Humana Healthy Horizons in Oklahoma ABA coverage (SoonerSelect).

Follows the SoonerCare rule: Under 21. OAC 317:30-5-313 requires that "The member is under twenty-one (21) years of age," and OHCA provides ABA "under the EPSDT benefit" (OAC 317:30-3-65.12). No lower age bound is set. (OHCA’s provider application page words it as "ages 21 and younger"; the rule text says under 21.) Humana Healthy Horizons in Oklahoma was checked for its own rule on this point and publishes nothing different, so the OHCA rule applies.^{[7][17][16][3][1]}

Follows the SoonerCare rule: The comprehensive diagnostic evaluation or clinical assessment "will only need to be completed at the first initiation of ABA services and should be no older than two (2) years old." No annual or biannual update is required, but OHCA may ask for one if diagnosis and recommendations are unclear or there are significant medical or behavioral changes, and a member who changes agencies must supply the evaluation during the initial authorization period. Separately, disruptive behaviour must be documented within the most recent 30 calendar days. Humana Healthy Horizons in Oklahoma was checked for its own rule on this point and publishes nothing different, so the OHCA rule applies.^[7][3][1]

Follows the SoonerCare rule: A definitive ASD diagnosis from one of: pediatric neurologist or neurologist; developmental pediatrician; licensed psychologist; psychiatrist or neuropsychiatrist; other licensed physician experienced in the diagnosis and treatment of ASD; or an interdisciplinary team of a licensed psychologist, physician, physician assistant or APRN. The provider must be in Oklahoma or within 50 miles of the border (OAC 317:30-3-89 through 92); out-of-state evaluations are accepted only if they meet the documentation standard and come from one of these disciplines. Humana Healthy Horizons in Oklahoma was checked for its own rule on this point and publishes nothing different, so the OHCA rule applies.^[7][3][1]

Follows the SoonerCare rule: No single instrument is mandatory. The evaluation must include a complete medical and social history and be "based on criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM)", and "may also include scores" from formal tests such as the ADI-R, ADOS-2 or CARS "or other tools with acceptable psychometric properties." "Screening scales are not sufficient to make a diagnosis and will not be accepted as the only formal scale." For the ABA clinical assessment itself, OHCA cites validated measures such as the Vineland, and accepts supporting assessments such as the ABLLS-R, AEPS and VB-MAPP with the PA request. Humana Healthy Horizons in Oklahoma was checked for its own rule on this point and publishes nothing different, so the OHCA rule applies.^{[7][12][8][3][1]}

Humana’s ABA policy and PA list require prior authorization, not a referral, for ABA; the plan follows OHCA Part 30, which requires none.^[3][2][8]

Telehealth "must comply with OHCA policy," be "completed in real time using interactive audio and video," carry written parent consent for minors naming the type, frequency and duration of services, and be "billed with the appropriate modifier." Under OHCA’s rule the modality must be justified in the PA, and OHCA’s telehealth code list carries 97151, 97155 and 97156, not 97153.^[1][8][14]

Standard decisions "no later than 7 calendar days following receipt of the request for service," expedited within 72 hours, with extensions of "up to 7 additional calendar days (for up to 14 calendar days total)"; retro requests within 30 days are decided within 7 calendar days. State law (56 O.S. § 4002.6) deems a complete portal request authorized if the 7-day or 72-hour deadline is missed. Request PA at least 14 days before the service date, and extensions in OHCA’s seven-day window.^[1][10][9]

"Humana Healthy Horizons is the payer of last resort," except for IHS, IEP/IFSP school services and crime-victim compensation. The manual adds that "Medicaid’s authorization that an item or service is covered under the plan ... meets the prior authorization requirements of primary coverage," names pay-and-chase for "Preventive pediatric services, including EPSDT" (without saying ABA is handled that way, so bill the primary first), and recommends submitting the secondary claim within six months of the other insurer’s payment.^[1][18]

Humana raises required case supervision "from 5% to 10%" of direct treatment hours effective October 12, 2026 (earlier adoption encouraged); until then OHCA’s 5% monthly RBT floor applies. The policy describes RBTs providing ABA "under the close supervision and direction of a BCBA," and OHCA’s conditions for concurrent RBT and supervision billing apply.^{[5][3][11][8]}

Follows the SoonerCare rule: Allowed, with conditions. "Providers may only concurrently bill RBT and supervision hours when the following criteria is outlined in the prior authorization request," and the BCBA or licensed psychologist must have directed the RBT in session. "ABA is not allowed to be billed concurrently during any other therapies (i.e., OT, PT speech, etc.)," and "ABA hours approved for one CPT code cannot be used in place of another." Humana Healthy Horizons in Oklahoma was checked for its own rule on this point and publishes nothing different, so the OHCA rule applies.^[8][3][1]

No per-day unit cap is published. Humana limits the initial assessment to 24 units (6 hours) and a reassessment (97151-TS) to 16 units (4 hours) every six months, with complexity exceptions; OHCA’s intensity tiers and 1–6 month authorizations govern treatment.^[3][7][8]

Follows the SoonerCare rule: Every assessment and treatment service must record the date, start and stop time for each session or unit billed, the physical location, the "Signature of the provider(s) rendering services" and their credentials, goals addressed, methods, progress, the member’s response and any new problems. Treatment plans and updates are "not valid until all signatures are present": the supervising BCBA or licensed psychologist, a parent or legal guardian, and any minor aged 14 or older, each dated with month, day and year. Humana Healthy Horizons in Oklahoma was checked for its own rule on this point and publishes nothing different, so the OHCA rule applies.^[12][3][1]

Follows the SoonerCare rule: Home, community or clinic ("ABA may be provided in a variety of settings, including home, community, or clinical"). "ABA services are not allowed in a daycare setting or school setting, without OHCA approval. If approved, it will be time-limited to three (3) months or less," with a plan to fade support to school staff; private-school transitions are also capped at three months. School or daycare shadowing and aide work is excluded. Telehealth is allowed if justified in the PA (97151, 97155, 97156 on OHCA’s telehealth code list). Humana Healthy Horizons in Oklahoma was checked for its own rule on this point and publishes nothing different, so the OHCA rule applies.^{[13][8][14][3][1]}

Humana requires billing and rendering NPIs and taxonomy codes that match the OHCA Master Provider List, and follows Part 30, under which BCaBAs and RBTs are not paid directly and payment goes to the supervising BCBA or employing agency. Humana publishes no ABA-specific rendering-versus-supervising rule.^{[1][3][15][16]}

Ask the plan: Humana Healthy Horizons in Oklahoma provider services (855-223-9868): ask whose NPI and taxonomy go in the rendering field for 97153 delivered by an RBT.