Maryland Medicaid covers ABA for children under 21 through the EPSDT benefit under COMAR 10.09.28 — and its structure is the simplest in our directory once you see it: there is exactly one pipeline. ABA (like all specialty behavioral health) is carved OUT of the nine HealthChoice MCOs and paid fee-for-service by the state through its Behavioral Health Administrative Services Organization (BHASO), Carelon Behavioral Health of Maryland. Whatever MCO card the family carries — Aetna Better Health, Priority Partners, Kaiser, UnitedHealthcare Community Plan — every authorization and every claim goes to Carelon, never to the plan. One credentialing path, one UM vendor, one statewide fee schedule (refreshed February 1, 2026), zero MCO variation.
The MDH ABA Provider Manual states it directly: ABA services are covered and reimbursed by the Medical Assistance fee-for-service program through its BHASO, Carelon Behavioral Health. MDH's HealthChoice pages say the same thing from the other side — specialty behavioral health is carved out of managed care, and the state pays providers directly. The practical consequences for intake: never route an ABA eligibility or authorization question to an MCO (Aetna Better Health, Priority Partners, MedStar, Wellpoint, or any of the nine); run benefits checks against Medicaid eligibility and Carelon, not the plan on the card; and expect parents to be confused by this — the MCO card is what they hold, but for ABA it's irrelevant. Providers enroll with Maryland Medicaid via ePREP and then register with the BHASO — that single path covers the whole state. (Carelon replaced Optum Maryland as the ASO; anything still pointing at Optum Maryland is stale.)[1][15][17]
Maryland Medicaid ABA is governed by a short stack of documents. The regulations are COMAR 10.09.28 (Applied Behavioral Analysis Services), COMAR 10.09.36 (general provider participation) and COMAR 10.09.49 (telehealth), which the MDH ABA Provider Manual (effective February 1, 2026) names as its legal authority. The manual carries the enrollment, documentation, clinic and school rules and the fee schedule. MDH transmittals change the rules between manual editions: PT 42-26 (combination of services, H2012 retired) and PT 60-26 (the 25% in-person floor for telehealth-eligible codes from April 1, 2026). Carelon, the BHASO, publishes the working documents: the ABA Medically Necessary Criteria, the ABA Authorization Guide, the Authorization Grid, the state Treatment Plan Template with the Telehealth Readiness Checklist, the ABA Referral Form, the Clinical Confirmation Form and the PBHS Provider Manual. Commercial plans in Maryland follow a different rulebook: Insurance § 15-835 and COMAR 31.10.39 (see the Aetna, Cigna, UnitedHealthcare and CareFirst Maryland guides).[1][11][12][13][14][3][4]
Carelon's preauthorization criteria require all five of the following: the participant is under 21; has a DSM-5 ASD diagnosis from a QHCP (developmental pediatrician, pediatric neurologist, child psychiatrist, independently licensed clinical psychologist, pediatrician, neuropsychologist or nurse practitioner with ASD training); has "an ABA referral/recommendation no older than 6 months"; has maladaptive behaviors or skill deficits attributable to ASD causing significant impairment in personal care, psychological, vocational, educational or social functioning, or communication; and "can be adequately and safely maintained in their home environment" without needing a more intensive level of care. The manual states the same gate in fewer words: under 21, living in a home/community setting, with confirmed ASD, and referred by a QHCP. Carelon will not authorize vocational or recreational services, respite, custodial care, travel, other educational services, or anything that duplicates a service the child already gets from another program or in school.[1][11][12][13][14][3][4]
An old diagnosis is accepted. The CDE has no expiry date. The one exception is set by the Clinical Confirmation Form (CCF). Carelon's criteria and Authorization Guide say: "If the participant was diagnosed before age 3 and 1 month and it has been more than two years since the initial diagnosis," submit a CCF "along with a copy of the QHCP visit notes dated within the last six months from the date the form was completed." The CCF itself states the trigger as "younger than 3 years old at the time of ASD diagnosis AND two years or more have passed." On the CCF, a QHCP re-confirms the DSM-5 criteria after a face-to-face evaluation within the past six months. What does go stale is the referral: it must be no older than 6 months at the initial assessment request, whatever the age of the CDE. One more rule for a family switching agencies: if the child already has an active authorization with another ABA provider, a new initial assessment needs a Continuity of Care Form plus a parent or guardian note naming the change and the last day of services with the current provider.[1][11][12][13][14][3][4]
All ABA services require prior authorization from the BHASO — the assessment included. The gate before everything is the Comprehensive Diagnostic Evaluation (CDE): a QHCP (developmental pediatrician, pediatrician, pediatric neurologist, child psychiatrist, clinical psychologist, neuropsychologist, or nurse practitioner) must complete a CDE with direct observation, caregiver interview, and developmental history, confirming the ASD diagnosis and referring for ABA. Only then can a psychologist, BCBA-D, or BCBA complete the 97151 assessment and treatment plan. Treatment authorizations run a maximum of 180 days; every cycle requires a reassessment (capped at 12 units / 3 hours per request unless more is justified) and a new PA on the state's Treatment Plan Template — biopsychosocial information, skill-acquisition goals, a behavior intervention plan, parent goals, and generalization, fading, discharge, and crisis plans. Requesting telehealth for 97155, 97156, or 97157 requires the Telehealth Readiness Checklist. Auths submit through Carelon's ProviderConnect; claims go through Availity Essentials; the ABA line is (800) 888-1965.[1][2]
Two documentation rules to design intake around: depending on the child's age at diagnosis and how long ago it was made, Carelon may require a Clinical Confirmation Form from a QHCP confirming the child still meets ASD criteria — so capture the diagnosis date, not just the diagnosis. And services must be home/community-based: clinic delivery needs individualized justification under COMAR 10.09.28.05C, participants over 6 are expected to be in school with an IEP, an RBT/BT may not serve as a 1:1 school aide, and school-based ABA is short-term and clinically justified only.[1][2]
The manual effective February 1, 2026 carries the current statewide fee schedule, tiered by credential per 15-minute unit: 97151 assessment pays $38.34 (psychologist/BCBA-D/BCBA, daily max 32 units); 97153 direct treatment pays $24.41 at the BCBA tier, $20.91 BCaBA, and $19.17 RBT/BT (daily max 32 units); 97155 protocol modification pays $38.34 (daily max 24 units, GT modifier for remote direction of a technician); and 97156 parent training pays $20.91 without the child present versus $38.34 with the child present, billed 97156-U2 (daily max 16 units). Also on the schedule: 97152 at $19.17, group codes 97154/97158, family-group 97157 at $12.91, and 0362T/0373T at $52.28.[8][10][1][3]
Two structural changes landed with this schedule. H2012 (ABA treatment planning) was discontinued effective February 1, 2026 — treatment planning folds into 97151 and care coordination into 97156, with existing H2012 auths honored through their end dates. And PT 42-26 (ABA Transmittal No. 8) loosened the combination-of-services rules effective January 1, 2026: ABA may now be billed same-date with other behavioral health services except 96156/96158/96159 and ECT, and Carelon is auto-reprocessing previously denied combination claims — if you ate those denials in 2025, watch for the reprocess.[8][10][1][3]
The schedule carried into state fiscal year 2027 unchanged. Carelon's FY27 ABA Fee Schedule (headed "Updated 02/01/2026") lists the same rates, including 97153 at $24.41/$20.91/$19.17, 97151 and 97155 at $38.34, and 97156 at $20.91 (BCBA) or $12.21 (BCaBA) without the child and $38.34/$20.91 with the child (U2). Carelon's September 23, 2026 alert repeats that H2012 claims and authorization requests are administratively denied and the denials are not appealable. It also says treatment-planning work goes under 97155 and 97151, and coordination of care under 97156.[8][10][1][3]
Only ABA groups, psychologists, BCBA-Ds, and BCBAs can bill directly — BCaBAs, RBTs, and BTs render under them. Maryland has an unusual workforce on-ramp: Behavior Technicians can enroll in Medicaid before earning RBT certification (specialty code 325), with a 90-day grace period to submit RBT proof. Licensed psychologists may render and bill ABA with an attestation (40 coursework hours in behavior analysis plus 1,500 supervised hours including ASD experience). Supervision has a hard floor — direction of BCaBA/RBT/BT staff must equal at least 10% of technician direct-service hours, and remote direction requires MDH/BHASO approval. Telehealth (GT modifier) is allowed only for direct supervision (97155), parent training (97156/97156-U2), and group parent training (97157) — direct 97153 treatment is not on the telehealth list at all. And as of April 1, 2026, those three telehealth-eligible codes carry a new in-person floor: PT 60-26 ("ABA Transmittal No. 9," issued February 27, 2026) ends 100%-telehealth delivery for 97155, 97156/97156-U2, and 97157 — at least 25% of the service must now be rendered in person, with up to 75% allowed via telehealth, superseding the older PT 11-22 telehealth-continuation guidance. And Maryland is a payment-in-full program: providers may not balance-bill participants for covered or denied services.[1][4]
Maryland's defining staffing rule: every individual who renders ABA — psychologist, BCBA-D, BCBA, BCaBA, RBT, and even not-yet-certified BTs — enrolls with Maryland Medicaid individually through ePREP, on top of the group's own enrollment. The technician floor is codified in state regulation, not just BACB policy: under COMAR 10.09.28.02, an RBT must be 18 or older, hold current BACB registration, hold a high school diploma or national equivalent (a copy attaches to the ePREP application), and work under a documented supervisory relationship with a licensed psychologist, licensed BCBA-D, or licensed BCBA. There is no separate Maryland RBT license or state technician registry — the binding credential is BACB certification plus individual Medicaid enrollment. The pre-certification BT on-ramp (specialty code 325, license number 'BT', 90-day expiration) covered above has one hiring trap: the 90-day grace period attaches to the person, not your company — a BT who used part of it at a prior employer doesn't restart the clock with you. Underneath all of this sits the BACB's own floor: RBT applicants must pass a criminal background check and abuse-registry check within 180 days of paying for the certification application, confirmed by the RBT Supervisor or Requirements Coordinator, and effective January 1, 2026 the 40-hour training must follow the updated 2026 curriculum, delivered by active BCBAs/BCaBAs who've completed the BACB's 8-hour supervision training.[18][1][6][7][19][20][21][22][23]
Enrollment itself is moving. Maryland Medicaid is replacing ePREP with a new portal, MPRIME, scheduled to launch October 13, 2026. ePREP went read-only for the transition, with an application hold from August 1, 2026, and providers lose all access to ePREP documents on October 1, 2026 (PT 28-27), so download anything you need before then. A BT who earns RBT certification enrolls again under the new provider type RB with a copy of the certificate, and gets a new Medicaid ID when the BT ID ends. The deadline to do that in ePREP was July 31, 2026; after that the upgrade waits for MPRIME (PT 02-27). Plan any hiring that depends on new individual enrollments around the MPRIME launch.[18][1][6][7][19][20][21][22][23]
State screening runs through two instruments, and both are yours to manage. First, the CJIS criminal background check: COMAR 10.09.28.02 makes a completed Criminal Justice Information System background check a condition of participation for the group and each enrolled individual — it's completed as part of ePREP enrollment, using the CJIS Private Party Petition form from the Department of Public Safety and Correctional Services (DPSCS). There's no separate fingerprint clearance card system for ABA staff; fingerprint-based CHRC obligations attach to licensure applicants (behavior analysts), while unlicensed staff clear through Medicaid enrollment. Second, ongoing exclusion screening: the provider manual makes agencies responsible for OIG exclusion checks of ALL staff who touch the Medicaid program — direct service or administrative support — every 30 days, with documentation maintained; failure to screen is subject to disciplinary action. Enrolled providers must also be sanction-free — no current sanctions or disciplinary actions from licensing authorities, Medicare, Maryland Medical Assistance, or other federally funded programs.[18][1][6][7][19][20][21][22][23]
At the supervisor tier, Maryland has required licensure since January 2015: anyone practicing behavior analysis needs a Licensed Behavior Analyst (LBA) license from the Board of Professional Counselors and Therapists — current BCBA/BCBA-D certification, a master's or higher from a BACB-accredited/approved program, and a criminal history records check obtained before applying; the license renews every 2 years with a fresh CHRC at each renewal (and the board moves to online-only applications June 20, 2026). For Medicaid, supervisors need both the LBA license and current BACB certification (a licensed psychologist with the ABA attestation is the alternative). The supervision floors that bind your staffing model: direction of a technician (BCaBA/RBT/BT) must equal at least 10% of the technician's direct-service hours AND be performed in person at least 25% of the time (COMAR 10.09.28.04) — with remote direction requiring MDH or BHASO approval, and 0362T requiring the supervisor onsite. The BACB's 5%-monthly RBT supervision minimum (two face-to-face contacts, one individual) layers underneath. One structural mercy: because ABA runs through a single BHASO, there is no plan-by-plan credentialing — enroll each person via ePREP (applications reviewed by MDH, not the ASO), then register once with Carelon for ProviderConnect/Availity access; Carelon publishes no separate staff-credentialing standard beyond the state's, though it does require sentinel-event reporting (including any sexual activity between a staff member and a participant) within 24 hours.[18][1][6][7][19][20][21][22][23]
There is no separate network to be admitted to. The MDH ABA Provider Manual says "All ABA providers must first enroll with Maryland Medicaid to receive a Medicaid provider number and then must register with the BHASO" (Carelon), and calls a newly enrolled group "an in-network provider." Carelon's ABA page lists the same two steps: enroll in Maryland Medicaid, then register with Carelon. Groups and every individual — psychologist, BCBA-D, BCBA, BCaBA, RBT and BT — enroll. The catch right now is the enrollment system, not a network closure: Maryland Medicaid put ePREP on an application hold and read-only status for its replacement, MPRIME, cut all ePREP access on October 1, 2026, and scheduled MPRIME to launch October 13, 2026 (PT 28-27). New group or individual enrollments wait for MPRIME.[1][17][7]
Maryland licenses the practice: “an individual shall be licensed by the Board before the individual may practice behavior analysis in the State” (Health Occupations § 17-6A-10(a)). Section 17-6A-10 itself exempts only students in a qualifying unpaid clinical educational experience, so plan on a Maryland license before treating a child located in Maryland remotely.[24][25][26][9]
Maryland Medicaid writes the license into its ABA regulation: an ABA provider “shall be licensed, certified, or otherwise legally authorized to provide ABA services in the jurisdiction in which the services are provided,” and a BCBA who renders ABA must “Be licensed by the Maryland Board of Professional Counselors and Therapists” and hold current BACB certification (COMAR 10.09.28.02B and G). Telehealth does not loosen that: a telehealth provider must meet the same participation conditions, and distant-site providers “may render services via telehealth within the provider’s scope of practice” (COMAR 10.09.49.04). Carelon does not credential; providers enroll with Maryland Medicaid first, then register with Carelon.[24][25][26][9]
Every ABA code on the CPT list is payable under the Maryland benefit. Carelon’s Description of Services Codes (updated April 2026) and the fee schedule cover 97151, 97152, 97153, 97154, 97155 (and 97155-GT), 97156 (and 97156-U2), 97157, 97158, 0362T and 0373T, each with its own daily cap: 32 units for 97151, 97152, 97153 and 0362T; 24 for 97155 and 0373T; 16 for 97154 and each of 97156 and 97156-U2; 10 for 97157 and 97158. Four codes are payable only with clinical justification: 97152 (and at least 4 units of 97151 should be requested with it), 97154, 0362T and 0373T. 97158 is “Not utilized as supervision of 97154 for this benefit,” since 97154 is supervised through 97155.[28][1][10]
What is not payable: H2012 (treatment planning), discontinued February 1, 2026, with claims administratively denied and the denials not appealable; 97151 by telehealth, including reassessments; any code by telephone or mail; and travel, missed appointments, forms and reports, respite, custodial care, and vocational or recreational services. The fee schedule tiers rates by the rendering credential: 97153, for example, pays $24.41 for a BCBA, $20.91 for a BCaBA and $19.17 for an RBT or BT per unit.[28][1][10]
Timely filing is 12 months. Carelon’s PBHS manual (§16.04): “Claims must be submitted and received within 12 months of the earliest date of service on the claim,” on a rolling basis (COMAR 10.09.36.06B). A claim filed within 12 months and denied may be resubmitted with more information inside that window, “OR after the 12-month period, within 60 days of Carelon’s last received date or last rejected date.” When commercial insurance is primary, the limit is 120 days from the other carrier’s EOB or 12 months from the first date of service, whichever is later.[30][32][31][5][33]
Payment runs weekly. “Carelon issues provider payments on a weekly check run. Payments are released each Thursday (by check or EFT).” The manual sets no clean-claim day count of its own. The federal rule for state Medicaid agencies is 42 CFR 447.45(d): pay 90 percent of practitioners’ clean claims within 30 days of receipt and 99 percent within 90 days.[30][32][31][5][33]
To appeal a denied or underpaid claim, a “complete appeal request* must be received within 90 calendar days from the date of the payment determination being appealed,” on the Provider Claims Appeals form, mailed to Carelon Behavioral Health, Provider Claim Appeals, P.O. Box 1856, Hicksville, NY 11802 or faxed to 781-994-7636. Carelon acknowledges within five business days, decides within 30 calendar days of a complete request, and reprocesses an overturned claim within 30 calendar days of the decision. Submit one appeal per participant. A clinical denial (an authorization) is a different track: a peer-to-peer reconsideration by phone at 1-800-888-1965, decided within 24 hours or by the close of the next business day.[30][32][31][5][33]
Taxonomy: Carelon’s BHOMD 837P companion guide (October 2024) lists no taxonomy (PRV) segment among its requirements. Claims identify providers by billing NPI and rendering NPI, plus the referring practitioner’s NPI in Field 17b from July 1, 2026. EVV: no Maryland Medicaid ABA document mentions electronic visit verification. CMS’s February 2024 EVV compliance letter to Maryland covers “home health care services” under section 1905(a)(7) home health and section 1915(c) waivers. ABA is an EPSDT service under COMAR 10.09.28, so it is outside that list.[30][32][31][5][33]
CPT codes only. The FY27 ABA fee schedule (updated 02/01/2026) and the fee schedule in the ABA provider manual list 97151, 97152, 0362T, 97153, 97154, 97155 (GT for remote direction), 97156 (and 97156-U2), 97157, 97158 and 0373T, each in 15-minute units with its own provider tier and daily maximum. No HCPCS H-code appears on the schedule, so H0031, H0032, H2014 or H2019 are not billable for ABA in the Maryland ABA program.[8][1]
Yes, since April 1, 2026. Carelon’s May 2026 ABA FAQ: “As of 4/1/26 graphs are required for skill acquisition, behavior reduction and parent/caregiver goals,” and for the reassessment report, “Integrating graphics for all goals is required as of 4/1/2026. Data should clearly reflect the data collection method and the mastery criteria for each goal.” The FAQ points to the Maryland Medicaid treatment-plan template and instructions and to MDH’s 3.27.26 provider bulletin. A reauthorization assessment (97151) may be approved for up to 12 units, against up to 32 for an initial assessment.[9]
The questions that decide whether a family can start with Maryland Medicaid (Medical Assistance), and what they have to bring. Each maps onto something intake should ask on the first call.
Under 21. The manual states that since January 1, 2017 MDH covers medically necessary ABA “for Medicaid enrolled participants under the age of 21,” and that “ABA services are only available under the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program,” which itself runs to under 21. There is no lower age bound and no hour, dollar or lifetime cap on the benefit. One age-linked expectation rather than a limit: after 6 years old, participants should be in school with an IEP.[1]
No fixed expiry on the Comprehensive Diagnostic Evaluation, so an old CDE is accepted, with one defined exception. The manual defines the Clinical Confirmation Form (CCF) as “a form to be completed by a QHCP to confirm a participant continues to meet the criteria for Autism Spectrum Disorder.” Carelon's ABA Medically Necessary Criteria and Authorization Guide set the trigger: “If the participant was diagnosed before age 3 and 1 month and it has been more than two years since the initial diagnosis,” a CCF is required “along with a copy of the QHCP visit notes dated within the last six months.” The CCF form states it as younger than 3 at diagnosis AND two years or more since. It is needed at the initial assessment request and at initial and concurrent treatment requests. Separately, the ABA referral or recommendation must be no older than 6 months. Capture the diagnosis date, the child's age at diagnosis and the referral date at intake.[1][11][12][13]
A closed list of seven. The ASD diagnosis must be made by a qualified health care professional (QHCP) “with training and experience to diagnose ASD”: a developmental pediatrician, a pediatrician, a pediatric neurologist, a child psychiatrist, a clinical psychologist, a neuropsychologist, or a nurse practitioner. The ABA assessment that follows is a separate role and a separate credential — only a licensed psychologist, BCBA-D or BCBA may complete it and write the treatment plan.[1]
Maryland names no specific instrument. The manual requires the QHCP to diagnose “through the use of a comprehensive diagnostic evaluation (CDE) and with the help of validated instruments” without listing which, and then specifies the CDE by its components instead: a direct observation of the participant outlining behaviors consistent with DSM-5 criteria; interviews with the parent or caregiver; documentation of developmental history, psychosocial history and current functioning across major domains of development; and a statement identifying the presenting diagnosis (F84.0, F84.5, F84.8 or F84.9). Build intake around those four components rather than around a named tool.[1]
Required, and it is part of the CDE rather than a separate note. The QHCP's comprehensive diagnostic evaluation must result “in a referral for ABA therapy services,” and the BHASO “will only authorize ABA services if a QHCP completes a CDE and prescribes medically necessary ABA services.” Access to the benefit additionally requires that the participant be under 21, reside in a home/community setting and carry a confirmed ASD diagnosis. Carelon adds a freshness rule: the preauthorization criteria require “an ABA referral/recommendation no older than 6 months,” and the Authorization Guide asks for a “Recommendation, referral, or prescription (RX) for ABA” dated 6 months or less with the initial assessment request. Carelon's Maryland Medicaid ABA Referral Form must be completed by one of the seven QHCP types and records the referring provider's NPI. Carelon's May 2026 FAQ confirms the form is optional: “the QHCP may use their prescription pad, and/or may provide a letter or statement recommending ABA services,” as long as it is within 6 months of the request. From July 1, 2026 the referring practitioner also has to be a Maryland Medicaid provider. Under PT 76-26 (ABA Transmittal No. 10), “The referring provider must be enrolled as a Medicaid provider and active on the date of service,” the claim must carry “the NPI of an individual referring practitioner in the Referring Provider field (Field 17b),” and a group or facility NPI there makes the claim non-reimbursable. So a referral from a QHCP who is not enrolled with Maryland Medicaid will authorize nothing you can be paid for. Every ABA service is prior-authorized by Carelon — assessment included — and authorizations run a maximum of 180 days.[1][11][12][14][9][5]
A short list, and no longer a full-time option. Only three services may be rendered by two-way audio-visual telehealth: direct supervision of a BCaBA/RBT/BT (97155), parent training (97156 and 97156-U2) and group parent training (97157). Direct 97153 treatment is not on the telehealth list at all, and “services rendered by mail or telephone” are expressly non-billable, so audio-only is out. Bill with the GT modifier and Place of Service 11, and attach the Telehealth Readiness Checklist to the treatment plan — a required element for any 97155, 97156 or 97157 telehealth request since October 16, 2023. Effective April 1, 2026, PT 60-26 ends 100 percent telehealth delivery for those three codes: at least 25 percent must be rendered in person, with up to 75 percent by telehealth. Carelon's May 2026 FAQ says the 25 percent is measured “each month,” that exceptions are “reviewed on a case-by-case basis” by MDH, that telehealth also needs documented client consent, and that the 97151 assessment, reassessments included, “must be completed in person and does not allow for telehealth.” Telehealth that does not meet COMAR 10.09.49 may not be billed.[1][4][9]
Carelon, the state’s BHASO, decides every ABA request on its published clock: “Prospective - Non-Urgent … Within 7 calendar days” and “Prospective - Urgent … Within 72 hours (3 days),” while a non-urgent concurrent (continuing-care) request “reverts to prospective.” The operational rule is the submission lead time: Carelon’s Authorization Grid asks for ABA initial and concurrent requests “30 CD in advance,” with backdating tolerated only as an exception, up to 20 calendar days. Authorizations run a maximum of 180 days, and a reassessment plus a new PA is required before each one ends — so put the reauth packet on the calendar a month ahead of expiry. One discrepancy to know about: the grid (turnaround section last revised 8/14/25) still lists ABA turnaround as “14 CD”; the PBHS manual’s 7-calendar-day rule is newer (Chapter 5 revised August 2026) and matches the federal standard for state Medicaid agencies since January 1, 2026 (42 CFR 440.230(e)).[30][35][1][36]
“Medicaid is always the payer of last resort.” Verify other coverage in EVS at intake. When commercial insurance is primary: “Submit the claim to the commercial carrier first and within the commercial carrier’s timely filing requirements,” then submit to Carelon “within 12 months of the first date of service or 120 days of the commercial carrier’s EOB, whichever is later,” with the primary payment or EOB attached — claims without it deny (“Primary insurance information or EOB required”). Maryland’s big simplifier: “Preauthorization is not required when Carelon is paying as secondary.” Carelon pays the difference between the commercial payment and the Medicaid allowed amount, and the family may not be billed for the gap between charges and what the two payers paid.[30]
Coverage decides whether Maryland Medicaid (Medical Assistance) 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.
Direction of a BCaBA, RBT or BT with protocol modification is performed by a psychologist, BCBA-D or BCBA and “must be performed on an ongoing basis, equal to at least 10 percent of the amount of hours that the BCaBA, RBT, or BT is providing direct ABA services to the participant, or group of participants.” COMAR 10.09.28.04 adds that at least 25 percent of that direction be performed in person, and remote direction requires approval from MDH or the BHASO. For 0362T and 0373T the psychologist/BCBA-D/BCBA must be onsite — defined on the fee schedule as “immediately available and interruptible to provide assistance and direction.” Every rendering individual, technicians included, must also be enrolled with Maryland Medicaid through ePREP. Neither the ABA provider manual nor Carelon’s May 2026 ABA FAQ caps how many technicians one BCBA may supervise; the binding numbers are the 10 percent direction floor and the 25 percent in-person share.[9][1][19]
Published code by code. Carelon’s Description of Services Codes (updated April 2026) says 97153 “Can be billed concurrently with 97155 or 97156” and 97155 “Can be billed concurrently with 97153,” so supervision during a technician session pays for both. The pairs that cannot overlap: “97156-U2 cannot be billed concurrently with 97153” (97156 without U2 can), “0373T cannot be billed concurrently with 97155,” and “0362T cannot be billed concurrently with 97155.” The May 2026 FAQ adds that 97151 “can occur simultaneously with 97153, provided there are distinct qualified health professionals rendering both services.” Same-date limits sit in MDH’s Combination of Services Review (revised February 2026): in-person 97155 and remote 97155-GT “cannot be billed together on the same date of service”; no ABA code may be billed on the same date as 96156/96158/96159; and 97153, 97154, 97155, 97156, 97157 and 97158 also exclude 90870 (ECT). Each code is limited to “one rendering provider and one location per day unless otherwise stated,” and 97153 allows up to three rendering providers a day within its 32-unit cap.[28][29][9][3]
Maryland publishes an explicit per-day unit ceiling on every ABA code, in the fee schedule at the back of the provider manual (15-minute units): 97151, 97152, 0362T and 97153 at 32 units per day; 97155 and 0373T at 24; 97154 and 97156/97156-U2 at 16; 97157 and 97158 at 10. Group codes carry their own size limits — 97154 and 97158 are limited to 2–8 ABA participants, 97157 to 2–8 families. The reassessment is separately capped: a maximum of 12 units (three hours) authorized per treatment request, with more available if the standard 12 are used before the end of the authorization for clinical need. Carelon's May 2026 FAQ adds two working rules: the 97153 ceiling is per child, not per technician (“Up to three different providers can deliver services under code 97153, but the combined total for all providers should not exceed 32 units (8 hours) in a single day”), and 97151 for an initial assessment “may be approved for up to 32 units per authorization period,” against up to 12 for a reauthorization. The FY27 fee schedule carries the same daily maximums.[1][9][8]
The manual lists what each service note must contain and closes it with the signature rule: “a legible signature, along with the printed or typed name of the individual providing care, with the appropriate title.” The rest of the required record is consent to treatment from the participant or parent/guardian; the location, date, start time and end time of the service; a brief description of the service with reference to the treatment plan; a description of the participant's behaviors or symptoms in measurable terms; and a description of the parent or caregiver's participation including their name, relationship, date and time — or documented consent to be absent. No co-signature requirement and no signing deadline are stated, and services “rendered but not documented in accordance with COMAR 10.09.28.04” may not be billed.[1][19]
Home and community first. Under COMAR 10.09.28.05C “ABA services shall be delivered in a home or community setting, including a clinic, when medically necessary,” and a clinic-based request must carry an individualized rationale, a plan for transitioning care into the home/community, the objectives targeted in each setting, a description of caregiver involvement, and the anticipated schedule of hours across settings. School is narrower still: it “is not the standard model of the Maryland Medicaid ABA benefit,” is short-term and must be clinically justified, an RBT/BT “may not serve as a 1:1 educational aide,” and the plan needs an observation narrative, a fading plan, evidence of no duplication and a copy of the IEP. After age 6 participants should be in school with an IEP. Not payable anywhere: services in a 24-hour, 365-day residential program funded with federal, State or local government funds; vocationally- or recreationally-based services; respite; and travel to and from the site of service.[1]
The Program reimburses only an ABA group or an individual ABA provider — psychologist, BCBA-D or BCBA. “BCaBAs, RBTs and BTs rendering ABA services cannot bill directly to the Maryland Medical Assistance Program and receive reimbursement,” so technician-delivered 97153 goes out under the enrolled group or supervising analyst. Claims bill on the CMS-1500 or the 837P and go to the BHASO, not to the participant's HealthChoice MCO. Every rendering individual still enrolls with Maryland Medicaid separately (ePREP until it closes; MPRIME from its October 13, 2026 launch), including not-yet-certified BTs on specialty code 325. For dates of service from July 1, 2026, the claim must also carry the referring practitioner’s individual NPI in Field 17b, and that practitioner must be actively enrolled with Maryland Medicaid on the date of service, or the claim is denied (PT 76-26). Carelon’s PBHS manual (§16.03) separates the two NPIs: “All claims must include a billing NPI,” which “identifies the facility, group or individual provider receiving payment,” while “The rendering NPI identifies the individual practitioner providing the service within a group.” The multi-staff codes are the exception to individual rendering: for 0362T and 0373T, “This is an all-inclusive code. Billing is done under the NPI of the highest certification for ALL QHCPs involved,” with the technicians’ presence recorded in the session note.[1][30][28][18][5][7]
Yes — for children under 21 with a confirmed ASD diagnosis, under the EPSDT benefit (COMAR 10.09.28). Every ABA service requires prior authorization from Carelon Behavioral Health, the state's BHASO, with authorizations running up to 180 days.
None of them. ABA is carved out of all nine HealthChoice MCOs and paid fee-for-service through Carelon. Authorizations go through ProviderConnect, claims through Availity — the MCO on the family's card never touches ABA.
Per the fee schedule effective February 1, 2026: 97153 direct treatment pays $24.41/15-min unit at the BCBA tier, $20.91 BCaBA, $19.17 RBT/BT; 97151 assessment and 97155 pay $38.34; 97156 parent training pays $20.91 without the child present or $38.34 with (billed 97156-U2).
Yes — a confirmed ASD diagnosis (F84.0, F84.5, F84.8, or F84.9) made through a Comprehensive Diagnostic Evaluation by a qualified health care provider, plus a referral. Depending on the child's age at diagnosis and time elapsed, a Clinical Confirmation Form may also be required.
COMAR 10.09.28 (ABA services), 10.09.36 (provider participation) and 10.09.49 (telehealth); the MDH ABA Provider Manual (eff. Feb 1, 2026) with its fee schedule; MDH transmittals PT 42-26 and PT 60-26; and Carelon's ABA Medically Necessary Criteria, Authorization Guide, Treatment Plan Template, Referral Form and Clinical Confirmation Form. Commercial plans follow Insurance § 15-835 and COMAR 31.10.39 instead.
A Medicaid participant under 21, with a DSM-5 ASD diagnosis from a QHCP, an ABA referral no older than 6 months, maladaptive behaviors or skill deficits from ASD that significantly impair functioning, and who can be safely maintained at home without a more intensive level of care. Services must be home/community-based (clinic needs justification).
Yes. The CDE must result in a referral for ABA from a QHCP, and Carelon requires the referral or recommendation to be no older than 6 months when the initial assessment is requested. Carelon publishes a Maryland Medicaid ABA Referral Form for it.
Yes. The CDE does not expire. The exception: if the child was diagnosed before age 3 years 1 month and more than two years have passed, Carelon requires a Clinical Confirmation Form from a QHCP plus visit notes from the last six months. The referral, unlike the CDE, must be 6 months old or less.
Yes, and the child does not have to be discharged first. Carelon's May 2026 FAQ: "Participants can obtain authorization from an initial assessment while still receiving services from their current provider. The Continuity of Care Form will be required along with a parent/guardian note." The Authorization Guide asks that the note name the change of ABA providers and the last day of services with the current provider, sent to MDH.ABACareCoordinatorsFAX@carelon.com or by phone at 1-800-888-1965. If the first agency has already stopped services, there should be a discharge report or date on file; if the system still shows its authorization as active, the parent's note serves as the request to amend it.
Yes, for dates of service from July 1, 2026. PT 76-26 says the referring practitioner "must be enrolled as a Medicaid provider and active on the date of service," and every ABA claim must carry that individual's NPI in Field 17b; a group or facility NPI there, or an unenrolled referrer, gets the claim denied. Check the referrer in the Provider Verification System at intake.
Not for 97155 (RBT/BCaBA/BT supervision), 97156/97156-U2 (parent training), or 97157 (group parent training) — effective April 1, 2026, PT 60-26 ("ABA Transmittal No. 9") requires at least 25% of those three services to be rendered in person, with up to 75% allowed via telehealth. Direct 97153 treatment was never on the telehealth list at all.
Yes, there is no closed network: enroll with Maryland Medicaid, then register with Carelon. But new enrollments are waiting on the system change: ePREP is closed (access ended October 1, 2026) and the new portal, MPRIME, is scheduled to open October 13, 2026.
Maryland requires a Maryland license to practice behavior analysis (Health Occupations § 17-6A-10). Maryland Medicaid requires a rendering BCBA to be licensed by the Maryland Board of Professional Counselors and Therapists (COMAR 10.09.28.02G).
No ABA code is excluded outright. Carelon’s April 2026 code descriptions cover 97151–97158, 0362T and 0373T. 97152, 97154, 0362T and 0373T need clinical justification, and each code has a daily cap: 97152 is capped at 32 units (8 hours) a day, the same as 97151, 97153 and 0362T. H2012 is discontinued and its denials are not appealable. 97151 cannot be done by telehealth. 97158 cannot be used to supervise 97154; use 97155 for that. Rates are tiered by credential (for 97153: BCBA $24.41, BCaBA $20.91, RBT/BT $19.17 per unit).
97156-U2 (parent training with the child present) cannot be billed at the same time as 97153. 0362T and 0373T cannot be billed at the same time as 97155. In-person 97155 and remote 97155-GT cannot both be billed on the same date. 97153 can be billed concurrently with 97155 or with 97156 without U2. 97151 may run at the same time as 97153 if a different professional renders each one. No ABA code may be billed on the same date as 96156, 96158 or 96159 (Carelon code descriptions, April 2026; MDH Combination of Services Review, February 2026).
Twelve months from the earliest date of service on the claim (Carelon PBHS manual §16.04). A denied claim filed on time can be resubmitted within that window, or within 60 days of Carelon’s last received or rejected date after it. When commercial insurance is primary: 120 days from that carrier’s EOB or 12 months from the first date of service, whichever is later.
File a complete Provider Claims Appeals request within 90 calendar days of the payment determination. Mail it to Carelon Behavioral Health, Provider Claim Appeals, P.O. Box 1856, Hicksville, NY 11802, or fax it to 781-994-7636. Carelon decides within 30 calendar days and reprocesses an overturned claim within 30 days after that. An authorization denied for medical necessity goes to peer-to-peer reconsideration at 1-800-888-1965 instead.
No Maryland Medicaid ABA document requires it. The ABA provider manual, Carelon’s PBHS manual and the ABA FAQ do not mention electronic visit verification. CMS’s 2024 EVV compliance letter to Maryland covers home health services and 1915(c) waiver services, and ABA is an EPSDT service.
Carelon’s BHOMD 837P companion guide (October 2024) does not list one. What the claim must carry is a billing NPI, the rendering NPI of the practitioner within the group, and, for dates of service from July 1, 2026, the enrolled referring practitioner’s individual NPI in Field 17b.
Only a short backdate. Carelon’s May 2026 FAQ: “Carelon allows backdating of ABA authorizations up to 20 calendar days.” COMAR 10.09.28.04 covers ABA only when “Preauthorized by the Program or its designee.” No authorization is needed when Maryland Medicaid is the secondary payer.
No. The Maryland ABA fee schedule lists only CPT 97151–97158, 0362T and 0373T (97156 also with U2), billed in 15-minute units.
Yes. Since April 1, 2026, Carelon requires graphs for every skill-acquisition, behavior-reduction and parent/caregiver goal in the treatment plan and reassessment, showing the data collection method and mastery criteria for each goal.
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.
Carelu collects all of this automatically.
Every ID, document, and detail this payer requires — gathered conversationally the moment a family reaches out, with insurance verified before your team touches the file.
Get a Demo