---
title: "HSCSN ABA coverage: the intake guide."
url: "https://carelu.com/payers/hscsn-district-of-columbia"
markdown_url: "https://carelu.com/payers/hscsn-district-of-columbia.md"
state: DC (District of Columbia)
payer: Health Services for Children with Special Needs (HSCSN)
kind: Medicaid managed care plan (MCO)
parent_program: District of Columbia Medicaid (CASSIP)
description: "How HSCSN, the District of Columbia’s CASSIP plan for children and young adults with SSI, covers ABA: 12 evaluation units a year without PA, treatment authorization, BCaBA and RBT roles, telehealth codes, claims and what intake should collect."
last_reviewed: October 2026
---

# HSCSN ABA coverage: the intake guide.

_Payer Guide · HSCSN · District of Columbia · Last updated October 2026 · 9 primary sources_

> DC’s CASSIP plan for children with SSI (birth to 26): 12 ABA evaluation units a year with no PA; treatment authorized in 14 days.

Health Services for Children with Special Needs (HSCSN) is the plan DHCF contracts with for the Child and Adolescent Supplemental Security Income Program (CASSIP). It serves children and young adults "from birth to 26" who receive SSI or have SSI-eligible conditions, and each enrollee has a care manager. HSCSN publishes more ABA detail than any other DC plan: its January 2026 manual, a 2024 newsletter and a 2022 billing letter together set the evaluation allowance, who may deliver care and which codes to bill.

This plan administers the **District of Columbia Medicaid (CASSIP)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [District of Columbia Medicaid guide](https://carelu.com/payers/district-of-columbia-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: No, within limits. "ABA Evaluations (CPT Code 97151) do not require prior authorization. HSCSN will allow 12 units of ABA evaluations within a 12-month period"; more units need PA (provider manual, January 2026) [1][2]
- **Prior auth for treatment**: Yes. "ABA initial and ongoing therapy services require prior authorization"; the ABA provider sends its evaluation report and recommendations to HSCSN UM (UM@hschealth.org, fax 202-721-7190) [1]
- **Autism diagnosis required?** _(ask the plan)_: Not stated by HSCSN, which covers ABA on medical necessity and imposes "no benefit and/or age limit." The DC Medicaid State Plan ties ABA to an ASD diagnosis; ask HSCSN whether it authorizes ABA for other conditions [1][7]
  - Ask the plan: HSCSN Utilization Management (UM@hschealth.org, 202-721-7190): ask which diagnoses it accepts for ABA.

## At a glance

- **Covers ABA?:** Yes; "no benefit and/or age limit on ABA services," subject to medical necessity
- **Evaluation:** 97151: no PA for 12 units per rolling 12 months; PCPs can refer directly to in-network ABA providers
- **Treatment PA:** Required; UM@hschealth.org or fax 202-721-7190; decision within 14 calendar days
- **Codes:** 97151, 97153, 97155 (replaced H0031/H2019 on 10/1/2022)
- **Staff:** BCBA; BCaBA (direct care since 8/17/2024) and RBT under BCBA supervision
- **Telehealth:** 97153 or 97155 with modifier GT on the claim
- **Claims:** 365 days from service; COB claims within 180 days of the primary’s payment

## Evaluation, authorization and treatment schedules

Since September 2, 2024, HSCSN enrollees can use "twelve (12) units of ABA Evaluations with a rolling 12-month period as a covered benefit," and PCPs "can refer directly to HSCSN in-network ABA providers for an ABA Evaluation." Once the benefit is used up and a clinical need remains, the provider uses the "HSCSN Provider Request for ABA Evaluation" form, which an MD or NP completes and which asks about the behaviors to be addressed and, for children under 4, early intervention (attach the IFSP) or, from age 4, the IEP. [2][4][1]

Treatment always needs prior authorization. The ABA provider "submits their written evaluation report and recommendations for therapy to the HSCSN UM Department," treatment schedules must be in the report and ongoing plans, and "The treatment schedules should not disrupt regular school attendance for a school-age enrollee." Families and providers hear back "within the standard HSCSN review timeframe of fourteen (14) calendar days." Services must come from HSCSN participating providers. HSCSN does not cover ABA during hours a child attends an HSCSN-funded summer program. [2][4][1]

## Staffing, codes and telehealth

HSCSN’s ABA policy (UM_21) now lets a BCaBA "provide direct ABA care in a role similar to a Registered Behavioral Technician (RBT)," supervised by a BCBA (effective August 17, 2024; groups send staffing changes to C6@hschealth.org). A contract amendment removed the requirement that an ABA technician hold at least a bachelor’s degree, while keeping all license and certification rules. [1][2][5][3]

HSCSN’s October 2022 letter set the codes: 97151 replaced H0031, 97153 replaced H2019 HN and 97155 replaced H2019 HO. Under that letter "Telehealth is covered using 97153 or 97155," with the GT modifier on the claim (authorization letters omit it); "97155 is only authorized for direct treatment by a BCBA"; "97155 and 97153 cannot be billed at the same time"; and "Supervision will not be authorized separately." The letter predates the 2024 evaluation change, so confirm its other terms are still current. [1][2][5][3]

## Claims, other insurance and appeals

HSCSN accepts claims "no later than three hundred and sixty-five (365) days from the date of service," pays 90% of clean claims within 30 days and 99% within 90, and owes interest under the District’s Prompt Payment Act (1.5%, then 2%, then 2.5%). As a Medicaid plan it pays last: bill other coverage first, attach the EOB, and file within 180 days of the primary’s payment (still within 365 days of service). Claim payments or denials can be appealed in writing within 90 days; an adverse benefit determination is appealed within 60 calendar days. [1]

## Intake gates

The questions that decide whether a family can start with Health Services for Children with Special Needs (HSCSN), and what they have to bring.

- **Referral required?**: PCPs "can refer directly to HSCSN in-network ABA providers for an ABA Evaluation"; extra evaluation units need the provider request form signed by an MD or NP. [2][4]
- **Telehealth**: "Telehealth is covered using 97153 or 97155"; claims carry the GT modifier although authorization letters do not (2022 billing letter). DHCF’s guidance adds POS 10 home, 03 school or 02 other. [3][10]
- **Other insurance (who pays first)**: HSCSN is "the payer of last resort when the enrollee has other insurance coverage." Bill the other carrier first, attach the EOB or EOMB, and file within 180 days of the primary’s payment and within 365 days of service; claims without the EOB are denied. [1][9]
- **Age limit** _(plan-dependent)_: HSCSN enrolls children and young adults "from birth to 26" and states "There is no benefit and/or age limit on ABA services." DC Medicaid’s State Plan ASD benefit is written for beneficiaries under 21, so for an enrollee aged 21–25 confirm coverage with HSCSN. [1][7]
  - Ask the plan: HSCSN UM, UM@hschealth.org: confirm ABA coverage for an enrollee 21 or older.
- **Prior-auth decision time** _(plan-dependent)_: HSCSN responds "within the standard HSCSN review timeframe of fourteen (14) calendar days." Federal law caps standard decisions at 7 calendar days for rating periods starting on or after January 1, 2026. [1][8]
  - Ask the plan: HSCSN UM, 202-721-7190.
- **Diagnosis recency** _(ask the plan)_: Not stated by HSCSN. [1]
  - Ask the plan: HSCSN UM, UM@hschealth.org or 202-721-7190.
- **Who may diagnose** _(ask the plan)_: Not stated by HSCSN. The ABA evaluation request form (used once the 12 units are exhausted) must be completed by an ordering MD or NP. [4][1]
  - Ask the plan: HSCSN UM: ask who may make the diagnosis it relies on.
- **Diagnostic tools required** _(ask the plan)_: Not stated by HSCSN. [1]
  - Ask the plan: HSCSN UM, UM@hschealth.org.

## Delivery and billing rules

Coverage decides whether Health Services for Children with Special Needs (HSCSN) 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**: BCaBAs and RBTs deliver direct care under a BCBA (UM_21, as summarized in the January 2026 manual); "Supervision will not be authorized separately" (2022 billing letter). No numeric ratio is published. [1][3]
- **Concurrent billing (97153 + 97155)**: "97155 and 97153 cannot be billed at the same time," and "97155 is only authorized for direct treatment by a BCBA" (HSCSN billing letter, October 2022). [3]
- **Daily limits / MUEs**: Evaluation: 12 units of 97151 per rolling 12 months without PA. Treatment hours are set per authorization; HSCSN says there is "no benefit and/or age limit on ABA services." [1][2]
- **Place of service**: Treatment schedules "should not disrupt regular school attendance for a school-age enrollee," ABA is not covered while the child is in an HSCSN summer program, and telehealth is billed with GT. No other setting rule is published. [1][3]
- **Session-note signature** _(ask the plan)_: HSCSN publishes no session-note signature rule for ABA. [1]
  - Ask the plan: HSCSN Provider Relations, (202) 467-2737, or UM policy UM_21.
- **Bill as provider** _(ask the plan)_: HSCSN credentials ABA staff by group (send practitioner lists to C6@hschealth.org) but publishes no rule on whose NPI goes in the rendering field for RBT or BCaBA services. [2][1]
  - Ask the plan: HSCSN Credentialing, C6@hschealth.org or (202) 495-7526.

## What intake should collect for Health Services for Children with Special Needs (HSCSN)

- **CASSIP eligibility:** Confirm HSCSN enrollment (SSI or SSI-eligible, under 26) on the date of service.
- **PCP referral:** PCPs can refer directly to in-network ABA providers for the evaluation.
- **Evaluation units used:** 12 units per rolling 12 months without PA; check with Customer Care, 202-467-2737.
- **IFSP or IEP:** The ABA evaluation request form asks for the IFSP (under 4) or IEP (4 and older), or why there is none.
- **School schedule:** Treatment schedules must not disrupt school attendance.
- **Other insurance:** Bill the primary first and attach its EOB.

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

## Common questions

### Does HSCSN require prior authorization for the ABA evaluation?

No, up to 12 units of 97151 in a rolling 12 months. PCPs can refer directly to in-network ABA providers. More units need the HSCSN Provider Request for ABA Evaluation form.

### Can a BCaBA deliver ABA to HSCSN members?

Yes. Since August 17, 2024 BCaBAs can provide direct care in a role like an RBT, supervised by a BCBA.

### Can ABA be delivered by telehealth for HSCSN?

HSCSN’s billing letter covers telehealth for 97153 and 97155, billed with the GT modifier.

### Is there an age limit on HSCSN ABA?

HSCSN says there is no benefit or age limit on ABA, and it enrolls members up to age 26. Confirm coverage for a member over 21, since the state’s ASD benefit is written for under 21.

## Primary sources

1. [HSCSN — Provider Manual (updated January 2026)](https://hscsnhealthplan.org/sites/default/files/2026-01/hscsn-provider-manual-january-2026-508C.pdf)
2. [HSCSN — Provider Newsletter, November 2024 (BCaBA direct services; 12 units of ABA evaluation)](https://www.hscsnhealthplan.org/sites/default/files/2024-11/Provider-Newsletter-November-2024-508.pdf)
3. [HSCSN — ABA Billing Codes Change letter (Oct. 21, 2022; codes effective Oct. 1, 2022)](https://www.hscsnhealthplan.org/sites/default/files/HSCSN%20Update%20to%20ABA%20Authorized%20Codes.pdf)
4. [HSCSN — Provider Request for ABA Evaluation form (8/9/2023)](https://www.hscsnhealthplan.org/sites/default/files/hscsn-provider-request-for-%20ABA-Evaluation-%208-9-23.2.pdf)
5. [HSCSN — Amendment to Provider Participation Agreement (ABA technician bachelor’s-degree requirement removed)](https://hscsnhealthplan.org/sites/default/files/aba_provider_contract_change_notice.pdf)
6. [DHCF — Medicaid Managed Care Plans (MCPs): AmeriHealth Caritas DC, MedStar Family Choice DC, HSCSN (CASSIP)](https://dhcf.dc.gov/page/medicaid-managed-care-plans-mcps)
7. [DC State Plan Amendment 23-0009 — Autism Spectrum Disorder services under EPSDT (approved Aug. 25, 2023; effective Oct. 1, 2023)](https://www.medicaid.gov/medicaid/spa/downloads/DC-23-0009.pdf)
8. [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)
9. [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)
10. [DHCF — Telemedicine Provider Guidance (January 2023, Transmittal 23-11)](https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/page_content/attachments/Telemedicine%20Provider%20Guidance_January%202023%20-%20Transmittal%2023-11.pdf)

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.