a QHP attached," and once Horizon confirms eligibility, diagnosis and the script it issues the 32-unit/30-day assessment authorization without full clinical review. Treatment is the second step — the post-assessment ABA Request Form back through NaviNet, reviewed against MCG criteria within 14 days, approved in 6-month spans. So collect the script at first contact: it is not a referral, but it functions as one here.[1][6]
Yes, and Horizon NJ Health publishes the billing rule. Its Telemedicine and Telehealth reimbursement policy (NJ FamilyCare/Medicaid and FIDE-SNP; revised September 24, 2026) lists every ABA code on its telemedicine code list — 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T and 0373T. The claim must carry: “Modifier -95 or -GT is appended to eligible real-time audio and video CPT or HCPCS codes” (modifier -93 or -FQ for eligible audio-only codes), “Place of service 10 is appended for services provided to a member who is physically in their home,” and “Place of service 02 is appended for services provided to a member who is physically in an office or facility.” So remote 97153 to a child at home bills 97153-95 with POS 10. On the authorization: “Telemedicine services shall be subject to the same authorization requirements as they would for in-person visits,” and “Any service requiring a medical necessity review for a face-to-face visit also requires a medical necessity approval for services provided through telemedicine channels” obtained before the service. The policy does not ask for telehealth to be named on the request, so ask Horizon when you request units whether it wants telehealth delivery noted. Only in-network providers are paid for telemedicine, at the same rate as in person. This matches the state’s place-of-service rule for encounter claims (Medicaid Alert MA-2023-02: POS 10 for telehealth in the patient’s home, POS 02 elsewhere) and the state statute, N.J.S.A. 30:4D-6k (P.L.2021, c.310), which requires NJ FamilyCare to cover telehealth on the same basis as in-person care with no originating-site restriction.[12][14][9]
Horizon NJ Health's UM timeframes policy (last reviewed December 10, 2025): for Medicaid behavioral health, non-urgent prior authorization decisions within seven (7) calendar days of receipt of the request, with an extension of up to 14 calendar days at the member's or provider's request or when in the member's best interest; urgent outpatient requests decided within 24 hours of receipt of the necessary information — if the request is incomplete Horizon asks for more information within 24 hours and decides within 24 hours of receiving it, "but no later than seventy-two (72) hours, from receipt of the original request." Continued or extended services for a member in a course of treatment: decided within 24 hours of the request. For Medicaid only, "If Horizon fails to respond to an authorization request within the specific timeframes, the hospital or physician request shall be deemed approved." Federal floor for every NJ FamilyCare MCO: standard decisions within 7 calendar days of the request for contract rating periods starting on or after January 1, 2026 (14 days before that), extendable by up to 14 calendar days at the member's or provider's request or when the plan justifies needing more information; expedited within 72 hours.[16][17]
Horizon NJ Health's manual: "Horizon NJ Health is the payor of last resort on all claims" — verify other coverage and document that the claim was first processed by the other insurer. Do not file with Horizon "until they receive the EOB from the member's other insurance carrier(s)"; then submit the claim, PCP referral and the primary's EOB (all pages) within 60 days of the other carrier's correspondence or 180 days from the date of service, whichever is later. Authorization still applies when Horizon is secondary: "With the exception of Medicare, Horizon NJ Health's same notification policies that are routinely applied and required must be followed for any claims to be considered for payment" — get Horizon's ABA authorization even when the commercial plan pays first. State rule underneath: NJ FamilyCare pays last: "All TPL, for example, health insurance, Medicare, CHAMPUS, prepaid health plans… shall, if available, be used first and to the fullest extent." Bill the commercial plan first; supplementation claims "shall not be filed with the program unless accompanied by a statement of payment, Explanation of Benefits (EOB), or denial from the other carrier." Two traps: "No program payments shall be made when the third-party payer requires a contracting or participating provider to accept that third-party payer's payment as payment in full," and when NJ FamilyCare is secondary it pays the lesser of its allowed amount minus other payments, or the patient liability. TRICARE and CHAMPVA both pay ahead of Medicaid: TRICARE rules state "Medicaid is not a double coverage plan. In any double coverage situation involving Medicaid, CHAMPUS is always the primary payer," and CHAMPVA "assumes primary payer status" over Medicaid.[10][18][19][20]
Not published. Neither the DMAHS newsletter nor Optum's New Jersey entry sets a maximum age for the diagnostic evaluation, and the state's written position runs the other way: Optum's NJ Medicaid entry says flatly that "A comprehensive diagnostic evaluation is not required to access ABA services," so there is no comprehensive evaluation whose recency could be gated. What is dated in New Jersey is the authorization rather than the diagnosis — Horizon issues 32 units of 97151 valid for 30 days, and treatment authorizations run in 6-month spans. Horizon is the plan those clocks come from: its assessment authorization is 32 units of 97151 valid for 30 days, so book the assessment before requesting it. Search excerpts of Horizon's 1/1/2026 medical-policy revision reference standardized-instrument testing no more often than every 6 months, but that text could not be confirmed against the live policy.[1][6]
Ask the plan: Horizon NJ Health provider services, or the ABA UM escalation contact on the DMAHS BH integration contact sheet.
Coverage decides whether Horizon NJ Health 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.
The state sets who supervises whom, but no ratio, percentage or caseload cap. The NJ FamilyCare managed care contract’s ABA service description (01/2026): “A BCaBA may only practice under the supervision of a BCBA or BCBA-D. A BCaBA may supervise a Registered Behavior Technician (RBT) or Behavior Technician (BT) but may not create or modify a treatment plan,” and “Behavior Technicians (BTs) are paraprofessionals practicing under the supervision of a BCaBA, BCBA, or BCBA-D.” A BT or RBT “may provide only those services delegated to them by a licensee,” the licensee may not delegate “the assessment of a client, the development of a treatment plan, or the development of interventions,” and the licensee “is responsible for the care a client receives.” The billing side of supervision is the founding DMAHS newsletter’s: 97155 counts only while the analyst is with the child or directing the technician, never for supervision without the technician present. Horizon NJ Health publishes no technician-per-analyst cap or supervision percentage of its own (its provider manual and ABA reimbursement policy checked), so no numeric cap applies beyond your contract and the BACB’s RBT supervision standard.[11][6]
New Jersey says yes, in writing, and draws the line precisely. “If the QHP is overseeing the activities of the technician, the time of direct supervision by the QHP shall be concurrently billable using code 97155.” But “billing for 97155 is limited to time where the QHP is either engaged directly with the patient or is directing a technician in implementing a modified protocol with the patient. Billing for supervision where the technician is not present is not allowed.” Two other concurrency rules ride along: 97156 may be billed while the RBT delivers direct treatment to the child “in a separate location”; and for 0373T “providers may not bill for the QHP time concurrently” and billing is limited to a single technician’s face-to-face time, never the combined time of multiple technicians (three technicians for two hours bills eight units, not twenty-four). This is NJ FamilyCare state policy and the operative floor for Horizon NJ Health; no plan-specific deviation was found in Horizon NJ Health’s published material.[6]
Ask the plan: Horizon NJ Health provider services, to confirm the plan has not layered its own concurrency edit on top.
The current rule is the NJ FamilyCare managed care contract, not the 2020 newsletter. The contract’s ABA service description (Appendix B.4.4, 01/2026 edition) sets “Medically Unlikely Edit (MUE) Limits” per day, in 15-minute units: 97151 32, 97152 16, 97153 32, 97154 18, 97155 24, 97156 16, 97157 16, 97158 16, 0362T 16, 0373T 32. That is higher on three codes than the founding DMAHS newsletter’s April 2020 table (97152 8, 97154 12, 0362T 8), which the newsletter labelled “for guidance purposes only” and overridable “when medically necessary based on individual need” under EPSDT. Plan against the contract figures as the edits the MCOs run; a request above them needs explicit EPSDT medical-necessity framing rather than a quiet resubmission. Horizon NJ Health also publishes its own table: its ABA reimbursement policy (revised March 26, 2026) “shall apply the maximum daily allowable units” of 97151 32, 97152 16, 97153 32, 97154 18, 97155 24, 97156 16, 97157 16, 97158 16, 0362T 16 and 0373T 32, the same figures as the contract. These are authorization-backed edits, not a separate allowance: “Billing of ABA codes in excess of what has been authorized as medically necessary will not be considered for reimbursement,” units above the daily maximum need medical-necessity review, and billing the same services under other codes to get around the limit “will be denied and/or subject to medical necessity review.”[13][11][6]
Ask the plan: Horizon NJ Health’s provider manual / claim-edit list.
Under the behavior analyst, not the technician. Horizon NJ Health’s ABA reimbursement policy (revised March 26, 2026): “Horizon NJ Health shall only consider ABA services for reimbursement when submitted by a Board Certified Behavior Analyst (BCBA®/BCBA-D®) or Licensed Behavioral Analyst,” and it “shall not consider for reimbursement claims for ABA services submitted by a specialty other than” a BCBA, BCBA-D or Licensed Behavioral Analyst. The claim must also carry an F84.0–F84.9 diagnosis from a qualified health professional, and every ABA code needs prior authorization. Taxonomy goes on every claim, at the rendering level in box 24j and the billing level in box 33b.[13][10]
This one has moved and the two live sources disagree. The founding DMAHS newsletter is flat: “ABA services may be provided in the therapist’s office, a community setting or the child’s home. Services may not be provided within a school facility.” Optum’s ABA State Mandates document (annual review 7/2026), whose NJ Medicaid entry tracks the same state policy, now reads: “Services may be provided in the school setting as long as services are not provided during normal school hours.” Office, home and community are settled; school is plan-dependent and moving; group home is addressed by neither. The NJ FamilyCare managed care contract (01/2026) now says: “Services may be provided in the home, provider office or community settings,” and “Covered services do not include services required to be provided in school as part of a child’s Individual Education Plan (IEP).” That carves out IEP services rather than every school building, so school stays a question for the plan. Neither position is republished by Horizon NJ Health, so resolve it with the plan before scheduling school-based sessions.[11][6][7]
Ask the plan: Horizon NJ Health provider services.
Neither the state nor Horizon NJ Health publishes a session-note signature rule for ABA — no named signer and no timeframe.
Blocked on: Horizon NJ Health’s provider manual documentation chapter, or DMAHS’s Autism Line (609-588-8522).
Yes — it administers the NJ FamilyCare ABA benefit under EPSDT, with its own medical policy and MCG-based review layered on the state code set. Both assessment and treatment require prior authorization via NaviNet.
Fast — once eligibility, an ASD diagnosis, and a QHP script are confirmed, Horizon issues a 32-unit 97151 authorization valid for 30 days without a full clinical review. Treatment requests then get MCG review within 14 days, in 6-month spans.
For NJ FamilyCare members, one change: H0032 is retired for ABA effective July 15, 2026 — use 97151–97158/0362T/0373T. Authorizations created through July 14, 2026 with H0032 are honored, and H0032 is still paid on authorized services rendered through January 14, 2027. Horizon's January 1, 2026 ABA medical-policy revision applies to its commercial and ASO plans, not to Horizon NJ Health Medicaid members.
Yes. Horizon NJ Health’s telehealth policy lists 97151–97158, 0362T and 0373T as telemedicine codes. Add modifier 95 or GT for audio-video (93 or FQ for audio-only), and use POS 10 when the child is at home or POS 02 when the child is somewhere else. Telehealth needs the same authorization as in-person care.
No. Since July 15, 2026 Horizon NJ Health bills ABA only with 97151–97158, 0362T and 0373T. H0031 is not an ABA code in its policy. H0032 is paid only on authorizations created through July 14, 2026, for services through January 14, 2027.
The analyst. Horizon NJ Health pays ABA claims only when they are submitted by a BCBA, BCBA-D or Licensed Behavioral Analyst, and denies ABA claims from any other specialty.
Yes, narrowly. Its manual accepts retrospective review of outpatient behavioral health authorizations, ABA included, within six business days; submit through Availity as "Post Service." Horizon has up to 30 days to decide. Eligibility problems or a primary plan's exhausted benefit are reviewed case by case with documentation.
Yes. Its manual says taxonomy codes must be on all claims and claims without them are denied: billing-level taxonomy in box 33b (ZZ qualifier) and rendering-level taxonomy in the shaded part of box 24j, or PRV03 in loops 2000A and 2420A on an 837P.
Claims must arrive within 180 calendar days of the date of service; corrected claims within 365 days; claims after another insurer within 60 days of that insurer’s payment notice. Horizon NJ Health pays clean claims within 30 days for electronic claims and 40 days for paper; the state contract expects behavioral health claims, ABA included, to be processed within 15 days electronic and 30 days paper. Horizon publishes no weekly submission cutoff: the clock starts on the day it receives the claim.
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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