---
title: Humana Healthy Horizons in Virginia ABA coverage (Cardinal Care MCO).
url: "https://carelu.com/payers/humana-healthy-horizons-virginia"
markdown_url: "https://carelu.com/payers/humana-healthy-horizons-virginia.md"
state: VA (Virginia)
payer: Humana Healthy Horizons in Virginia
kind: Medicaid managed care plan (MCO)
parent_program: Virginia Medicaid (DMAS)
description: "How Humana Healthy Horizons administers Virginia Medicaid ABA — the July 2025 entry replacing Molina, DMAS standardized forms, the PA list's 0362T quirk, and credentialing for the new network."
last_reviewed: October 2026
vob_data_updated: 2026-10-15
---

# Humana Healthy Horizons in Virginia ABA coverage (Cardinal Care MCO).

_Payer Guide · Humana Healthy Horizons (VA) · Last updated October 2026 · 11 primary sources_

> Virginia's newest MCO (7/2025, ex-Molina members); DMAS forms, one PA-list quirk on 0362T.

Humana Healthy Horizons is Virginia's newest Cardinal Care MCO: it entered July 1, 2025, the day after DMAS terminated Molina's contract, and absorbed Molina's members automatically. Like the other four plans it runs ABA on DMAS criteria and standardized forms — but as a new plan it comes with fresh credentialing, transition-honored authorizations, and one genuine quirk on its PA list worth knowing.

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

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Not required for 97151/97152 (off the PA list) — but Humana's list does flag 0362T, unlike DMAS [1]
- **Prior auth for treatment**: Required — 97153–97158, 0373T per the plan's PA list (eff. 7/1/2025), on DMAS standardized forms [1]
- **Autism diagnosis required?**: NO — not autism-restricted, and not category-restricted either. DMAS Appendix D admits a youth under 21 who meets criteria for a primary ICD diagnosis correlating to a DSM diagnosis, OR who has a provisional psychiatric diagnosis developed by an LMHP when no definitive diagnosis has been made, plus at least two functional-impairment criteria. The ABA criteria name no diagnostic category list and never mention autism [4]

## At a glance

- **Plan type:** Cardinal Care MCO — entered 7/1/2025, replacing Molina
- **Clinical rules:** DMAS criteria + standardized service-specific forms
- **Assessment auth:** 97151/97152 PA-free; 0362T IS on Humana's PA list (plan quirk)
- **Transition:** Molina members auto-moved; prior auths honored ≥30 days post-transition
- **BH contact:** VA_BH_Medicaid@humana.com; Availity portal
- **Access standard:** BH appointment within 5 business days of coverage determination

## The transition, and what it means for intake

Former Molina members transitioned to Humana automatically on July 1, 2025 (with a 90-day plan-change window through September 30, 2025), and existing service authorizations were honored for at least 30 days past the transition. By now any Molina-era authorization has cycled through Humana's own process — but member cards, portal registrations, and stale directory listings can still say Molina, so verify plan identity on every "Molina" inquiry. Providers contract and credential through VA_BH_Medicaid@humana.com, keeping DMAS PRSS enrollment current, and the plan's behavioral-health access standard commits to an appointment within 5 business days of a coverage-criteria determination. [3][2]

## The PA list, including the 0362T quirk

Humana's Virginia PA and notification list (effective 7/1/2025) requires prior authorization on 97153–97158 and 0373T, with 97151 and 97152 correctly PA-free per the DMAS baseline. The quirk: the list also flags 0362T — a code DMAS treats as an authorization-free assessment code — as PA-required. If your assessments use 0362T for Humana members, request the authorization rather than litigating the discrepancy on the back end, and note the DMAS rule in the request. [1]

## What are Humana Healthy Horizons in Virginia’s claim deadlines, and must it pay at least the DMAS rate?

Virginia’s Cardinal Care contract (July 2026 – June 2027) lists ABA as a mental health service billed on the CMS-1500. It requires every MCO to pay mental health service providers “no less than the current Medicaid FFS rate,” and puts those services on a minimum fee schedule at 100% of the fee-for-service rate. DMAS’s December 2025 memo removed a broader pay-at-least-FFS line from Chapter V, but the minimum still applies to the contract’s Chapter 12 list, which includes mental health services. The MCO must adjudicate 99% of clean mental health claims within 14 calendar days and all of them within 30. Its timely filing limit must be at least three and at most twelve months from the date of service, counted from the primary payer’s payment or denial when the member has other coverage. [7][8][10]

Humana’s own provider resource guide: “Claims must be submitted within 365 days from the date of service, and corrected claims should be submitted within 180 days of receipt of the explanation of payment.” Claim disputes, also called reconsiderations, are due within 60 calendar days “from the date of service or discharge,” as the guide words it. Humana pays clean claims within 30 days unless a signed agreement sets another timeframe. Electronic claims use payer ID 61101. Missing or incorrect NPI, ZIP code or taxonomy is a common rejection reason, and a service-location address that does not match the state Medicaid file denies the claim. [7][8][10]

## Reauthorization: what a continued-stay request must contain (graphs required)

Follows the Virginia Medicaid (DMAS) rule, which Appendix D addresses to “the FFS service authorization contractor or MCO” alike. Continued-stay (reauthorization) requests must include the Continued Stay Service Authorization Form; the original Comprehensive Needs Assessment with an addendum (it can be a progress note) on new information, progress, interventions to date and the rationale for continuing; an updated ISP that reflects current goals and any use of telemedicine; and a treatment-progress summary that opens with a “graphical presentation of progress on each goal and objective in the ISP,” followed by family involvement, generalization across settings, progress toward discharge (including any planned step-down) and care coordination. Ongoing documentation must also carry “graphical analysis of goals and objectives as defined by the most current ISP.” So yes — Virginia Medicaid requires graphs at reauthorization. [4]

Code set (DMAS rule): ABA is billed under CPT 97151–97158, 0362T and 0373T, each treatment code authorized with its own predetermined number of units; the HCPCS codes in Appendix D (H2033, H0036) belong to MST and FFT, not ABA. [4]

## Intake gates

The questions that decide whether a family can start with Humana Healthy Horizons in Virginia, and what they have to bring.

- **Age limit**: Follows the Virginia Medicaid (DMAS) rule: under 21 — Appendix D's ABA admission criteria state it as the first requirement, and the benefit rides EPSDT, so there is no hard hour cap beneath it. [4][1]
- **Diagnosis recency**: Follows the Virginia Medicaid (DMAS) rule: no recency window on the diagnosis. Appendix D admits on a current primary ICD diagnosis correlating to a DSM diagnosis, or on a provisional psychiatric diagnosis developed by an LMHP where no definitive diagnosis has been made — and DMAS states there is no timeframe for the use of a provisional psychiatric diagnosis, expecting the LBA to follow up with the youth's physician or other LMHPs as more information is gathered. What must stay current is the assessment: it is reviewed and updated at least annually by the LBA, LABA or LMHP, and continued-stay criteria test symptoms within the past 30 days. [4][5][1]
- **Who may diagnose**: Follows the Virginia Medicaid (DMAS) rule: two different questions, and Appendix D answers both. The diagnosis: the youth must currently meet criteria for a primary ICD diagnosis that correlates to a DSM diagnosis, or have a provisional psychiatric diagnosis as developed by an LMHP — Appendix D does not restrict the benefit to autism or name a specialty list of diagnosing clinicians. The ABA assessment: it must be completed by an LBA, LABA or LMHP acting within scope (an LMHP-R, LMHP-RP or LMHP-S with completed education and training in ABA may complete it under the supervising LMHP), conducted in person with the youth and the family or caregivers, and an assessment completed by an LABA may be used only for ABA, not as a Comprehensive Needs Assessment for other services. [4][5][1]
- **Diagnostic tools required**: Follows the Virginia Medicaid (DMAS) rule: the initial assessment must include a functional assessment using validated tools, completed by the LBA, LABA or LMHP within scope, and documentation must describe any assessment tools used. DMAS publishes no approved list — the QHP may use clinical judgement to choose the best assessments for the youth — so what is audited is that a validated instrument was used and named, not which one. One Humana deviation matters at the assessment step: unlike DMAS, Humana's own PA and notification list (eff. 7/1/2025) flags 0362T as prior-authorization-required, so a team-based assessment for a Humana member needs an authorization the state rule would not require. [1][4][5]
- **Referral required?**: Follows the Virginia Medicaid (DMAS) rule: no physician order. DMAS retired the requirement for an order or letter recommending services signed by a physician, nurse practitioner or physician assistant — what replaced it is a notification duty: the QHP must notify the youth's primary care physician that the child is receiving ABA, providers must communicate the results of the assessment and treatment planning to the PCP, and care coordination with the PCP must be documented in the youth's record. Humana's behavioral-health access standard commits to an appointment within 5 business days of a coverage-criteria determination. [5][4][2]
- **Telehealth**: Follows the Virginia Medicaid (DMAS) rule, which DMAS's December 2025 ABA clarifications bulletin addresses to Acentra and the Cardinal Care MCOs alike as the service-authorization contractors: initial assessments must be conducted in person with the youth and the family or caregivers, by the LBA, LABA or LMHP — and DMAS's December 2025 ABA clarifications bulletin makes that a condition of payment: "Initial assessments must be conducted in person by an LBA, LABA or LMHP in order for ABA services to be reimbursable by Medicaid," and services built on an assessment that does not meet DMAS requirements are non-reimbursable. No part of the initial assessment has a telehealth path. The Telehealth Services Supplement (rev. 1/5/2026, Table 2) allows 97151 and 97152 by telemedicine "for reassessments only," and Appendix D lets 97151, 97152 and 0362T be billed only "as part of the initial assessment or full reassessments" — so follow-up observations and sessions with additional caregivers that are part of completing the initial assessment are initial-assessment time and must also be in person. DMAS defines no separate assessment window that would move them under telehealth rules. The one exception is non-face-to-face work: care coordination, data analysis and treatment-plan preparation without the youth present may be billed under 97151 at the time of the initial assessment, and care coordination billed under 97151 or 97155 does not have to be face to face. Once the initial assessment is complete, further QHP observation, data review and protocol changes bill as 97155 and caregiver sessions as 97156, both on the Supplement's telemedicine list (0362T and 0373T are not), and a full reassessment may be done by telemedicine. Any telemedicine delivery must be justified in the ISP submitted with the initial and continued-stay authorization: a schedule of when services are delivered by telemedicine and when in person, clinical evidence that telemedicine is appropriate, and how in-person needs will be met — and the provider must document that the youth and caregiver can take part meaningfully and safely. Chapter IV adds that an assessment done by telemedicine cannot serve as the assessment for a service that requires an in-person one. Edge cases go to DMAS's Behavioral Health Division at enhancedbh@dmas.virginia.gov. MCO-contracted providers must consult their contracted MCO for that plan's telehealth policies. [4][5][1][16][17][13]
- **Prior-auth decision time**: Virginia Medicaid rule, applied by Humana Healthy Horizons in Virginia: since January 1, 2026 DMAS requires FFS and every Cardinal Care MCO to decide standard (non-urgent) requests within 7 calendar days of receipt and expedited requests within 72 hours; the 7-day clock can extend up to 14 calendar days if the member or provider asks, or if the extra time is justified in the member's interest to obtain more medical evidence. Humana's manual text says the same ("not to exceed 7 calendar days following receipt of the request"; expedited "no later than 72 hours after receipt"), though its summary tables still print 14 calendar days for nonurgent preservice — the 7-day DMAS rule controls. Timing from Appendix D: submit treatment requests (initial and continued stay) by the requested start date — "If submitted after the required time-frame, the begin date of authorization will be based on the date of receipt," so a late reauthorization leaves an unpaid gap. [18][19][4][20]
- **Other insurance (who pays first)**: Medicaid pays last. Humana's manual: "Claims should be submitted to a patient's TPL coverage for payment before submitting to Humana. Humana reduces its payments based on TPL coverage payments made for covered services," and "All claims that involve other insurance must be accompanied by an explanation of benefits (EOB) or a remittance advice (RA) that clearly states how the claim was paid or the reason for denial." Providers are required to identify TPL coverage and should ask members for all insurance at the time of service; Humana's COB records can be checked on Availity. Humana's manual publishes no secondary-payer authorization exemption. Appendix D makes payment for every non-assessment ABA service conditional on service authorization ("Services other than assessment (97151, 97152 and 0362T) must be service authorized by the FFS service authorization contractor or MCO") and names no exemption for a secondary claim, so get the Medicaid authorization even when the commercial plan pays first. 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. [18][5][4][21][22]

## Delivery and billing rules

Coverage decides whether Humana Healthy Horizons in Virginia 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**: Follows the Virginia Medicaid (DMAS) rule: three separate floors. The LBA, LABA or LMHP must at a minimum observe the youth and supervise services monthly, with supervision documented as a review of progress notes and data plus dialogue with supervised staff about progress and the effectiveness of the ISP. Supervision of unlicensed staff must occur at least twice a month by the LBA, LABA or Licensed Clinical Psychologist, demonstrated by the contemporaneously dated signature of the licensed supervisor. Clinical supervision is required for services rendered by an LABA, LMHP-R, LMHP-RP or LMHP-S, consistent with the scope of practice set by the applicable Virginia Department of Health Professions board — on the nature of supervision DMAS defers to that board and to the BACB. Supervision time without the individual present is not billable; the technician rates were built to include it. [4][5][1]
- **Concurrent billing (97153 + 97155)**: Follows the Virginia Medicaid (DMAS) rule: Appendix D publishes the combinations that may be billed at the same time: 97152 with 97151 (except 97152 HN together with 97151 HN); 97153 with 97155 (except 97153 HN together with 97155 HN) — DMAS adds that 97155 and 97153 may be billed together for supervision activities when the QHP is directing the technician in delivering treatment and the QHP, technician and youth are all present; 97154 and 97158 at the same time for different youth in the same group, with identical professional-level modifiers; 97153 at the same time for two technicians when the reason is documented in a service-authorized ISP; and services with the youth alongside family or group family training when delivered by different qualified staff. What is barred: an additional technician-level code alongside 97158 or 97154. Separately, ABA may not be authorized concurrently with Intensive In-Home, Mental Health Skill Building, Psychosocial Rehabilitation, Partial Hospitalization or Assertive Community Treatment, though short-term authorization overlaps are allowed during transitions. For DMAS fee-for-service claims, ABA at the same time as speech, occupational or physical therapy: DMAS publishes no ABA-specific overlap rule — Appendix D's same-time list names ABA codes only, and neither the MHS manual nor the Rehabilitation manual addresses ABA alongside a therapy session. What reaches it is the claim-edit layer. Chapter V says DMAS runs the Medicaid NCCI edits on the "same member, same provider, and same date of service": the column-one code pays, the column-two code denies, and only CMS-listed NCCI modifiers can bypass an edit that allows one. In the CMS Medicaid NCCI practitioner PTP table active 10/1–12/31/2026, speech treatment 92507 is column one over 97153, 97154, 97155, 97156, 97157 and 0373T; 97153 is column one over group speech treatment 92508; and therapeutic activities 97530 (OT/PT) is column one over 97153–97158 and 0373T — every pair with modifier indicator 0, so no modifier unbundles it. One provider billing 92507 and 97153 for the same child on the same date of service will see the 97153 line deny. The edits key on the same provider, so they do not by themselves stop a separately enrolled speech therapist from seeing the child the same day; for that, Chapter IV requires care coordination with all active treating providers, documented in the ISP and progress notes, to prevent duplication of services. Humana's Virginia Medicaid prior-authorization list publishes no ABA-with-therapy rule (it lists outpatient OT, PT and speech therapy separately, with authorization required after 5 visits), so whether its claim editor applies the same NCCI pairs and MUEs is a question for Humana provider services. [4][5][1][12][13][14]
- **Daily limits / MUEs**: Follows the Virginia Medicaid (DMAS) rule: no ABA-specific per-day ceiling in Appendix D. Assessment codes 97151, 97152 and 0362T carry no service authorization and no unit limit, but may only be billed as part of an initial assessment or a full reassessment. Since dates of service 10/15/2025 every treatment code is authorized with its own predetermined number of units rather than bundled under 97155. Requests at or above 20 hours (80 units) a week must include an individualized schedule of activities that distinguishes therapeutic from recreational time — a general schedule of clinic-based activities is not sufficient. Group sizes follow CPT guidelines. In Residential Treatment Services settings, including therapeutic group homes and PRTFs, the payable ABA set narrows to 97151, 97154 (with modifier HN, HO or TF only), 97155, 97156 and 97157. Humana's PA list matches DMAS on 97151 and 97152 being authorization-free but adds 0362T to its PA list — request the authorization and note the DMAS rule in the request rather than litigating it on the back end. DMAS fee-for-service claims also run the Medicaid NCCI medically unlikely edits per member, per servicing provider, per date of service — units above the MUE deny the claim (Chapter V). The CMS Medicaid practitioner MUE table active 10/1–12/31/2026 sets 97151 at 32 units, 97152 at 16, 97153 at 32, 97154 at 18, 97155 at 24, 97156 at 16, 97157 at 16, 97158 at 16, 0362T at 16 and 0373T at 32. Whether Humana Healthy Horizons in Virginia enforces the same per-day MUEs on its own claims is a question for its provider services line. [1][4][6][12][15]
- **Session-note signature**: Follows the Virginia Medicaid (DMAS) rule: documentation must carry the initial assessment completed by the LBA, LABA or LMHP including the assessment instruments used, dates of service and face-to-face contacts, staff and participant names, and staff credentials and signatures. Treatment progress must be documented through daily data collection plus a weekly summary note, with graphical analysis of goals and objectives for those dates of service. Supervision is demonstrated by the contemporaneously dated signature of the licensed supervisor. The ISP must be reviewed at least every 30 calendar days — a progress note satisfies the review if it documents the discussion, any alterations, and the individual's response; the individual's signature is not required, and the 30-day review is held for audit rather than submitted. [4][5][1]
- **Place of service**: Follows the Virginia Medicaid (DMAS) rule: ABA may be provided in home or community settings where the targeted behaviors are likely to occur, and in clinic settings — the setting must be justified in the ISP. School is the constrained one: ABA may only be provided in the school setting when the purpose is observation and collaboration by the QHP related to behavior and skill acquisition, not direct therapy, and only when authorized by the school, the parent and the provider and included in the ISP. Technician-level codes may not be billed for school observation and collaboration, and DMAS interprets school as any education setting, private or public; additional school ABA may be available under school health services through the local education agency. Services rendered primarily by a relative or guardian who is legally responsible for the youth's care are not covered. [4][5][1]
- **Bill as provider**: Follows the Virginia Medicaid (DMAS) rule: ABA providers must be enrolled with DMAS under the ABA provider types (PCT 156 or 456 with PS 903; PCT 020 or 023; PCT 256 with PS 104), licensed by the applicable Virginia Department of Health Professions board, and credentialed with the youth's Medicaid MCO for managed-care members. Every CPT code is billed with the staff modifier that identifies the professional providing the service: HN for an LABA, HO for an LBA, TF for an LMHP. QHP-level codes must be provided by an LBA or LMHP, with an LABA able to act as a QHP as determined by the supervising LBA under 18VAC85-150-120, and LMHP-Rs, LMHP-RPs and LMHP-Ss with completed ABA education and training able to provide them under the supervising LMHP. Technician-level codes may be delivered by an LMHP-R/RP/S under supervision, an LABA under an LBA, personnel supervised by an LBA or LABA under 18VAC85-150-10 et seq., personnel supervised by a Licensed Clinical Psychologist under § 54.1-3614, or by an LBA or LMHP acting as the technician — LBAs may bill technician-level codes with the appropriate modifier. Unlicensed personnel include but are not limited to RBTs; Virginia does not require the RBT credential. [4][1]

## What intake should collect for Humana Healthy Horizons in Virginia

- **Plan identity on "Molina" inquiries:** Molina exited 6/30/2025 — those members are Humana now; verify the current card.
- **ASD diagnosis:** Then book the assessment — 97151/97152 need no authorization (0362T does, per Humana's list).
- **Units per CPT code:** The DMAS 10/15/2025 per-code rule applies to Humana requests.
- **Credentialing status:** New network — confirm your contracting/credentialing is complete before quoting start dates.

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

## Verification of benefits (VOB) data

How Humana Healthy Horizons in Virginia ABA benefits route and read on an eligibility check. Data last updated 2026-10-15.

### EDI routing

- **Payer ID (pVerify):** 00112 — pVerify has no VA-specific Humana row; 00112 = generic "Humana" (Medical, Eligibility=Yes). Confirm the Humana Healthy Horizons Virginia-specific mapping via pVerify payer search (plan entered VA 7/1/2025, replacing Molina).
- **Payer ID (Availity):** 61101 — QA 2026-07-23 downgraded verified->unverified: 61101 appears in NEITHER cited source (the Humana VA PAL carries no payer IDs; the pVerify list carries Humana only as 00112). 61101 is Humana's widely-used universal ID but is not document-backed by a cited/reachable source here — confirm on Humana's official VA Medicaid claims page before treating as verified.
- **Payer ID (Change Healthcare / Optum):** 61101 — Same as payerId.availity: 61101 not present in either cited source; QA 2026-07-23 downgraded verified->unverified. Confirm via Humana's VA Medicaid claims page.
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** none (DMAS pass-through; Humana administers ABA on DMAS forms via Availity)
- **BH administrator payer ID:** 61101
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Not required — DMAS rule: assessment codes 97151, 97152, 0362T need no service authorization | No hard cap — EPSDT medical necessity governs; comprehensive assessment typically authorized in a bounded window per the treatment request per n/a (no SA on assessment codes) | home, office/clinic (11), school (03), community, telehealth (GT) | Reassessments only — the DMAS Telehealth Services Supplement (rev. 1/5/2026) allows 97151 and 97152 by telemedicine (GT) "for reassessments only." The initial assessment, including any follow-up observation or caregiver session billed under 97151/97152 to complete it, must be in person with the youth and caregivers; only care coordination, data analysis and treatment-plan preparation without the youth present (billed under 97151 at the initial assessment) need not be face to face. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97152 | Yes | Not required — DMAS rule: assessment codes 97151, 97152, 0362T need no service authorization | No hard cap — EPSDT medical necessity governs; comprehensive assessment typically authorized in a bounded window per the treatment request per n/a (no SA on assessment codes) | home, office/clinic (11), school (03), community, telehealth (GT) | Reassessments only — the DMAS Telehealth Services Supplement (rev. 1/5/2026) allows 97151 and 97152 by telemedicine (GT) "for reassessments only." The initial assessment, including any follow-up observation or caregiver session billed under 97151/97152 to complete it, must be in person with the youth and caregivers; only care coordination, data analysis and treatment-plan preparation without the youth present (billed under 97151 at the initial assessment) need not be face to face. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97153 | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97154 | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97155 | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97156 | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97157 | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97158 | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 0362T | Yes | Required — PLAN QUIRK: Humana's VA PA and notification list (eff. 7/1/2025) flags 0362T as PA-required, unlike the DMAS baseline where 0362T is an authorization-free assessment code. Request the auth rather than litigating the discrepancy; note the DMAS rule in the request. | No hard cap — EPSDT medical necessity per per authorization | home, office/clinic (11), school (03), community | No — not on the DMAS Telehealth Services Supplement's telemedicine list (rev. 1/5/2026 lists 97151-97158 only), and Appendix D requires the QHP on site with two or more technicians. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 0373T | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community | No — not on the DMAS Telehealth Services Supplement's telemedicine list (rev. 1/5/2026 lists 97151-97158 only), and Appendix D requires the QHP on site with two or more technicians. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |

Code notes:

- **97151:** 97151 is PA-free on Humana's VA PA list (effective 7/1/2025), consistent with the DMAS baseline.
- **97152:** 97152 is PA-free on Humana's VA PA list, consistent with the DMAS baseline.
- **97153:** PA required on 97153–97158 and 0373T per Humana's VA PA list (eff. 7/1/2025).
- **97154, 97155, 97156, 97157, 97158, 0373T:** PA required per Humana's VA PA list.
- **0362T:** The one genuine deviation from the DMAS assessment-code baseline among the Cardinal Care MCOs — carried honestly rather than normalized to the state rule.

### Medicaid rates

Source: DMAS CPT fee file (cptmedical4.csv for 97151–97158; cptmedical1.csv for 0362T/0373T), read directly from the live file: licensure-tiered per-15-minute ABA rates effective 12/01/2021 (end 12/31/9999), still current in the file that also carries 07/01/2026 rows. Tiers flagged by modifier: no modifier = technician, HN/U1 = LABA, TF/U2 = LMHP, HO/U3/U7 = LBA; ABA rows are the OP (outpatient) place-of-service lines. Trap (confirmed): the file also carries generic "REGULAR & CSB" IP rows for 97151/97152/97156/97157 at a few dollars per unit (e.g. 97151 IP $6.75) — those are the non-ABA physician-fee lines, NOT the ABA program rates. Modifier definitions cross-checked against VirginiaABA's (draft) DMAS billing guidance. No Humana Healthy Horizons in Virginia-specific ABA fee schedule is publicly posted. The Cardinal Care Managed Care Contract (July 1, 2026 - June 30, 2027) lists ABA among the mental health services (section 12.2.4.3) that every MCO must pay "no less than the current Medicaid FFS rate" (section 12.2.4; minimum fee schedule at 100% of FFS, section 12.1.14) — so this DMAS table is the contractual floor; the plan's negotiated rate may be higher Effective 2021-12-01.

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | $23.48 (LABA) / $39.40 (LMHP) / $46.63 (LBA) | 15min | HN (LABA): $23.48; TF (LMHP): $39.40; HO (LBA): $46.63 |
| 97152 | $15.00 (technician) / $23.48 (LABA) | 15min | technician: $15.00; HN (LABA): $23.48 |
| 97153 | $15.00 (technician) | 15min | technician: $15.00; HN (LABA): $23.48; TF (LMHP): $39.40; HO (LBA): $46.63 |
| 97154 | $12.77 (technician) — group | 15min | technician: $12.77; HN (LABA): $15.60; TF (LMHP): $13.13; HO (LBA): $15.55 |
| 97155 | $23.48 (LABA) / $39.40 (LMHP) / $46.63 (LBA) | 15min | HN (LABA): $23.48; TF (LMHP): $39.40; HO (LBA): $46.63 |
| 97156 | $23.48 (LABA) / $39.40 (LMHP) / $46.63 (LBA) | 15min | HN (LABA): $23.48; TF (LMHP): $39.40; HO (LBA): $46.63 |
| 97157 | $7.83 (LABA) / $13.13 (LMHP) / $15.55 (LBA) — multi-family group | 15min | HN (LABA): $7.83; TF (LMHP): $13.13; HO (LBA): $15.55 |
| 97158 | $22.83 (LABA) / $28.13 (LMHP) / $30.54 (LBA) — group w/ protocol mod | 15min | HN (LABA): $22.83; TF (LMHP): $28.13; HO (LBA): $30.54 |
| 0362T | $53.47 (LABA) / $69.39 (LMHP) / $76.62 (LBA) — team supporting assessment | 15min | HN (LABA): $53.47; TF (LMHP): $69.39; HO (LBA): $76.62 |
| 0373T | $53.47 (LABA) / $69.39 (LMHP) / $76.62 (LBA) — team treatment | 15min | HN (LABA): $53.47; TF (LMHP): $69.39; HO (LBA): $76.62 |

### Contacts

- **Provider services phone:** 844-881-4482
- **Hours:** Monday-Friday, 7 a.m.-7 p.m. Eastern time
- **Portal:** [Humana provider portal](https://provider.humana.com/medicaid/virginia-medicaid)

Questions to ask on a verification call:

- Can you confirm prior authorization is on file for 0362T before we schedule? Humana requires PA on this code even though the state baseline doesn't.
- What places of service are approved under this member's authorization — home, school, community, or telehealth?
- Does Humana Healthy Horizons pay these ABA codes at the DMAS fee-schedule rate, or is there a plan-specific rate?

### VOB data sources

- https://assets.humana.com/is/content/humana/VA%20Medicaid%20PALpdf (accessed 2026-07-23)
- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://www.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23)
- https://vamedicaid.dmas.virginia.gov/sites/default/files/2026-07/MES%20EDI%20270-271%20Companion%20Guide_R100_20220509-PK%202.pdf (accessed 2026-07-23)
- https://vamedicaid.dmas.virginia.gov/sites/default/files/2025-07/MHS%20-%20Appendix%20D%20(updated%207.17.25)_Final.pdf (accessed 2026-07-23)
- https://www.dmas.virginia.gov/media/4271/project-bravo-services-faqs-aba.pdf (accessed 2026-07-23)
- https://vamedicaid.dmas.virginia.gov/sites/default/files/2026-01/Telehealth%20Services%20Supplement%20(updated%201.5.26)_Final.pdf (accessed 2026-09-27)
- https://vamedicaid.dmas.virginia.gov/bulletin/applied-behavior-analysis-aba-policy-and-regulatory-clarifications (accessed 2026-09-27)
- https://vamedicaid.dmas.virginia.gov/bulletin/service-authorization-update-applied-behavior-analysis-aba-effective-october-15-2025 (accessed 2026-07-23)
- https://www.dmas.virginia.gov/media/cptcodes/cptmedical4.csv (accessed 2026-07-23)
- https://www.dmas.virginia.gov/media/cptcodes/cptmedical1.csv (accessed 2026-07-23)
- https://virginiaaba.org/wp-content/uploads/2021/11/ABA-Billing-Guidance-from-DMAS-Nov21.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.dmas.virginia.gov/media/cdclvnox/virginia-cardinal-care-managed-care-contract-fy-2026.pdf (accessed 2026-10-07)
- https://provider.humana.com/medicaid/virginia-medicaid/contact-us (accessed 2026-07-23)

## Common questions

### Does Humana Healthy Horizons in Virginia cover ABA?

Yes — it administers the Cardinal Care ABA benefit on DMAS criteria and standardized forms, having entered Virginia on July 1, 2025 as Molina's replacement.

### What happened to Molina members in Virginia?

DMAS terminated Molina's contract effective June 30, 2025; members auto-transitioned to Humana with a 90-day plan-change window and authorizations honored at least 30 days. Verify plan identity on any inquiry that mentions Molina.

### Does Humana require PA on ABA assessments?

Not on 97151/97152 — but unlike DMAS, its PA list flags 0362T as PA-required. Request the auth for 0362T rather than assuming the state rule carries.

### What happens to the authorization when switching ABA providers on Humana Healthy Horizons in Virginia?

The DMAS rule applies to the MCO by name: if ABA lapses for more than 31 consecutive days, the provider must discharge the youth and notify the MCO, and resuming needs a new service authorization with a new assessment and ISP. DMAS publishes no rule moving an authorization between agencies, so ask Humana Healthy Horizons in Virginia whether the incoming agency needs its own authorization.

### Can a Humana Healthy Horizons in Virginia member receive ABA while staying across the border in North Carolina, for example on weekends?

Only with the plan’s agreement. The Cardinal Care contract says the MCO “is not responsible for services obtained outside the Commonwealth” except emergency or crisis care, where using another state’s medical resources is general practice in the member’s locality, where medically necessary services are not available in-network in Virginia, or under a transition-of-care plan. The clinician also needs North Carolina licensure to practice there (G.S. 90-746). A temporary NC license covers only “a limited and defined period of service approved by the Board” (G.S. 90-740). Get Humana Healthy Horizons in Virginia’s written approval before scheduling sessions in North Carolina.

### Does Humana Healthy Horizons in Virginia cover CPT 96112?

Yes, with prior authorization. Humana’s Virginia Medicaid prior authorization and notification list (eff. 7/1/2025, rev. 9/4/2025) lists 96112 and 96113 under neuropsychological testing.

### What is Humana Healthy Horizons in Virginia’s timely filing limit?

365 days from the date of service; corrected claims within 180 days of the explanation of payment; claim disputes within 60 calendar days (provider resource guide).

### Does Humana Healthy Horizons in Virginia require graphs for an ABA reauthorization?

Yes — under DMAS Appendix D, which applies to the MCOs, the continued-stay request must include a graphical presentation of progress on each ISP goal and objective, with an updated ISP and a needs-assessment addendum.

## Primary sources

1. [Humana Healthy Horizons VA — PA and notification list](https://assets.humana.com/is/content/humana/VA%20Medicaid%20PALpdf)
2. [Humana Healthy Horizons VA — BH provider resource guide](https://assets.humana.com/is/content/humana/VA_BH_Provider_Resource_Guidepdf)
3. [VirginiaABA — July 1, 2025 Medicaid changes](https://virginiaaba.org/july-1st-medicaid-changes-what-providers-need-to-know/)
4. [DMAS — MHS manual Appendix D (ABA)](https://vamedicaid.dmas.virginia.gov/sites/default/files/2025-07/MHS%20-%20Appendix%20D%20(updated%207.17.25)_Final.pdf)
5. [DMAS — Project BRAVO ABA FAQ](https://www.dmas.virginia.gov/media/4271/project-bravo-services-faqs-aba.pdf)
6. [DMAS — ABA service authorization update (eff. 10/15/2025)](https://vamedicaid.dmas.virginia.gov/bulletin/service-authorization-update-applied-behavior-analysis-aba-effective-october-15-2025)
7. [DMAS — Cardinal Care Managed Care Contract (July 1, 2026 – June 30, 2027)](https://www.dmas.virginia.gov/media/cdclvnox/virginia-cardinal-care-managed-care-contract-fy-2026.pdf)
8. [DMAS memo — Update to Chapter 5, Correction Regarding MCO Payment Rates (12/4/2025)](https://vamedicaid.dmas.virginia.gov/node/3748)
9. [N.C.G.S. Chapter 90, Article 43 — behavior analyst licensure (G.S. 90-740, 90-745, 90-746)](https://www.ncleg.gov/EnactedLegislation/Statutes/HTML/ByArticle/Chapter_90/Article_43.html)
10. [Humana Healthy Horizons in Virginia — Provider Resource Guide (VAHMAKWEN0126)](https://assets.humana.com/is/content/humana/VA_Provider_Resource_Guidepdf)
11. [Humana Healthy Horizons in Virginia — Communications and network notices (notices + provider newsletter archive)](https://provider.humana.com/medicaid/virginia-medicaid/communications)
12. [DMAS — Mental Health Services Manual, Chapter V: Billing Instructions (rev. 12/5/2025)](https://vamedicaid.dmas.virginia.gov/sites/default/files/2025-12/MHS%20-%20Chapter%205%20%28updated%2012.5.25%29_Final.pdf)
13. [DMAS — Mental Health Services Manual, Chapter IV (rev. 10/2/2026)](https://vamedicaid.dmas.virginia.gov/sites/default/files/2026-10/MHS%20-%20Chapter%204%20%28updated%2010.2.26%29_Final.pdf)
14. [CMS — Medicaid NCCI PTP edits, practitioner services (2026 Q4, active 10/1–12/31/2026)](https://www.cms.gov/files/zip/medicaid-ncci-2026-q4-ptp-edits-practitioner-services.zip)
15. [CMS — Medicaid NCCI MUE edits, practitioner services (2026 Q4, active 10/1–12/31/2026)](https://www.cms.gov/files/zip/medicaid-ncci-2026-q4-mue-edits-practitioner-services.zip)
16. [DMAS — Telehealth Services Supplement (rev. 1/5/2026), Table 2](https://vamedicaid.dmas.virginia.gov/sites/default/files/2026-01/Telehealth%20Services%20Supplement%20(updated%201.5.26)_Final.pdf)
17. [DMAS bulletin — ABA Policy and Regulatory Clarifications (12/16/2025)](https://vamedicaid.dmas.virginia.gov/bulletin/applied-behavior-analysis-aba-policy-and-regulatory-clarifications)
18. [Humana Healthy Horizons in Virginia — Cardinal Care Provider Manual (2025)](https://assets.humana.com/is/content/humana/VA_Provider_Manualpdf)
19. [DMAS bulletin — Interoperability and Prior Authorization Final Rule implementation update](https://vamedicaid.dmas.virginia.gov/bulletin/interoperability-and-prior-authorization-final-rule-implementation-update)
20. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/section-438.210)
21. [32 CFR 199.8 — TRICARE double coverage (eCFR)](https://www.ecfr.gov/current/title-32/section-199.8)
22. [38 CFR 17.272 — CHAMPVA benefit limitations; Medicaid exception (eCFR)](https://www.ecfr.gov/current/title-38/section-17.272)

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.