Indiana Medicaid — the Indiana Health Coverage Programs (IHCP) — covers ABA for autism when medically necessary, across traditional Medicaid and its managed-care entities. The program is in the middle of the most consequential rule changes of any state we track: an EPSDT-only shift, a hard under-21 cutoff, a lifetime hour allocation, published rate cuts, and a provider-accreditation mandate. Intake teams need both the baseline and the moving parts.
IHCP covers ABA when medically necessary for the treatment of ASD, and all ABA services require prior authorization — for fee-for-service through Acentra Health, and through each managed-care entity's own process for MCE members. The clinical bar is specific: an ASD diagnosis supported by a comprehensive diagnostic evaluation (CDE) performed by a doctoral-level HSPP psychologist, physician, APRN, or PA; a physician referral; and a behavior assessment that must include the Vineland (with the Maladaptive Behavior domain), the BASC parent rating questionnaire, and an age-appropriate direct skills assessment, signed by the lead analyst and a parent. A CDE older than one year needs an updated statement of need, referral, and current behavior assessment. One tool-currency note: IHCP accepted either the BASC-3 Parent Rating Questionnaire or its successor, BASC-4, through October 1, 2026 — since then only BASC-4 satisfies the requirement.[2][3][15][9][10]
Each PA runs at most 6 months, up to 40 hours/week may be requested (more than 40 hours of direct therapy needs additional PA), and — since the 2026 rules — every ABA PA must include caregiver coaching (up to 18 hours per standard 6-month authorization), with a minimum of 1 hour of BCBA supervision per 8 hours of technician services. IHCP Bulletin BT2026136 (8/18/2026) clarifies that floor rather than raising or lowering the ceiling: the required minimum can be reduced below the standard 12-hour/6-month caregiver-coaching floor from BT202662 when documented barriers exist — custody or foster-care disruptions, medical crises, homelessness, legal restrictions, and similar circumstances — provided a caregiver-coaching "improvement plan" is documented at reauthorization whenever the minimum wasn't met.[2][3][15][9][10]
Effective April 1, 2026, IHCP covers ABA exclusively through the EPSDT benefit; members 21 and older had a transition window through September 30, 2026, and for dates of service on or after October 1, 2026 IHCP no longer authorizes or reimburses ABA for members 21+ — making age a first-order intake question. Also effective April 1, 2026: comprehensive ABA (16+ hours/week, billed with modifier UA) draws from a 4,000-hour (16,000-unit) lifetime allocation per member — 97155 and 97156 are excluded from the allocation, and the IHCP Portal's "Limit Details" panel shows usage — while targeted ABA is capped at 15 hours/week but exempt from the lifetime cap. Codes 97151, 97152, 97153, 97154, and 0373T can no longer be billed with telehealth modifier 95.[1][4][5][6][11][12][13][14]
Separately, an accreditation mandate now binds every ABA group enrollment — new and existing. Currently enrolled agencies must submit documentation showing accreditation has been initiated with the Autism Commission on Quality (ACQ) or the Behavioral Health Center of Excellence (BHCOE) by August 1, 2026 (to INXIXabaenrollments@gainwelltechnologies.com or via the IHCP Portal) — that deadline has now passed, and IHCP's bulletin list through BT2026155 (9/24/2026) carries no extension — and must hold active accreditation by October 1, 2027. Missing either milestone results in enrollment deactivation, not just a warning. IHCP reissued this deadline as a reminder in Bulletin BT2026118 (7/14/2026) with no extension and sharper enforcement language: "Failure to provide documentation will result in the enrollment being deactivated." One footnote worth reading twice: BT202646 states a previous BHCOE accreditation is accepted only "until an agency's reaccreditation with ACQ," so agencies choosing an accreditor should plan the reaccreditation path, not just the first credential.[1][4][5][6][11][12][13][14]
A second, separate restriction landed in between: effective June 6, 2026, CMS approved a provider-enrollment moratorium on new ABA agency enrollments and changes of ownership in Indiana Medicaid (initial 6 months, renewable in 6-month increments) — new individual rendering-provider (RBT/BCaBA/BCBA) enrollment is unaffected, and already-accredited agencies can request an exception via OMPPProviderRelations@fssa.in.gov. HHS-OIG's own audit-report page confirms the moratorium follows an OIG finding of improperly paid Indiana ABA claims, though the IHCP bulletin itself doesn't name the audit. New or expanding ABA agencies should treat this moratorium, not just the accreditation deadline, as the binding constraint on growth in Indiana this year.[1][4][5][6][11][12][13][14]
Four more bulletins landed September 29, 2026, tightening clinical documentation rather than coverage. BT2026160 simplifies the statement-of-need/referral rule: "statement of need" and "referral" are now interchangeable, required only at onset of ABA (CDE >1 year old), at reauthorization when an active member's CDE crosses the one-year mark, or with a new PA after a 6-month service gap — not with every reauthorization or annually — and it cannot be completed by a BCaBA, BCBA, PT, SLP, or OT. BT2026162 requires a complete functional behavior assessment (FBA) — a named indirect assessment tool plus ABC data, triggers/precursors, and a hypothesized function statement — for every behavior targeted by a behavior intervention plan (BIP), effective October 29, 2026; BIPs built without one no longer pass review. BT2026159 sets an AAP-based right to nap/sleep during ABA hours (members can't be kept awake, woken by physical contact, or penalized for non-billable 97153 time lost to a documented nap) that must be written into the schedule of services. BT2026161 ends fee-for-service peer-to-peer PA reviews on November 1, 2026 (scheduling stops October 31, 2026) — administrative review and appeal is the only path left for Acentra FFS denials; MCE members are unaffected, and member appeal rights don't change.[1][4][5][6][11][12][13][14]
Indiana publishes its ABA max fees, which makes revenue modeling unusually concrete — including the pain: a 6% reduction on individual ABA codes for dates of service on/after April 1, 2026, and a further 4% on all ABA codes on/after April 1, 2027. Per 15-minute unit: 97153 (technician, U1) $17.06 → $16.04 → $15.39; 97155 (BCBA, U3) $27.63 → $25.97 → $24.93; 97156 (BCBA, U3) $28.23 → $26.54 → $25.47; 97151 assessment (U3) $27.63 → $25.97 → $24.93. From 4/1/2026, 97153 also became billable at the BCaBA/BCBA tiers, and group codes were restratified into group-size tiers with their own rates. MCE-contracted rates are negotiated but the IHCP max fee is the benchmark. The January 1, 2027 rebase of the IHCP Professional Fee Schedule to 100% of Medicare does not touch these: BT2026143 (8/27/2026) lists applied behavior analysis among the services "that will not be affected by these rate changes," so the 4/1/2027 cut is the next ABA rate event.[1][32]
Not to new agencies right now. IHCP Bulletin BT202692 (6/4/2026) announced CMS approval of a statewide ABA provider-enrollment moratorium effective June 6, 2026, "in place for an initial period of six months" and extendable "in six-month increments." It "will prevent enrollment for brand-new ABA group enrollments as well as changes of ownership for existing ABA therapy agencies," but "will not apply to rendering provider enrollment requests for individuals" — an already-enrolled agency can keep adding RBTs, BCaBAs and BCBAs. IHCP will consider limited exceptions "to ensure sufficient member access to ABA therapy services to areas in need"; an agency asking for one must already be accredited under BT202646 and applies by email to OMPPProviderRelations@fssa.in.gov. The moratorium reaches the managed-care networks too: federal rule requires the state to "screen and enroll" all network providers of its MCOs, and an MCO must drop a network provider the state cannot enroll. Existing agencies face their own gate — accreditation documentation was due August 1, 2026 and full ACQ/BHCOE accreditation by October 1, 2027, or the enrollment is deactivated. IHCP's bulletin list through BT2026164 (9/29/2026) shows no extension or early end yet; check for one before the first six months run out in early December 2026.[6][7][4][8]
IHCP does not publish a transfer rule for an authorization when a family changes ABA providers, so expect the new agency to need its own approval: all ABA services require prior authorization, and each PA request runs at most six months. What is written down is how much of the old work carries over. "If a comprehensive behavior assessment has been completed within six months, any new provider is expected to obtain the assessment from the original provider" — so get the prior agency's assessment (with consent) before re-testing. The CDE and referral follow the child, not the agency: under BT2026160 (9/29/2026) a new statement of need/referral is needed only if the CDE is over a year old, or with a new PA after a six-month gap in ABA services. And the 4,000-hour lifetime allocation for comprehensive ABA is per member, not per provider, so hours used at the previous agency count; check the IHCP Portal's Limit Details panel at eligibility verification (it lags claims). Whether the old agency's open PA must be ended before a new one is approved is not published — ask Acentra Health (fee-for-service) or the member's MCE.[2][11][1]
Indiana is one of the few states where technicians enroll in Medicaid individually. Since December 18, 2024, RBTs enroll with the IHCP as rendering providers (provider type 11, specialty 625 — ABA Therapist RBT), and all RBTs and BCaBAs had to be individually enrolled by April 1, 2025 — each with their own Type 1 NPI, enrolled once and then associated with every group they render for. Since April 1, 2025 the rendering NPI on claims must align with the credential-level modifier (U1 RBT / U2 BCaBA / U3 BCBA-HSPP), though a bulletin update note delayed enforcement of that alignment. There is no separate state RBT license: IC 25-8.5-3-6 lets "direct contact technicians" practice without a license when implementing plans under the supervision and direction of a licensed behavior analyst, so the certification floor is the BACB's — age 18+, high-school education, the 40-hour training, competency assessment, and the RBT exam, plus the BACB's own requirement that every applicant pass a criminal background check and an abuse-registry check within 180 days before applying.[16][17][1][18][19][20]
On top of that, IHCP classifies all three ABA specialties (615 Masters/Doctoral-HSPP, 624 Bachelors, 625 RBT) as HIGH risk at enrollment — which triggers a fingerprint-based criminal background check for every individually enrolling RBT, BCaBA, and BCBA before the application can be completed. Fingerprints go through the Indiana State Police, the provider pays the fee, and results are sent to the FSSA (not the agency) for review; the check is specific to the individual, so an enrolled RBT joining a second group doesn't need a new one. Enrolled school corporations are exempt, but group providers rendering ABA in school settings are not, and specialty 615 group/billing enrollments additionally get a site visit. FSSA can deny enrollment for convictions it "determines is inconsistent with the best interest of IHCP members" — violent, financial, substance, abuse, and firearm offenses are the published examples. Build the fingerprint step into your hiring timeline: it sits between offer and first billable session.[16][17][1][18][19][20]
Supervisor-side, Indiana now licenses behavior analysts: LBA and LABA credentials under IC 25-8.5 (applications live May 13, 2025), with LBA licensure requiring current BCBA certification plus a national criminal history background check ($100 application; LABAs pay $75 and must file a signed supervision contract with a licensed behavior analyst). For IHCP enrollment, specialty 615 is limited to HSPP-licensed or BCBA/BCBA-D-certified providers, and the assessments feeding every PA may only be performed by a psychologist, BCBA-D, or master's-level BCBA. The binding ratio since April 1, 2026: at least 1 hour of BCBA (or IHCP-approved qualifying clinician) supervision per 8 hours of technician-delivered therapy — and with 97153 now in-person only, that supervision capacity has to exist where the sessions happen. These screening rules ride on IHCP enrollment across fee-for-service and the MCEs; we found no evidence the plans add employee-level checks beyond the state baseline, but current MCE provider manuals weren't exhaustively reviewed — confirm with each plan at credentialing.[16][17][1][18][19][20]
Indiana licenses the practice: an individual may not “practice applied behavior analysis” unless the individual “holds a license issued under this chapter” (IC 25-8.5-3-6(a)); the PLA takes reciprocity applications ($75 for an LBA). Indiana’s telehealth law (IC 25-1-9.5) defines a telehealth “practitioner” as someone holding “an unlimited license to practice” in Indiana and lists “a behavior analyst licensed under IC 25-8.5,” so plan on an Indiana license before treating a child located in Indiana remotely.[19][22][23][24]
Indiana Medicaid enrolls some out-of-state providers (405 IAC 5-5), but the IHCP Provider Enrollment Type and Specialty Matrix “indicates which provider types and specialties are ineligible for out-of-state enrollment,” and “In general, all out-of-state services rendered to IHCP members require prior authorization (PA)” on top of the ABA PA. That extra out-of-state PA is waived for “Telehealth services if providers have the subtype ‘Telemedicine’ attached to their enrollment,” and for providers granted “in-state” status for service locations in designated border-area counties (Cook County, Illinois, is one). Check the Matrix for the ABA specialties (615, 624, 625) before applying.[19][22][23][24]
Only in the IHCP’s listed situations. The Prior Authorization module says PA is given after services have begun only for: pending or retroactive member eligibility (request within 12 months of the date the caseworker entered the eligibility); services outside Indiana by a provider not yet IHCP-enrolled; mechanical or administrative delays or errors by the contractor or the county DFR office; certain out-of-state transportation; a provider unaware the member was eligible (only with documented refusal or inability to give the Member ID, continued pursuit of payment from the member, and a PA request within 60 calendar days of discovering eligibility); and cases where the exact procedure cannot be known until afterward. An approved retroactive PA extends timely filing to 180 days from approval, and the claim must carry a copy of the PA marked “retroactive prior authorization.” Retroactive changes to an existing PA’s start date are not allowed. These are fee-for-service rules; for managed care members the module sends providers to the MCE’s own manual.[33]
180 days. “Providers must submit claims to the Indiana Health Coverage Programs (IHCP) within 180 calendar days of the date the service was rendered” (405 IAC 1-1-3). Claims past the limit are considered only with supporting documentation attached to each claim. This is the fee-for-service rule; managed care members’ claims follow their MCE’s filing limit.[26][27]
Taxonomy. On the CMS-1500 the billing provider’s taxonomy goes in 33b with qualifier ZZ or PXC, and IHCP requires it when needed to establish a one-to-one match between the NPI and an IHCP Provider ID — for example a provider with several service locations. The rendering provider’s taxonomy in 24J is “optional unless required for a one-to-one NPI/Provider ID match.”[26][27]
Appeals. A request for administrative review must be filed within 60 calendar days of notification of the claim payment or denial; Gainwell acknowledges it within 10 business days and answers within 45 calendar days. An adverse administrative review can be appealed within 15 calendar days of notification of the decision.[26][27]
The IHCP's claim module sets the general rule: "When providing medical services or supplies resulting from an order, prescription or referral, federal regulations require providers to include the National Provider Identifier (NPI) of the ordering, prescribing or referring (OPR) provider on Medicaid claims. Reimbursement to the billing provider requires the OPR provider to be enrolled in Medicaid." The IHCP checks both: "Medical claims will be denied if an NPI for the OPR provider is not present on the claim or if the OPR provider is not enrolled as an IHCP provider." On a CMS-1500 the NPI goes in field 17b ("Referring Provider or Other Source NPI"). On an 837P it goes in loop 2310A (NM101 = P3 or DN). On the IHCP Portal it goes in the Referring Provider ID field.[26][2]
ABA specialty 615 is not on the IHCP's list of specialties whose claims "will not adjudicate without" an OPR NPI (therapy clinics, PT, OT, speech, pharmacy, DME, labs and others). The module adds that "Claims from other specialties may also require an OPR NPI in certain circumstances, such as for specific services that always require physician's order." Indiana ABA rests on a referral: eligibility requires that "a physician has made a treatment referral recommending ABA therapy." So the safe practice is to report the referring practitioner's NPI in 17b and check before the first visit that this practitioner is enrolled in the IHCP, using the OPR Provider Search Tool. Search date by date, because the tool is specific to the date of service. MCE claims follow each plan's own editing, so confirm with the member's plan.[26][2]
Filing deadline: “Providers must submit claims to the Indiana Health Coverage Programs (IHCP) within 180 calendar days of the date the service was rendered” (405 IAC 1-1-3). A denied claim resubmitted with corrected information is treated as an initial claim and stays inside the same 180 days; a claim adjustment or electronic void/replacement of a paid claim, and a written request for administrative review, must each be filed within 60 days of the remittance advice date. The 180 days are extended to one year from the date retroactive member eligibility was entered, to 180 days from approval of a retroactive PA, and — for a secondary claim held up by another payer — to 180 days from the date on the primary payer’s EOB, which must be attached.[26][30]
Payment clock and cycle: Gainwell “must adjudicate clean paper claims within 30 calendar days of receipt. Clean electronic claims must be adjudicated within 21 calendar days of receipt,” and claims that miss those windows accrue interest under IC 12-15-21-3(7)(A) (claims under medical or prepayment review excepted). “The IHCP financial cycle runs every Friday”; check payments are dated, and EFT payments deposited, the Wednesday following the financial cycle, and the weekly remittance advice posts to the IHCP Portal after the cycle runs. IHCP publishes no submission cut-off hour for a given Friday’s cycle — a claim is paid in the first cycle after it adjudicates.[26][30]
Reauthorization: each ABA PA runs up to six months, and continuing past it takes a new PA request. It is approved when the member still meets ABA criteria and the treatment plan is resubmitted with measurable progress to date on each goal, a revised timeline for each goal based on the initial and interim assessments, clinically significant progress in social, communication and language skills, adaptive functioning and behavior, and updates to hours, schedule, parent training and school-transition plans. Continuing members need no new comprehensive diagnostic evaluation but do need an updated behavior assessment and treatment plan (BT202562), and the behavior assessment’s “complete scoring report, including outcome measure scores and graphs, must be submitted with prior authorization requests.” Graphs are therefore required — of the standardized assessment results — and discharge follows when measurable functional improvement is not documented or progress stalls across successive authorization periods.[2][3][1]
Code set: IHCP’s ABA rate tables (BT202627) bill ABA under CPT 97151–97158, 0362T and 0373T with credential, group-size and comprehensive-therapy (UA) modifiers; no HCPCS H-code appears in the ABA code set.[2][3][1]
The questions that decide whether a family can start with Indiana Medicaid (IHCP), and what they have to bring. Each maps onto something intake should ask on the first call.
Twenty and younger — and the cutoff just became real. The provider reference module covers ABA “for members 20 years of age and younger,” and BT202562 restates it. Effective April 1, 2026 ABA is covered exclusively through the EPSDT benefit; members 21 and older had a transition window through September 30, 2026, and for dates of service on or after October 1, 2026 IHCP no longer authorizes or reimburses ABA for members 21+. Age is therefore a first-call intake question in Indiana, and for a member approaching 21 the runway is a coverage fact worth stating out loud.[2][1][3]
One year on the CDE, six months on the behavior assessment — and BT2026160 (9/29/2026) rewrote when the paperwork behind that has to be refreshed. “Statement of need” and “referral” are now defined as interchangeable: a referral from an HSPP, physician, APRN, or physician assistant, required at onset of ABA if the CDE is already more than a year old, at reauthorization if an actively-served member’s CDE crosses the one-year mark, or with a new PA whenever the member has had a six-month gap in ABA services (and again with each subsequent PA if the gaps keep recurring) — it is explicitly not required with every reauthorization or annually once submitted. Members continuing current services without a gap do not need a new CDE at all, but do need an updated behavior assessment and treatment plan (reassessment every six months regardless); new behaviors or a request for services not previously authorized may require more frequent behavior assessments. Separately, “if a comprehensive behavior assessment has been completed within six months, any new provider is expected to obtain the assessment from the original provider” — so ask an incoming family who tested them and when before you re-test.[3][11][2]
BT202562 names the credentials outright. The qualified healthcare provider performing the comprehensive diagnostic evaluation must have “specialized training in the application of the most recent Diagnostic and Statistical Manual of Mental Disorders (DSM) autism criteria” and hold one of: a doctoral-level licensed clinical psychologist endorsed as a health service provider in psychology (HSPP); a licensed physician; a licensed advanced practice registered nurse (APRN); or a licensed physician assistant. The provider reference module carries a slightly broader formulation that adds “other behavioral health specialist with training and experience in the diagnosis and treatment of ASD.” The behavior assessment is a different role with a different list — psychologist, BCBA-D or master's-level BCBA only.[3][2][17]
Indiana is one of the few states that names the instruments, and it names three. The behavior assessment conducted before ABA starts “must include three core standardized behavior instruments”: the Vineland Comprehensive Parent Interview Form including the Maladaptive Behavior domain; the Behavior Assessment System for Children, Parenting Relationship Questionnaire (BASC PRQ); and an age-appropriate, objective direct skills assessment. It must be signed by the lead analyst and the parent or guardian, and “the complete scoring report, including outcome measure scores and graphs, must be submitted with prior authorization requests.” One currency note: IHCP accepted either the BASC-3 Parent Rating Questionnaire or its successor BASC-4 through October 1, 2026 — since then only BASC-4 satisfies the requirement. The CDE behind the diagnosis has its own component list rather than a named tool: caregiver interview, structured observation of social communication skills and behaviors, review of available external evaluations or screenings, documentation of a completed DSM-based screening/diagnostic evaluation, and documentation that the individual cannot adequately participate in home, school or community activities or presents a safety risk.[2][9][15]
Required, from a physician, and it appears twice. Member eligibility requires that “a physician has made a treatment referral recommending ABA therapy,” and the CDE’s own required components include “a physician’s referral for autism-specific services.” Where the CDE is more than a year old, the updated statement of need must itself carry a referral from an appropriate referring practitioner. As of BT2026160 (9/29/2026), the qualifying referral sources are HSPP-endorsed doctoral psychologists, licensed physicians, licensed APRNs, and licensed physician assistants — a BCaBA, BCBA, PT, SLP, or OT cannot complete the statement of need/referral. All ABA services require prior authorization on top of the referral — through Acentra Health for fee-for-service, and through the member's MCE otherwise — with each PA limited to six months.[2][3][11]
Assessment in person; remote supervision and caregiver training only, with conditions. Effective April 1, 2026, IHCP no longer allows 97151, 97152, 97153, 97154 or 0373T to be billed with telehealth modifier 95, because they "require direct, in-person interaction" — so the initial assessment, every reassessment and follow-up observational assessment (97151/97152), direct treatment and group treatment must all be delivered in person. Only 97155 and 97156 may be delivered via telehealth, and the provider reference module attaches three conditions: RBTs and BCaBAs "may not deliver any ABA therapy service via telehealth" (only an HSPP, BCBA or BCBA-D may use telehealth when supervising remotely); 97155 is reimbursable via telehealth "only when an HSPP, BCBA or BCBA-D is providing guidance/supervision to an RBT remotely, and the RBT is rendering adaptive behavioral treatment (procedure code 97153) in person to the member"; and every ABA telehealth service must be synchronous audio-video — audio-only is never reimbursable. Bill modifier 95 with 97155/97156 when delivered via telehealth, with U3 alongside it. BT202662 (4/28/2026) confirms that supervision “may be rendered via synchronous telehealth and billed using modifier 95,” but that telehealth supervision “is intended to supplement, not replace, the majority of in-person services” — no numeric cap on the remote share is set, and remote supervision counts toward the 1-hour-per-8 floor. The module itself is written for fee-for-service; managed-care members follow their MCE.[1][2][21]
For fee-for-service members, the PA contractor is Acentra Health and the clock is federal-floor fast. From January 1, 2026 (BT2025165), Acentra must decide a standard request “within seven calendar days of the initial standard PA request,” extendable “up to an additional seven calendar days” only if the member or provider asks or Acentra requests more information; an urgent/expedited request must be decided “within 72 hours,” and “No pend (extension) time frame will be allowed for urgent/expedited FFS PA requests.” That matches 42 CFR 440.230(e). When Acentra pends a request for information, the clock restarts on receipt, and the information must arrive within 30 calendar days of the original request or “the request is systematically denied.” Reauthorization lead time is written down: submit new PA requests for continuation of ongoing services “at least 30 calendar days before the current authorization period expires,” and a denial or cut to a continuing service needs “at least 10 days’ notice plus three days’ additional mailing time.” Two process changes land in late 2026, per BT2026161 (9/29/2026): Acentra has built InterQual (IQ) criteria into the FFS authorization-submission workflow (first announced in BT2026142, not independently re-verified here) to outline the documentation medical necessity generally requires — completing IQ criteria doesn’t guarantee approval — and effective November 1, 2026, FFS peer-to-peer reviews are discontinued (scheduling ends October 31, 2026); a denied FFS PA now goes straight to administrative review and appeal, which keeps its existing timelines, and member appeal rights are unchanged. Most IHCP ABA members are in managed care, where the module says to ask the MCE for its own time parameters — see the Anthem, CareSource and MHS guides (Indiana law gives MCEs a 48-business-hour clock); this peer-to-peer change is FFS-only.[34][33][35][14]
Medicaid pays last, and Indiana enforces it by cost avoidance. The TPL module cites 42 CFR 433.139 for IHCP as “the payer of last resort” (only Victim Assistance, First Steps, CSHCS and CHOICE are billed after IHCP); if the eligibility check shows other coverage and the claim arrives without proof the other resource was billed, the claim is denied. Bill the commercial plan first, then send IHCP proof of the denial or payment — the EOB/EOP/RA or a qualifying adjustment reason code — including when the primary paid zero toward a deductible or copay; IHCP pays up to its allowable less the primary payment, and if the other insurer has not answered in 90 days the claim can go to IHCP with the billing evidence. Two ABA-critical rules: (1) get the IHCP PA anyway — “the provider must follow the primary insurer's requirements for obtaining PA and must also obtain PA from the appropriate IHCP PA contractor”; (2) be in the primary plan's network — IHCP “will not reimburse for claims that the primary carrier denied because the member received out-of-network services when the carrier required services to be delivered by in-network providers,” and the 90-day provision cannot be used to get around that. The pay-and-chase exception for preventive pediatric care, including EPSDT, only reaches claims carrying a diagnosis code from IHCP's “Preventive Pediatric Care Diagnosis Codes That Bypass Cost Avoidance” list; nothing in the module puts ABA on it, so bill the primary first. TRICARE is not a problem here: 32 CFR 199.8 excludes Medicaid from the “double coverage plans” TRICARE pays after, so for a child with both, TRICARE pays before Medicaid.[36][33][37][38]
Coverage decides whether Indiana Medicaid (IHCP) 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.
Two layers, and the second one is new money. The provider reference module requires that ABA performed by a BCaBA or credentialed RBT “must be under the direct supervision of a BCBA, BCBA-D or HSPP.” On top of that, since April 1, 2026 IHCP sets a numeric floor: at least 1 hour of BCBA (or IHCP-approved qualifying clinician) supervision per 8 hours of technician-delivered therapy. Because 97153 lost telehealth modifier 95 on the same date, that supervision capacity has to exist physically where the sessions happen. Assessments feeding a PA are a separate, narrower role: only a psychologist, BCBA-D or master's-level BCBA may perform the behavior assessment. BT202662 (4/28/2026) defines how the floor is measured: monthly, per member (“not aggregated across technicians or across Medicaid members”), proportionally when a member gets fewer than eight technician hours in the month, and counting both billable 97155 and documented nonbillable case supervision (fidelity checks, session-note review) — but not administrative supervision such as scheduling or staff meetings. Shortfalls are subject to claim audit, postpayment review and recoupment.[2][1][3][21]
Yes, for 97155 alone — IHCP answered this in BT202662 (4/28/2026): “CPT code 97155 may be billed concurrently only with CPT codes 97153 and 97154.” It is the billable supervision code only when a BCBA, BCBA-D or other IHCP-approved supervising clinician “is actively directing a technician in implementing a modified treatment protocol during service delivery,” and IHCP “expects clear evidence of protocol modification and technician direction when CPT code 97155 is billed.” 97155 billed for observation, protocol evaluation or the analyst’s own direct implementation without directing a technician is not supervision of technician services and does not count toward the 1:8 floor, though it may otherwise be billable when documented.[21]
Indiana caps by the week and by the lifetime rather than by the day. Up to 40 hours per week may be requested; “ABA therapy services extending beyond 40 hours per week of direct therapy must be medically necessary and require an additional prior authorization.” Each PA is limited to six months — “PA requests for longer periods will not be approved.” Since April 1, 2026 comprehensive ABA (16+ hours/week, billed with modifier UA) draws from a 4,000-hour (16,000-unit) lifetime allocation per member, with 97155 and 97156 excluded from the allocation and usage visible in the IHCP Portal’s Limit Details panel; targeted ABA is capped at 15 hours/week and is exempt from the lifetime cap. Caregiver coaching is capped at up to 18 hours per standard six-month authorization. There is also a per-day claim edit: IHCP “applies Medicaid NCCI methodologies of MUEs and PTP edits” to medical services on professional claims, per member, per rendering provider (or billing provider when there is none), per date of service (NCCI module, v7.0). 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. Additional hours outside the authorized PA may be requested for a limited period on a named list of triggers — a sudden increase in self-injury, aggression or elopement, regression in major self-care or language, a shift in family or home dynamic, or a non-mental-health health crisis or comorbidity.[2][1][10][28][29]
Published, in the provider reference module’s ABA documentation requirements. Providers must keep — and be able to produce within 72 hours of a request — "session notes, which must be signed by the rendering practitioner," and each note must include the date, time, location and duration of services plus the session-specific targeted skills and the individual’s response addressing the treatment plan goals. The behavior assessment and the treatment plan are a separate signature rule: each must be signed by the lead analyst and the parent or guardian. No signing deadline (for example, within a set number of hours after the session) is published.[2]
School is in scope as a provider type, and out of scope as a duplicate. IHCP enrolls School Corporations (provider type 12, specialty 120) to bill ABA, and the treatment plan must be built around “the individual’s needs, age, school attendance (including homeschooling) and other daily activities.” But two named exclusions bound it: services “that focus solely on recreational or educational outcomes” are not covered, and neither are “services that are duplicative of other covered services, such as services rendered under an individualized educational program (IEP) that address the same goals using the same techniques as the treatment plan.” The plan must also document plans for parent/guardian training and school transition. Enrolled school corporations are exempt from the high-risk fingerprint screening, but group providers rendering ABA in school settings are not. ABA under an IEP, 504 plan or other approved education plan is billed by the school corporation with modifier TM on every code (TL and TR are not used), the education plan serves as prior authorization, the school corporation's NPI is both billing and rendering provider, and the claim goes to fee-for-service (Gainwell), never to the student's MCE.[2][17][25]
The claim goes out under the enrolled analyst or school corporation, never the technician. “ABA therapy services rendered by a BCaBA or RBT must be billed under the NPI of an IHCP-enrolled ABA therapist or school corporation,” and all ABA claims bill on a professional claim (CMS-1500 or its electronic equivalent). Indiana nonetheless makes technicians enroll individually: since December 18, 2024 the ABA specialties are 615 (Masters/Doctoral or HSPP), 624 (Bachelors) and 625 (RBT), and beginning July 1, 2025 reimbursement requires the rendering practitioner to be enrolled under one of them — except for school-based ABA billed by school corporations. Since April 1, 2025 the rendering NPI on the claim must align with the credential-level modifier (U1 RBT / U2 BCaBA / U3 BCBA-HSPP), though a bulletin update delayed enforcement of that alignment.[2][1][17]
Yes — IHCP covers medically necessary ABA for autism with prior authorization on all services. Since April 1, 2026 it is covered exclusively through EPSDT, and coverage ends for members 21+ for dates of service on or after October 1, 2026.
Comprehensive ABA (16+ hours/week) draws from a 4,000-hour (16,000-unit) lifetime allocation per member, tracked in the IHCP Portal. 97155 and 97156 don't count against it, and targeted ABA (≤15 hrs/week) is exempt.
Published max fees, per 15-minute unit — e.g., 97153 at $16.04 (technician tier, DOS on/after 4/1/2026, dropping to $15.39 on 4/1/2027) and 97155 at $25.97 (BCBA tier). MCE rates are contractual but benchmark against the IHCP schedule. The 2027 Medicare-based rebase of the Professional Fee Schedule excludes ABA (BT2026143), so the 4/1/2027 4% cut is the next scheduled change.
Only partly. Since April 1, 2026, 97151, 97152, 97153, 97154 and 0373T cannot be billed with modifier 95, so assessments and reassessments are in person. 97155 and 97156 may be done by audio-video telehealth (modifier 95 with U3) by an HSPP, BCBA or BCBA-D only — and remote 97155 only while the RBT delivers 97153 in person. RBTs and BCaBAs may not use telehealth, and audio-only is never paid.
Not new agencies, for now. A CMS-approved moratorium (effective June 6, 2026, six months at a time) blocks new ABA group enrollments and changes of ownership; individual RBT/BCaBA/BCBA enrollment is unaffected. Accredited agencies can ask for an access exception at OMPPProviderRelations@fssa.in.gov. It reaches MCE networks too, since MCE network providers must be state-enrolled.
No transfer rule is published, so plan on a new PA for the new agency (each PA is up to six months). The new provider is expected to obtain a behavior assessment done within the last six months from the original provider, and lifetime comprehensive-ABA hours carry over. Confirm with Acentra Health or the MCE whether the old PA must be closed first.
Yes — BT2026159 (9/29/2026) requires providers to follow AAP sleep recommendations by age, write necessary nap time into the schedule of services, and never keep a member awake or wake one by physically moving them. Lost 97153 billable time from a documented nap must be explained in the treatment plan, not penalized.
Indiana requires an Indiana license (IC 25-8.5-3-6), and its telehealth law counts only Indiana-licensed behavior analysts as practitioners. The IHCP enrolls some out-of-state providers, but out-of-state services generally need extra PA and some specialties are ineligible; check the Enrollment Matrix.
Only in IHCP’s listed cases, chiefly pending or retroactive eligibility (request within 12 months of the eligibility entry) or a provider who could not have known the child was eligible (request within 60 days of discovery). Managed care members follow their MCE’s rules.
The same ABA CPT codes, billed by the school corporation with modifier TM. The IHCP School Corporation Services module (Sept. 29, 2026) lists ABA therapy among school-based Medicaid services and says “the TM modifier must be attached to the end of all billing codes” for services under an IEP, a 504 plan or another approved education plan; TL and TR are not used. The education plan serves as prior authorization, the school corporation’s NPI is both billing and rendering provider, and claims go to fee-for-service (Gainwell), never to the child’s MCE.
180 calendar days from the date of service for fee-for-service claims (405 IAC 1-1-3). Managed care members’ claims follow their MCE’s own filing limit.
Only when it is needed to match the NPI to a single IHCP Provider ID — for example a provider with several locations. The billing taxonomy then goes in box 33b with qualifier ZZ or PXC; the rendering taxonomy in 24J is optional unless needed for that match.
A comprehensive diagnostic evaluation (CDE) by an HSPP psychologist, physician, APRN or physician assistant trained in DSM autism criteria. It must include a physician's referral for autism-specific services, and member eligibility separately requires that "a physician has made a treatment referral recommending ABA therapy." The IHCP checklist also asks for documented current ASD symptoms within the past year and the history of prior treatment. Before ABA starts, the behavior assessment must carry three core instruments: the Vineland Comprehensive Parent Interview Form with the Maladaptive Behavior domain, the BASC PRQ (only BASC-4 is accepted after October 1, 2026), and a direct skills assessment. Submit full scoring reports with graphs, signed by the lead analyst and parent. The PA itself goes on the IHCP Universal Prior Authorization Form with codes, modifiers and units, plus a treatment plan with baselines and parent-training detail.
The CDE is good for one year at the start of ABA. If it is older, an updated statement of need carrying a referral from an HSPP, physician, APRN or PA is required (BT2026160). Members continuing without a gap do not need a new CDE but need a reassessment every six months. A new referral is required after a six-month gap in services. If another provider completed a behavior assessment within six months, obtain that one rather than re-testing.
The IHCP requires the NPI of the ordering, prescribing or referring provider on claims for services that result from an order or referral, and denies claims without it or when that provider is not IHCP-enrolled. It goes in CMS-1500 field 17b (837P loop 2310A). ABA specialty 615 is not on the list of specialties where every claim hard-edits for it. But Indiana ABA is delivered on a physician's referral, so report the referring practitioner's NPI and check that they are enrolled in the IHCP (OPR Provider Search Tool) before services start.
Fee-for-service claims are due within 180 calendar days of the date of service (adjustments and administrative reviews within 60 days of the RA). Gainwell must adjudicate clean electronic claims within 21 days and paper within 30; the financial cycle runs every Friday and payment (check date or EFT deposit) follows on the Wednesday after.
Yes. Every ABA PA request, continuation included, must carry the behavior assessment’s complete scoring report “including outcome measure scores and graphs,” plus an updated treatment plan showing measurable progress on each goal. ABA bills under CPT 97151–97158, 0362T and 0373T with IHCP modifiers.
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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