Humana Healthy Horizons in South Carolina is one of the five Healthy Connections Medicaid MCOs. Its 2026 provider manual covers autism spectrum disorder services for members younger than 21 and says it "adheres to guidelines as outlined in the SCDHHS Autism Spectrum Disorder (ASD) Services Provider Manual." One wrinkle: the manual’s link points to the September 2025 edition of that state manual, while SCDHHS replaced it on July 1, 2026, so confirm Humana has moved to the new telehealth and diagnosis rules.
Humana "provides autism spectrum disorder (ASD) coverage for members younger than 21 years," delivered by BCBAs, BCaBAs and RBTs and by approved licensed independent practitioners, and it "adheres to guidelines as outlined in the SCDHHS Autism Spectrum Disorder (ASD) Services Provider Manual." Its behavioral health quick reference adds that 97154 and 97158 are limited to six hours a day. Humana lists an "Applied Behavioral Analysis Authorization Form" among its South Carolina behavioral health prior-authorization forms. The form requests units of 97153, 97155 and 97156, names the supervising BCBA and certification number, asks whether services were "ordered by a board-certified psychiatrist, psychologist, or pediatrician qualified to provide ABA oversight" (attach the order), and wants the diagnosing provider, the standardized tool used, current IQ, IEP/504 status, a treatment plan with baseline data, and transition and discharge plans.[1][6][5][4]
Standard prior-authorization notice comes "no later than 7 calendar days following receipt of the request," expedited within 72 hours. If you fail to get a required authorization, you have 180 calendar days from the date of service (or from the primary carrier’s EOP) to ask for retrospective review. Claims are due within one year of the date of service.[1][6][5][4]
Humana’s South Carolina billing guide and 2026 manual: claims, "including corrected claims, must be submitted within 1 year from the date of service or discharge." When Medicare is primary, secondary claims are due within two years of the date of service or six months from Medicare’s adjudication; with other insurance primary, Humana recommends billing it "within 30 days from the other insurance payment date," and the primary’s remittance must reach Humana within one year of the date of service. A claim denied for missing COB information must be fixed within the remainder of the original filing period. The manual says Humana pays 90% of clean claims within 30 calendar days of receipt and 99% within 90, and issues payment for a clean paper or electronic claim within 30 business days of receiving everything it needs. "Paper checks are printed and mailed twice a week, Sundays and Wednesdays." No submission cut-off for a check run is published.[3][2]
The questions that decide whether a family can start with Humana Healthy Horizons in South Carolina, and what they have to bring. Each maps onto something intake should ask on the first call.
Younger than 21 ("members younger than 21 years").[1]
Humana states no rule; the SCDHHS manual it follows sets no expiry on the diagnosis. The ABA form asks for the diagnosis date and the date of the most recent assessment.[1][4][7]
The form asks for the "Standardized Tool Used for Diagnosis"; the SCDHHS manual Humana follows requires an in-person ADI-R, ADOS or CARS.[4][7]
The form asks whether services have been "ordered by a board-certified psychiatrist, psychologist, or pediatrician qualified to provide ABA oversight" and to include a copy of the order.[4]
Standard decisions "no later than 7 calendar days following receipt of the request," expedited within 72 hours; either may be extended by 14 calendar days. Retrospective review may be requested within 180 days of the date of service.[1][10]
Humana collects COB information so that "Medicaid programs [are] the payer of last resort." Secondary claims need the primary’s remittance, within 2 years of the date of service or 6 months of the primary’s EOB.[1][11]
Through the SCDHHS manual it follows: The comprehensive diagnostic assessment must be administered directly by a licensed physician (MD/DO), licensed psychologist (PhD/PsyD) or licensed psycho-educational specialist (LPES). A medical-care-home physician may confirm a prior diagnosis, or make an initial diagnosis for a medically uncomplicated child aged 18–36 months. SCDHHS "does NOT accept autism evaluations completed by any other provider type," naming nurse practitioners, physician assistants, LISWs, ABA providers and ST/OT/PT; a school IDEA designation of ASD or a BHDD-OIDD autism eligibility determination counts once a physician confirms it. Diagnoses made by telehealth are not valid. The form separately asks whether services were ordered by a board-certified psychiatrist, psychologist or pediatrician.[1][4][7]
Ask the plan: Humana Healthy Horizons in South Carolina, 866-432-0001: Humana’s manual links the September 2025 SCDHHS edition, so confirm it applies the July 2026 diagnosis rules.
Humana publishes no ABA telehealth rule and follows the SCDHHS manual, but cites the September 2025 edition. The current state rule: Under the SCDHHS ASD manual (July 1, 2026), only two ABA codes may be delivered by telehealth: 97156 (family guidance), with the GT modifier and no extra authorization, and 97155 (protocol modification), only when the QIO approves it during prior authorization, for up to 25% of authorized and rendered 97155 units, for a member receiving in-home ABA in a rural location with limited access. Telehealth must be synchronous audio and video, GT goes in the secondary modifier position, and POS is 02 or 10. "The BIA can not be completed by telehealth," and 97152, 97153, 97154, 97157, 97158, 0362T and 0373T are not deliverable by telehealth. An ASD diagnosis made by telehealth is not valid.[1][7]
Ask the plan: Humana Healthy Horizons in South Carolina, 866-432-0001: confirm it applies the July 1, 2026 telehealth limits.
Coverage decides whether Humana Healthy Horizons in South Carolina 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.
Humana adheres to the SCDHHS ASD manual, which sets: BACB supervision applies: "each RBT must be supervised for a minimum of 5% of the hours spent providing ABA services per month," with at least two face-to-face, real-time contacts a month, one of which observes the RBT with the member; that professional supervision is not billable. Caseload caps: a BCBA may carry 12 cases (16 with a BCaBA), a BCaBA 12, where 30–40 hours a week is one case, 10–25 hours half a case and under 10 hours a quarter case. A behavior technician gets one 90-day grace period to earn the RBT credential, and may work only in a clinic with a BCBA on site during it. The ABA form asks for the supervising BCBA’s name and certification number.[1][4][7]
97154 and 97158 are limited to six hours a day (Humana’s quick reference); otherwise Humana follows the SCDHHS section 8 limits (97153 160 units a week; 97155 up to 10% of 97153 and 64 units a month).[6][1][7]
Through the SCDHHS manual it follows: home, clinic, and school or community settings only with authorization; an adult caregiver must be present for in-home ABA.[1][7]
Humana publishes no rule of its own; the SCDHHS manual it follows bars concurrent 97153 billing except as section 8 allows. On ABA alongside other therapies, Humana publishes nothing of its own; the state baseline: the SCDHHS ASD manual's non-covered list is explicit — "Concurrent billing of 97153 with any other service or therapy is excluded except as detailed in Section 8," and Section 8's exceptions are ABA-with-ABA only. It also excludes "ABA services while the member is at another medical appointment," and, in the other direction, ABA treatment "that precludes, or requires the member's family to stop engaging with other critical supports … speech therapy, occupational therapy, or IDEA recommended school-based curriculum and supports." So speech and ABA can both continue, but not on the same clock time as a billed 97153 unit. The manual also binds providers to the National Correct Coding Initiative edits and related coding policy unless it says otherwise.[1][7][14]
Ask the plan: Humana Healthy Horizons in South Carolina, 866-432-0001.
Humana publishes no ABA note rule of its own; the SCDHHS manual requires notes signed by the enrolled BCBA/BCaBA and the rendering BT/RBT before billing.[1][7]
Ask the plan: Humana Healthy Horizons in South Carolina, 866-432-0001.
The ABA form separates the requesting/billing provider, the servicing provider and the supervising BCBA. Humana’s billing guide requires rendering NPIs and taxonomy on the claim and on the SCDHHS provider list; it does not say how RBT time is billed.[4][3]
Ask the plan: Humana Healthy Horizons in South Carolina, 866-432-0001: ask whether RBT services bill under the supervising BCBA’s NPI.
One year from the date of service for initial and corrected claims; secondary claims after Medicare within two years or six months of Medicare’s adjudication; other-insurance remittances within one year. It pays 90% of clean claims in 30 days and prints paper checks on Sundays and Wednesdays.
Yes, for members younger than 21, following the SCDHHS ASD Services Provider Manual.
With its ABA Behavioral Health Authorization Request Form, by email to CorporateMedicaidCIT@humana.com or fax to 833-441-0950.
You can request a retrospective medical-necessity review within 180 calendar days of the date of service; later requests are denied and cannot be appealed.
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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