Idaho Medicaid ABA coverage: the intake guide.

Birth through the month of the 21st birthday. There is no lower age limit, but specialists and professionals serving children from birth to three must meet added early-childhood qualifications unless they are EBM (BCBA or ESDM) providers. Participants aged 18 to 21 may be able to receive both CHIS and adult DD services, and the handbook’s crosswalk rules out adult behavioral consultation/crisis management and high or intense supported living as duplicative.^[1][2][10]

No diagnosis is required, so there is no diagnosis-age rule. The recency clocks are: the ACTP’s comprehensive skills or developmental assessment must be "completed within the last 365 days"; the order and the screening are needed once but must be redone after more than 365 days without CHIS; and services are not billable more than 30 days before the signed order.^[1][2]

No diagnosing clinician is required. Eligibility is set by the Department-approved screening, which may be done by the family’s chosen CHIS provider, the Department, an independent assessment provider, a school, a psychologist, the DHW Crisis Prevention and Court Services team, Infant Toddler staff, a DDA or an independent CHIS provider. The ACTP is completed by an Intervention Specialist (with 10 hours of assessment training plus 5 supervised hours), an Intervention Professional, or an EBM Specialist or Professional. The EPSDT route in the general handbook requires only that the condition be "diagnosed by a physician, therapist, or other licensed practitioner operating within the scope of their licensure."^[2][3]

The eligibility screening is "the current version of the Vineland Standard Deviations Tool" using the Vineland Adaptive Behavior Scales, Third Edition, "administered under its protocol." It must show deficits of 1.5+ standard deviations in three or more of eight areas. The ACTP must then use "an objective and validated comprehensive skills or developmental assessment approved by the department," listed on the Department’s ACTP Tools form, in its most current version.^[2][1]

Yes. CHIS must be ordered "by a healthcare professional within their scope of practice such as a physician, physician assistant and nurse practitioner." The order is required once, before the initial PA request, and must be renewed after a gap of more than 365 days without CHIS. Services more than 30 days before the signed order are not billable. The ordering provider must be enrolled with Idaho Medicaid: "Any service ordered, prescribed, or referred by a provider who is not an enrolled Medicaid provider will not be reimbursed." The Healthy Connections primary-care referral program was removed from the handbook in December 2025.^[2][1][3]

The published Idaho sources do not agree, and the federal floor is stricter than both. The CHIS handbook says "the department or its contractor reviews the documents submitted within 10 business days," and gives the provider 10 business days to answer a request for missing information. Telligen’s 2025 manual lists CHIS pre-service review at "Non-urgent: 10 business days" and "Urgent/Crisis: 3 business days." Telligen’s February 2026 memo says its "standard review times align with the CMS rule of seven business days." The federal rule, 42 CFR 440.230(e), actually says that from January 1, 2026 a state agency must decide a standard request "in no case later than 7 calendar days after receiving the request" (extendable by up to 14 days) and an expedited one within 72 hours. Plan around the handbook’s timing: submit continuations at least 30 calendar days before the authorization ends, and use the 24-hour / 30-day allowance for new cases. Crisis intervention can be requested within 72 hours after it starts.^{[2][7][8][11]}

Medicaid pays last. Under the provider agreement, a provider "agrees to seek payment first from all other applicable sources of payment prior to submitting a claim" and acknowledges "MEDICAID as the payer of last resort"; IDAPA 16.03.26.026.05 says "Medicaid providers must bill all other sources of direct third-party payment." When another plan has paid, Medicaid pays the lowest of the provider’s charge, the Medicaid maximum, or "the third-party allowed amount minus the third-party payment." Two exceptions in the rule matter for this population. Preventive pediatric EPSDT care is paid and chased. The rule also lists "when PA has been approved under these rules, treatment services to control, correct, or ameliorate health problems found through diagnosis and screenings" among its exceptions. Do not rely on that for CHIS without written confirmation, because the handbook still points CHIS providers to the requirements for "billing all other third-party resources before submitting claims to Medicaid." The Medicaid CHIS prior authorization is still required when Medicaid is secondary, since the rule makes no exception for it. For commercial ABA the child’s other plan will usually bill 97-series codes, while Medicaid pays CHIS H-codes, so confirm how Gainwell crosswalks the primary payer’s payment. A provider "cannot refuse to furnish SERVICES to a participant if a third-party is potentially liable." TRICARE pays before other coverage except Medicaid, so Medicaid is still last. CHAMPVA pays last after other health insurance.^{[3][1][2][12][14][15]}

Only one CHIS service is named as virtual-care eligible: "Crisis intervention is an eligible virtual care service," following the general handbook’s virtual care rules. Those rules require real-time video or audio, the GT (audio-video) or FQ (audio-only) modifier, POS 02 or 10, consent, and payment at the face-to-face rate. The CHIS handbook does not say whether Behavioral Intervention, Habilitative Skill Building or the ACTP may be delivered virtually.^[2][3]

Blocked on: BDDS Children’s Program (Children’sDDIntake@dhw.idaho.gov, 208-334-6500) or Telligen (866-538-9510): ask in writing whether H0004, H2014 or H0032 may be delivered via virtual care under CHIS, and get the answer in writing before scheduling remote sessions.

Supervision "includes both face-to-face observation and direction to the staff regarding developmental and behavioral techniques, progress measurement, data collection, function of behaviors, and generalization of acquired skills," and "must be provided under the requirements of the EBM or each provider qualification." Crisis intervention technicians, intervention technicians and intervention specialists must be supervised by a specialist or professional who observes and reviews their services, and "Supervision must occur monthly." EBM paraprofessionals and specialists (RBTs, BCaBAs) are supervised under their model’s own standard, which for BACB credentials means BACB supervision requirements. Specialists serving children from birth to three must be supervised by someone who also meets the birth-to-three qualifications. Independent CHIS providers may not "receive supervision from an individual that they are directly supervising." Idaho sets no numeric hours-per-hours supervision ratio for CHIS.^[1][2]

Duplication is not reimbursable, and services are duplicative "when more than one (1) service is provided at the same time, unless otherwise authorized," or when goals are not separate and unique to each service. A child receiving both Behavioral Intervention and Habilitative Skill Building needs two separate sets of implementation plans. 2:1 staffing can be authorized when the ACTP justifies it: one request is made for the additional staff, identified with the procedure code, the qualification modifier and the EPSDT modifier (EP). Interdisciplinary Training (H2019 HT) is by definition collaboration with the participant present between the CHIS provider and a behavioral health, medical, OT, PT or speech professional.^[1][2]

No per-day or per-week unit ceiling is published for CHIS. Hours are whatever the ACTP justifies and Telligen authorizes, and providers "may not seek reimbursement for more than the total number of units/hours of authorized services per week." Providers can ask for the weekly total to be used interchangeably across provider qualification types. Structural limits: group services run at one staff to two or three participants; crisis intervention is short-term, 30 days or less; the screening is billable once for a maximum of one hour (four units); and pending the initial PA, services are capped at 24 hours within 30 calendar days.^[1][2]

Each visit or service must document the date, time and duration; a session summary (and for interdisciplinary training, who received it and the content); data matching the implementation plan; the location; and the "signature of the individual providing the service, date signed, and provider’s credentials." Records must be created at the time of service, and "records limited to checklists with attendance/appointments, procedure codes, and units of time are insufficient." The ACTP is signed by the assessor and the parent or legal guardian (or a person with parental power of attorney). Implementation plans are signed by a qualified provider, and the provider must document that a copy was offered to the parent. Since May 1, 2026, PA requests need a dated handwritten or compliant electronic parent or guardian signature, not documented verbal consent.^[1][2][9]

CHIS "may be delivered in the community, the participant's home, or in a DDA," and a certified residential facility counts as a home. Community means "natural, integrated environments outside the participant’s home, outside of DDA center-based settings, or at school outside of school hours." Educational services are excluded from Medicaid payment, meaning services in school buildings during the normal school day, services on the IEP, or services required by education law for ages 3 to 21. School-based CHIS runs through the separate School-Based Medicaid program. Crisis intervention is delivered in the home, school or community and can move into a DDA center only when needs cannot be met there. Recreation itself is not paid, but intervention delivered in the community while the child takes part is.^[1][2]

CHIS is billed by a certified Developmental Disability Agency or by an enrolled independent CHIS provider. Independent enrollment is open to Intervention Specialists, Intervention Professionals and EBM Specialists or Professionals, not technicians. Intervention Technicians and EBM Paraprofessionals (RBTs) deliver only as DDA employees. The rendering credential rides on the modifier: HA Intervention Technician, HN Intervention Specialist, HO Intervention Professional, TF EBM Intervention Specialist (BCaBA), TG EBM Intervention Professional (BCBA/ESDM), and no modifier for the EBM Paraprofessional on H0004 and H0005. An agency may reassign an authorization to a higher-qualified staff member and bill at the authorized rate, but not the reverse. Habilitative Skill Building is one code with no credential modifier, so any qualified staff can deliver it on the agency’s authorization. Ordering providers must themselves be enrolled in Idaho Medicaid.^[2][1][4]