---
title: "MassHealth (Massachusetts Medicaid) ABA coverage: the intake guide."
url: "https://carelu.com/payers/masshealth-massachusetts-medicaid"
markdown_url: "https://carelu.com/payers/masshealth-massachusetts-medicaid.md"
state: MA (Massachusetts)
payer: MassHealth (Massachusetts Medicaid)
kind: State Medicaid program
description: "How MassHealth covers ABA under EPSDT — the six behavioral-health administrators (MBHP, Carelon, Tufts, Optum), the Massachusetts Standard ABA PA Form, 101 CMR 358 rates and the 2026 rate freeze, the 1:10 supervision audit, and the new Down syndrome pathway."
last_reviewed: October 2026
vob_data_updated: 2026-10-15
---

# MassHealth (Massachusetts Medicaid) ABA coverage: the intake guide.

_Payer Guide · MassHealth · Last updated October 2026 · 25 primary sources_

> EPSDT under 21, no caps, 100% managed-care ABA via six BH administrators; 1:10 audit live.

MassHealth covers ABA for members under 21 through the EPSDT benefit — with no annual or lifetime dollar or unit caps — and administers it entirely through managed care. There is no fee-for-service ABA front door: MassHealth sets the rates (101 CMR 358) and the benefit is authorized by several behavioral-health administrators across the plan landscape — MBHP (a Carelon company), Carelon itself for Fallon's plans, WellSense's own in-house BH team (since it insourced from Carelon effective January 1, 2026), Tufts Health Together's internal UM, and Optum for Mass General Brigham Health Plan. Which administrator a family's plan routes to is the first fact intake needs, because it decides the form, the portal, and — as of 2026 — how hard the state's 1:10 supervision-ratio audit lands on your claims.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — the MA Standard ABA PA Form has a distinct "Request for initial evaluation"; PA is required for all ABA services/hours/units [4]
- **Prior auth for treatment**: Required — all treatment hours/units; continued-service authorizations in up to 6-month periods, submitted to the member's plan's BH administrator [4]
- **Autism diagnosis required?**: Yes — ASD via a comprehensive DSM-aligned assessment by a qualified licensed diagnostician; from 1/1/2026 also sole-diagnosis Down syndrome (genetic-testing confirmed) [4][5][17]

## At a glance

- **Covers ABA?:** Yes — under 21 (Standard/CommonHealth) via EPSDT; under 19 on Family Assistance
- **Annual limit:** None — no dollar or unit-of-service caps; EPSDT medical necessity governs
- **Prior auth:** Required for all ABA services/hours/units — assessment and treatment alike
- **Auth periods:** Up to 6 months (standard form); initial-evaluation requests may cover 3 months
- **Rates (per 15 min):** 97153 $16.37 · 97151/97155/97156 $30.73 · 97154 $13.91 (101 CMR 358)
- **Administered by:** MBHP, Carelon (Fallon), WellSense in-house (since 1/1/2026, was Carelon), Tufts internal UM, Optum (MGB)
- **Supervision watch:** CY2024 audit enforces a 1:10 97155:97153 floor — recoupment letters issued Feb–Mar 2026
- **Staff screening:** RBT not required (3 BT pathways); plan-level BRC + 262 CMR 8.04 employer checks — no blanket state CORI mandate

## Coverage & benefit

ABA is an EPSDT service for MassHealth Standard and CommonHealth members under 21 (under 19 on Family Assistance), with coverage driven by medical necessity — no annual or lifetime dollar caps, no unit-of-service limits. Historically the diagnosis gate was autism: a comprehensive assessment aligned with DSM criteria across the core ASD deficits, completed by a licensed physician, APRN, physician assistant, or psychologist experienced in ASD diagnosis and treatment. Effective January 1, 2026, Chapter 388 of the Acts of 2024 opens a second pathway: ABA for a primary, sole diagnosis of Down syndrome (Trisomy 21) confirmed by genetic testing — the standard PA form already carries the Down syndrome checkbox. One boundary for the youngest referrals: ABA cannot duplicate services the child already receives through Early Intervention. [5][17][4]

## Six administrators, one benefit

MassHealth managed care is a lattice of 15 Accountable Care Partnership Plans, 2 Primary Care ACOs, 2 MCOs, and the PCC Plan (roster per the April 2023 state deck; the current lineup — including Steward Health Choice's status after Steward's collapse, and the Tufts Health Together MCO's discontinuation effective 1/1/2026 — should be re-verified). What matters operationally is who authorizes ABA: PCC Plan, Primary Care ACO, and Health New England BeHealthy members route to MBHP; Fallon's ACPPs route to Carelon; WellSense's plans (Essential MCO + 8 ACPPs) administer ABA in-house as of January 1, 2026, having insourced from Carelon; Tufts Health Together runs its own internal UM; and Mass General Brigham Health Plan routes to Optum. Nearly all of them use the multi-payer Massachusetts Standard ABA PA Form — request types for initial evaluation, initial services, continued services, and amendments; the form says the BCBA rendering and/or supervising the services "should" complete it, while the requirement that the analyst be a LABA licensed under 262 CMR 10.00 comes from the Carelon/MBHP performance specification, not the form — with continued authorizations capped at 6 months. The one defector: as of October 2025, Tufts Health Together uses Point32Health's own updated ABA PA form instead of the state standard form — so "which plan?" also decides "which form?". Confirmed as of this review: Point32Health's own 2026 Public Plans Provider Manual (Behavioral Health chapter) describes Tufts Health Public Plans' behavioral-health team running BH clinical review, PA, and medical-necessity determinations entirely in-house — no mention anywhere of Carelon, Optum, Beacon, or any external BH vendor for Tufts — corroborating the internal-UM claim with a second, independent Point32Health document. [6][4][18][19][11]

## The 1:10 supervision audit — active enforcement risk

MassHealth audited CY2024 encounter data across all six ABA-administering plans and, via Carelon, issued recoupment letters in February–March 2026 enforcing a minimum 1:10 supervision ratio — one hour of protocol modification (97155) for every ten hours of direct treatment (97153). Ratios of 10:1 to 19:1 drew partial recoupment; 20:1 and beyond drew full recoupment of direct-service payments. A provider coalition (MPAAQ, MassABA, BABAT) is disputing the methodology and litigation has been threatened — but until that resolves, treat 1:10 as the operating floor. The intake and staffing implication is concrete: every ten hours of weekly 97153 you promise a family carries an hour of BCBA/LABA supervision your schedule must actually deliver, so capacity planning — not just authorization — is what keeps the revenue. [7]

## Rates: single-tier, and frozen

101 CMR 358.03 pays a single rate per code — no credential-tier modifiers; each rate is "full compensation" including necessary administration and professional supervision. Per 15-minute unit: 97151, 97155, and 97156 at $30.73; 97153 at $16.37 (about $65.48/hour); 97154 at $13.91; 97157 at $26.12 — effective September 27, 2024 (published as the October 1, 2024 schedule). Confirmed directly against EOHHS's own filing (accessed 10/1/2026): EOHHS filed a proposed re-adoption of 101 CMR 358.00 on May 22, 2026, held a remote public hearing on June 17, 2026, and both the proposed regulation text and the staff testimony state the same conclusion verbatim — "the proposed amendments maintain all rates established in 101 CMR 358.00 at their existing levels," for dates of service on or after December 1, 2026. As of this review the regulation is still in proposed/hearing-record status (no final-adoption notice for the 12/1/2026 cycle was located) — a rate freeze some providers are contesting, noting 97153 at ~$65/hour trails states like Arizona (~$88) and Maryland (~$83) per a secondary tracker; MCEs generally pay at or near this schedule, but plan contracts govern — whether a given plan pays exactly the schedule is a contracting question, not a lookup. [2][9][10][8]

## Staffing & credentialing: who you can hire, and what they must clear

Massachusetts does not require RBT certification for technicians — and has no state registry or license for them. Under the Carelon/MBHP ABA performance specification (updated February 15, 2026), a Behavior Technician must be 18 or older, work under the direct supervision of a Licensed Applied Behavior Analyst (LABA), and meet one of three pathways: a high school diploma or GED plus 12 months' experience with people with developmental disabilities, children, or families; an associate's degree in a human, social, or educational services discipline plus 6 months' experience; or BACB RBT certification plus 3 months' experience. That first pathway makes the MassHealth hiring pool meaningfully wider than in RBT-mandate states. Techs hired via the RBT route still carry the BACB's own floor: the 40-hour training, competency assessment, exam ($65 BACB + $45 Pearson VUE in 2026), and — often missed — a BACB-required criminal background check plus abuse-registry check passed no more than 180 days before the application, confirmed by an independent Attesting Certificant. [11][12][13][14][15][16]

On background checks, know where the obligation actually comes from: Massachusetts CORI checks are not state-mandated for MassHealth ABA providers. 101 CMR 15.03 requires CORI only for EOHHS, its agencies, and vendor programs, and expressly states that MassHealth providers are not subject to it solely by virtue of their status (an agency that also holds a DDS/DCF purchase-of-service contract does fall within the mandatory scope, and EOHHS retains discretion to consider CORI in participation decisions). The binding checks sit elsewhere: the Carelon/MBHP spec requires the ABA provider to ensure all staff have received a background record check (BRC); 262 CMR 8.04 obligates LABAs who employ unlicensed paraprofessionals to conduct criminal background checks and makes them professionally responsible for those staff's clinical oversight; and 42 CFR 455.436 federal exclusion screening (OIG LEIE and SAM, checked at enrollment and no less than monthly) is the floor most agencies mirror with monthly staff screening. [11][12][13][14][15][16]

Supervisors must hold the state license — the MBHP spec requires the supervising analyst to be licensed per 262 CMR 10.00, so a BCBA certificate alone does not satisfy the credentialed-team definition. LABA licensure (262 CMR 10.03) takes a qualifying graduate degree, supervised fieldwork (1,500 hours independent / 1,000 practicum / 750 intensive practicum), and the Board-approved exam; assistant-level LAABAs (262 CMR 10.04) must receive at least one hour per month of individual face-to-face supervision from a LABA, who must approve all treatment plans before treatment. The staffing ratio that binds capacity is the spec's supervision band: LABA supervision at no less than 10% of Behavior Technician direct-service hours (not above 25% without documented clinical rationale; minimum one hour per month for members with 10 or fewer direct hours) — and per the CY2024 audit, falling below 10% drew partial recoupment while falling below 5% drew full recoupment of direct-service payments. Round it out with the spec's hire-plus-annual staff training across 16 enumerated topics and its bar on staff having any pre-existing non-clinical relationship with the member. [11][12][13][14][15][16]

## What happens when a family switches ABA providers?

MassHealth publishes no rule on whether an existing ABA authorization follows the child to a new agency, so ask the member's behavioral-health administrator before the switch. What the Carelon/MBHP ABA performance specification does set is the handoff. The agency the family is leaving keeps a transition plan that names the planned discharge setting, schedules a discharge planning meeting when the family "no longer wants the service," and must "include an up-to-date copy of the treatment plan, which is given to the caregiver/guardian on the last date of service and to all current providers within seven days of the last date of service." If services end unplanned, it "makes every effort to contact the parent/caregiver" and to "provide appropriate referrals." On the receiving side, a provider that cannot start within 14 days of authorization must keep a waitlist and "offer caregivers contact information for alternative providers in the region who are accepting new clients," and once an initial authorization is approved it must offer the family a face-to-face interview within two business days. [11]

## What is MassHealth’s timely filing limit?

For claims billed to MassHealth directly, 90 days: “all claims must be received by the MassHealth agency within 90 days from the date of service or the date of the explanation of benefits from another insurer,” measured from the latest date when a service runs on consecutive dates (130 CMR 450.309, under M.G.L. c. 118E, § 38). Late claims that fit a listed exception need a 90-day waiver request, submitted electronically. Members whose ABA runs through MBHP or a managed care plan follow that administrator’s filing limit. [22]

## How fast does MassHealth pay a clean claim?

For claims MassHealth pays directly, the federal rule sets the clock: the agency “must pay 90 percent of all clean claims from practitioners, who are in individual or group practice or who practice in shared health facilities, within 30 days of the date of receipt,” 99 percent within 90 days, and all other claims within 12 months of receipt (42 CFR 447.45(d)). Most ABA members are enrolled with an ACO, MCO or MBHP, and each of those plans pays on its own schedule: WellSense aims for 30 calendar days and states that there is no late-payment penalty on MassHealth claims, Tufts Health Together sends a weekly explanation of payment, and Carelon’s documents for Fallon publish no day count. See each plan’s guide. [23]

## Which codes does MassHealth pay for ABA? (H0031 and other H-codes)

The rate regulation is the code list. 101 CMR 358.03(3) prices seven codes: 97151, 97153, 97154, 97155, 97156, 97157, and one HCPCS code, H0031-U2 (“Mental health assessment by physician or other qualified health professional (Assessment and case planning for home services by a licensed professional. 15-minute rate.)”), at $30.73 a unit. 97152, 97158, 0362T, 0373T and H0032 carry no MassHealth rate. The proposed re-adoption filed May 22, 2026 for dates of service from December 1, 2026 keeps the same seven codes and the same rates; the mass.gov regulation page still showed the 10/01/2024 version on October 18, 2026. Each managed care plan’s own code list governs its members (Tufts Health Together, for example, lists H0031 for BCBA assessment and treatment planning). [2][9]

## Intake gates

The questions that decide whether a family can start with MassHealth (Massachusetts Medicaid), and what they have to bring.

- **Age limit**: EPSDT sets the bound, and nothing else does. ABA is covered for MassHealth Standard and CommonHealth members under 21, and for Family Assistance members under 19 — with no lower age bound and no dollar, visit or unit-of-service cap underneath it. For the youngest referrals the binding rule is non-duplication rather than age: ABA cannot duplicate services the child already receives through Early Intervention. From 1/1/2026 the second diagnostic pathway (sole-diagnosis Down syndrome) rides the same age structure. [5][17]
- **Who may diagnose**: The standard form names them, and the list is broader than "send them to a developmental pediatrician." For autism it requires "A comprehensive assessment completed by a licensed physician (i.e. PCP, etc.), advanced practice registered nurse, physician's assistant, or psychologist experienced in the diagnosis and treatment of ASD with developmental or child/adolescent experience which aligns with DSM criteria across ASD core deficits." For the 1/1/2026 pathway it requires instead "A diagnosis of Down Syndrome (Trisomy 21) confirmed by genetic testing." Note the two signatures are different people: the diagnostician writes the assessment, while the form itself "should" be completed by the BCBA rendering and/or supervising the services — an analyst the performance specification requires to be a LABA licensed under 262 CMR 10.00. [4][11]
- **Diagnostic tools required**: No instrument is mandated. The standard form requires a comprehensive assessment "which aligns with DSM criteria across ASD core deficits" without naming ADOS-2, ADI-R, CARS-2 or any other tool, and the performance specification names no diagnostic battery either; the Down syndrome pathway replaces the instrument question entirely with genetic testing. Massachusetts puts its measurement requirement downstream of intake instead — in progress documentation and medical-necessity review, not in the diagnostic gate. [4][11]
- **Referral required?**: No referral and no physician order is a condition of authorization. The Massachusetts Standard ABA PA Form has no referral field and is completed by the rendering or supervising BCBA/LABA, and the performance specification's referral language is about timeliness rather than permission: "Fourteen calendar days from referral is the Medicaid standard of timely provision for services established in accordance with 42 CFR 441.56(e)," with a waitlist duty (and an obligation to hand caregivers other regional providers' contact information) where the provider cannot start inside it. What the state does require is PCP evidence in the chart rather than at the door: the complete medical record must hold "Referral and assessment documentation" and "Documentation confirming physical examinations by a PCP," and the continued-services pages ask for a dated primary-care care-coordination entry. [11][4]
- **Telehealth**: Every ABA code may be delivered by telehealth, including the 97151 assessment and 97155 supervision, under two layers. Clinical layer: the ABA provider "may deliver services and consultation via a Health Insurance Portability and Accessibility Act (HIPAA)-compliant telehealth platform at the parent/caregiver's request and if the service can be effectively delivered via telehealth as part of the intervention when appropriate," with the rationale documented and the documentation reflecting "clinical considerations for appropriateness across any service components being delivered via telehealth." Two guardrails ride along: telehealth "must not replace in-person availability," and the member or family "may rescind consent for telehealth at any time without risk of interruption of services." The billing layer is statewide. MassHealth All Provider Bulletin 379 (October 2023) lets a provider deliver any MassHealth-covered service by live video, audio-only or asynchronous telehealth when it is clinically appropriate and the member consents; the only exclusions are listed categories such as ambulance, surgery, laboratory, radiology, dialysis and personal care, and ABA is not among them. So the 97151 assessment and 97155 protocol modification (the BCBA/LABA supervision code) are telehealth-eligible like every other ABA code. Payment is at parity with in-person. Professional claims carry POS 02 (not in the patient's home) or POS 10 (in the home), plus modifier 95 for audio-video or 93 for audio-only, and FR "to indicate a supervising practitioner was present through a real-time two-way, audio and video communication technology." Managed Care Entity Bulletin 115 (April 2024) requires every ACPP, MCO and MassHealth's behavioral-health vendor to keep a telehealth policy "no more restrictive than" Bulletin 379. Neither bulletin nor the ABA specification sets a minimum share of supervision that must be in person. [11][20][21]
  - Ask the plan: Whether the member's BH administrator adds its own documentation or authorization steps for telehealth hours — under MCE Bulletin 115 a plan may be more generous than Bulletin 379, not stricter.
- **Prior-auth decision time**: The managed-care clock is the one that governs, because MassHealth has no fee-for-service ABA front door. Every request goes to the member's BH administrator, and federal law sets its deadline. For rating periods that start on or after January 1, 2026, a standard decision is due "as expeditiously as the enrollee's condition requires" and within state-set timeframes that "may not exceed 7 calendar days after receiving the request for service" (it was 14 before 2026). That can be extended "up to 14 additional calendar days" if the family or provider asks, or if the plan justifies needing more information. An expedited decision is due "no later than 72 hours after receipt of the request for service." Expedited applies when the provider indicates that the standard clock "could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum function." MassHealth's administrators have adopted this. WellSense moved standard decisions to "seven calendar days (previously 14 days)" on 1/1/2026 with 72 hours for expedited. Carelon's Massachusetts addendum lists 7 calendar days for standard MassHealth pre-service and concurrent requests and 72 hours for urgent ones, counted "from request." MassHealth's own fee-for-service rule, 130 CMR 450.303, still prints 21 calendar days for "all other MassHealth services." That clock starts when a request "conforms to all applicable submission requirements," and the provider gets four calendar days to fix a deficient one. From 1/1/2026, however, federal law caps state fee-for-service decisions at 7 calendar days (standard) and 72 hours (expedited) unless state law is shorter. No reauthorization lead time is set statewide. The standard form only sets request windows: up to 3 months for an initial request and 6 months for continued services. Each administrator sets its own lead time. Tufts, for example, asks for PA requests at least five business days before the service. [26][27][28][29][30][4]
  - Ask the plan: The reauthorization lead time the member's BH administrator expects: MBHP/Carelon via ProviderConnect, WellSense, Point32Health for Tufts, or Optum for Mass General Brigham.
- **Other insurance (who pays first)**: MassHealth pays last. Under federal law Medicaid is the payer of last resort. When other coverage is known, the agency "must reject the claim and return it to the provider" to bill the other payer first (42 CFR 433.139). MassHealth's rule puts the work on the provider. Under 130 CMR 450.316, "diligent efforts" mean asking the family about other insurance and checking EVS on each date of service, "submitting claims to all insurers," and "complying with the insurer's billing and authorization requirements." If the primary denies for "failure to obtain prior authorization" or for "providing services outside the service network," MassHealth treats that as a failure of diligent efforts. MassHealth also pays nothing if the provider "did not participate in the member's other health insurance plan." A claim for a service another insurer may cover is denied "unless the claim is accompanied by a final disposition from each insurer" (450.317(D)). MassHealth then pays no more than the member's remaining copay, coinsurance and deductible, capped at its own rate. In practice, be in the commercial plan's network, get its ABA authorization, bill it first, then bill MassHealth for the balance with its EOB. For ABA this situation is common. CommonHealth "may cover the co-pays for ABA, but the claims must be submitted by the primary insurer" first. A provider outside MBHP's network "will need to obtain a single-case or out-of-network agreement" for those copays to be paid. When the provider finds insurance that EVS does not show, it must copy both sides of the card and send the details to MassHealth (450.316(E)). TRICARE pays before MassHealth: "By law, TRICARE pays after all other health insurance, except for: Medicaid." The federal pay-and-chase exception for preventive pediatric (EPSDT) services is not applied to ABA in any MassHealth source read, so do not count on it. No MassHealth source read says whether the member's BH administrator also requires its own ABA PA while MassHealth is secondary. The PA rule says only that PA "does not establish or waive any other prerequisites for payment, such as ... resort to health-insurance payment." [31][32][33][30][34][5][35]
  - Ask the plan: Whether the member's BH administrator (MBHP, WellSense, Point32Health, Carelon for Fallon, Optum for MGB) requires its own ABA PA when MassHealth is secondary, which the regulations read here do not say.

## Delivery and billing rules

Coverage decides whether MassHealth (Massachusetts Medicaid) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: Massachusetts publishes a supervision band, and it is the field with live money attached. LABA supervision must be delivered to Behavior Technician-level staff “during direct service with the Member, as clinically indicated but no less than 10 percent of direct service hours and should not exceed 25 percent of direct hours without documented clinical rationale.” For members engaged in 10 hours or less of direct treatment per month, the LABA must deliver a minimum of one hour of direct supervision per month. The Behavior Technician works under the direct supervision of a LABA licensed per 262 CMR 10.00 — a BCBA certificate alone does not qualify — and the provider agency must ensure LABAs supervise all BTs and that every staff member has had a background record check. Falling below the band is not theoretical: the CY2024 encounter audit recouped against a 1:10 floor, so staff and schedule to at least one supervision hour per ten direct hours. [11]
- **Daily limits / MUEs**: Massachusetts is a no-cap state that nonetheless has one published per-day number. There are no annual, lifetime or unit-of-service ceilings on the EPSDT benefit, and 101 CMR 358.03 is a rate regulation, not a limit regulation — it fixes per-15-minute rates and states they are “full compensation” including “necessary administration and professional supervision associated with patient care.” The only per-day cap in the performance specification is for group instruction, which “may occur up to 4.5 hours a day as clinically indicated, in groups of 2-8 Members.” No per-code MUE regime is published, so what bites in practice is medical-necessity review and the supervision-ratio audit, not a unit edit. [2][11]
- **Session-note signature**: Both clinicians document, and the spec says what the note must contain rather than who countersigns it. “The LABA and BT document each contact in a progress report or notes in the ABA provider’s file for the Member,” and session notes must include how treatment time was utilized, the treatment interventions utilized, and the member’s response to treatment. The complete record must also hold referral and assessment documentation, treatment plans and progress reports, “evidence of supervision and training, including policies, procedures, and implementation,” the IEP and IFSP where applicable, and documentation confirming PCP physical examinations. No co-signature requirement and no signing deadline are stated. [11]
- **Place of service**: Home and community, with school carved out. ABA “is delivered by a contracted and credentialed provider in a variety of settings within a Member’s home and community,” and “services provided in a school setting are distinct and separate from those covered by the health plan and are typically covered by the educational system’s special education resources as part of the Individualized Education Program (IEP) pursuant to Public Law 94-142.” Providers “must not direct, limit, or discourage access to other medically necessary or school-based services.” Transition planning contemplates moving a member “from a center based setting to home/community settings,” so centers are in scope. Group homes are not addressed. [11]
  - Ask the plan: Group-home delivery is addressed by none of the published documents — confirm with the member’s BH administrator.
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not resolved in the published Massachusetts documents. The performance specification does carry one concurrency prohibition, but it is about siblings, not codes: in group caregiver training, “providers may not bill concurrently for services delivered to multiple children from the same family. When a parent/caregiver has more than one child receiving services, only one child’s session may be billed at a time.” The spec requires LABA supervision to be delivered during the BT’s direct service with the member, and MassHealth’s CY2024 audit measured 97155 hours against 97153 hours — but neither document states in terms that both codes may be billed for the same clock time. [11]
  - Ask the plan: The behavioral-health administrator behind the member’s plan — Carelon/MBHP via ProviderConnect, WellSense’s in-house BH team, Point32Health for Tufts, or Optum for Mass General Brigham. Ask whether 97155 pays alongside 97153 for the same clock time.
- **Bill as provider** _(ask the plan)_: Not published. Neither 101 CMR 358 nor the ABA performance specification names whose NPI carries the claim for technician-delivered 97153, and the rate regulation is explicitly single-tier — one rate per code, no credential-level modifiers — so there is no modifier to signal the renderer. [2]
  - Ask the plan: The member’s BH administrator and your contract; the rate regulation settles price, not claim identity.

## What intake should collect for MassHealth (Massachusetts Medicaid)

- **Plan → BH administrator:** PCC/ACO/HNE → MBHP; Fallon → Carelon; WellSense → in-house (since 1/1/2026, previously Carelon); Tufts Together → Point32 internal; MGB → Optum. It decides the form and portal.
- **Diagnosis + diagnostic report:** Comprehensive DSM-aligned ASD evaluation by a qualified licensed diagnostician — or, from 1/1/2026, genetic-testing confirmation of Down syndrome.
- **MassHealth plan type + age:** Standard/CommonHealth covers under 21; Family Assistance under 19 — the EPSDT clock differs.
- **LABA on the case:** The standard PA form is completed by the LABA rendering or supervising services — name one before submission.
- **Early Intervention status:** For under-3s: ABA can't duplicate EI services — map what EI already delivers.

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

## Verification of benefits (VOB) data

How MassHealth (Massachusetts Medicaid) ABA benefits route and read on an eligibility check. Data last updated 2026-10-15.

### EDI routing

- **Payer ID (pVerify):** 00133 — pVerify lists multiple MassHealth-family candidates (00133 'Massachusetts Medicaid', 01398 'MASSHEALTH', BO00082 'MASSHEALTH-BO', 01421 'MASSHEALTH-EDI') without a clearly canonical single ID — confirm which code your clearinghouse actually routes on before automating.
- **Member ID prefix:** Not used for eligibility — Mass.gov eligibility verification asks only for the 12-digit member ID; no alpha prefix is used.
- **Supports 270/271 eligibility:** Yes
- **Real-time eligibility:** Yes
- **Behavioral health administrator:** Varies by plan — MBHP (Carelon) is the default/largest administrator (PCC Plan, Primary Care ACOs, HNE BeHealthy); five other administrators exist per plan (Carelon-direct for Fallon, WellSense in-house since 1/1/2026, Point32Health internal UM for Tufts Health Together, Optum for Mass General Brigham Health Plan) — see the individual MA plan guides for administrator-specific routing. — QA 2026-07-23 downgraded verified->unverified: the six-administrator roster and its plan-by-plan routing are editorial synthesis of the individual MA plan guides (which DO each document their administrator) — the cited MassHealth 270/271 companion guide contains zero BH-carve-out-administrator content, so it cannot carry a "verified" label here. Confirm each member's administrator from the plan-specific guide (MBHP/Carelon, Fallon/Carelon, WellSense in-house, Tufts/Point32Health, MGB/Optum).
- **BH administrator payer ID:** 43324 (claim.md) / BHOVO (Stedi) / 00831 (pVerify) / ISA Receiver ID BEACON963116116 (Carelon national companion guide) — genuinely multiple identifiers across clearinghouses for the same Carelon/Beacon entity, not resolved to one canonical number.
- **Two-hop verification required:** Yes — QA 2026-07-23 downgraded verified->unverified: whether a second EDI hop is required varies by which administrator the member's plan uses (the administrator field itself says routing "varies by plan"), and the cited companion guide does not address BH claim-routing hops — resolve per the plan-specific guide.
- **Where the 271 carries MCO enrollment:** Loop 2110C EB01 = L (PCC managed care) / MC (MCO, ACO, ICO, CP, SCO, or PACE) / D (Community Partner); EB03 = 30 (service type); EB05 returns the PLAN NAME as free text; DTP01 = 307 for span dates.
- **Eligibility span granularity:** Both real-time (single-patient inquiries) and batch supported, contingent on a Trading Partner Agreement on file; system availability 24/7 except scheduled maintenance.

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | — | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |
| 97152 | Yes (assumed covered under the comprehensive EPSDT benefit; not separately priced in the current 101 CMR 358.03 fee schedule — see Layer 4 rates) | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | — | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |
| 97153 | Yes | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | — | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |
| 97154 | Yes | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | 18 units/day (≤4.5 hrs), group size 2–8 members per day | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |
| 97155 | Yes | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | — | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |
| 97156 | Yes | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | — | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |
| 97157 | Yes | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | 18 units/day (≤4.5 hrs), group size 2–8 members per day | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |
| 97158 | Yes (assumed covered under the comprehensive EPSDT benefit; not separately priced in the current 101 CMR 358.03 fee schedule — see Layer 4 rates) | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | — | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |
| 0362T | Yes (assumed covered under the comprehensive EPSDT benefit; not separately priced in the current 101 CMR 358.03 fee schedule — see Layer 4 rates) | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | — | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |
| 0373T | Yes (assumed covered under the comprehensive EPSDT benefit; not separately priced in the current 101 CMR 358.03 fee schedule — see Layer 4 rates) | Required — PA is required for all ABA services/hours/units, assessment and treatment alike | — | home/community (default), center-based/clinic (documented clinical justification required per the Carelon/MBHP performance spec), school (carved to IEP/DESE — not billed to the health plan) | Yes, as a modality — allowed at parent/caregiver request when clinically appropriate per the Carelon/MBHP performance spec; must not replace in-person availability. No telehealth modifier (GT/95) or POS code is specified in the spec. | — |

Code notes:

- **97151, 97153, 97155, 97156:** QA 2026-07-23: paRequired fieldStatus downgraded verified->unverified — neither 101 CMR 358 (a rate regulation that explicitly disclaims being an authorization: "101 CMR 358.00 is not authorization for or approval of the services") nor the Carelon/MBHP performance spec states a blanket ABA PA requirement; the requirement is plausibly true but its load-bearing source (MassHealth ABA Provider Manual/Bulletin) is not cited here — verify there.
- **97152, 97158, 0362T, 0373T:** Not separately priced in the current fee schedule — see Layer 4 for the individual-consideration note. QA 2026-07-23: paRequired fieldStatus downgraded verified->unverified — neither 101 CMR 358 (a rate regulation that explicitly disclaims being an authorization: "101 CMR 358.00 is not authorization for or approval of the services") nor the Carelon/MBHP performance spec states a blanket ABA PA requirement; the requirement is plausibly true but its load-bearing source (MassHealth ABA Provider Manual/Bulletin) is not cited here — verify there.
- **97154, 97157:** Group-session cap and size come from the Carelon/MBHP performance spec, not a fee-schedule/coding source. QA 2026-07-23: paRequired fieldStatus downgraded verified->unverified — neither 101 CMR 358 (a rate regulation that explicitly disclaims being an authorization: "101 CMR 358.00 is not authorization for or approval of the services") nor the Carelon/MBHP performance spec states a blanket ABA PA requirement; the requirement is plausibly true but its load-bearing source (MassHealth ABA Provider Manual/Bulletin) is not cited here — verify there.

### Medicaid rates

Source: 101 CMR 358.00: Rates for Applied Behavior Analysis, Final Adoption (Mass. Register, published 2024-09-27; effective 2024-10-01). EOHHS's proposed re-adoption (filed 5/22/2026, hearing 6/17/2026) reprints these same figures unchanged for dates of service on/after 12/1/2026 — still proposed, not yet confirmed final-adopted as of 10/1/2026. Effective 2024-10-01.

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | $30.73 | 15min | — |
| 97152 | Not in the published 101 CMR 358.03(3) fee schedule — reimbursed by individual consideration per 358.03(4)(b); no administrative bulletin naming an applied rate for this code was found. | 15min | — |
| 97153 | $16.37 | 15min | — |
| 97154 | $13.91 | 15min | note: Group code — face-to-face, 2+ patients per session |
| 97155 | $30.73 | 15min | — |
| 97156 | $30.73 | 15min | — |
| 97157 | $26.12 | 15min | note: Multiple-family group, up to 8 participants |
| 97158 | Not in the published 101 CMR 358.03(3) fee schedule — reimbursed by individual consideration per 358.03(4)(b); no administrative bulletin naming an applied rate for this code was found. | 15min | — |
| 0362T | Not in the published 101 CMR 358.03(3) fee schedule — reimbursed by individual consideration per 358.03(4)(b); no administrative bulletin naming an applied rate for this code was found. | 15min | — |
| 0373T | Not in the published 101 CMR 358.03(3) fee schedule — reimbursed by individual consideration per 358.03(4)(b); no administrative bulletin naming an applied rate for this code was found. | 15min | — |
| H0031-U2 | $30.73 | 15min | U2: Assessment/case-planning for home services by a licensed professional |

### Contacts

- **Benefits by phone:** Yes
- **Provider services phone:** 1-800-841-2900
- **Phone menu path:** Automated Voice Response (AVR) eligibility line: 1-800-554-0042 (24/7), per MassHealth All Provider Manuals Subchapter 5 and the 2026 WellSense MA Provider Manual. For a live representative (eligibility operator), call the main number above. TTY/TDD: 711.
- **Hours:** Monday-Friday, 8:00 a.m.-5:00 p.m. ET (MassHealth Customer Service for Providers); the Eligibility Verification System itself is available 24/7
- **Portal:** [MassHealth Provider Online Service Center (POSC) / Eligibility Verification System (EVS)](https://newmmis-portal.ehs.state.ma.us/EHSProviderPortal/providerLanding/providerLanding.jsf)
- **Fax:** 617-988-8910

Questions to ask on a verification call:

- Which of the six BH administrators (MBHP/Carelon, Fallon/Carelon, WellSense in-house, Point32Health/Tufts internal UM, or Optum for Mass General Brigham Health Plan) manages this member's specific MassHealth plan?
- Since the 271 returns the enrolled plan name as free text rather than a numeric MCO code, can you confirm the exact plan name this member is enrolled in?
- For codes 97152, 97158, 0362T, and 0373T - since none of them appear in the published 101 CMR 358.03 fee schedule - what individual-consideration rate applies for this member's claims?
- Are there any per-code unit caps beyond the published group-code caps (97154/97157) that apply to this member?
- What billing modifiers, if any, does this plan require on ABA claims?

### VOB data sources

- https://www.mass.gov/doc/masshealth-standard-companion-guide-health-care-eligibilitybenefit-inquiry-and-information-response-270271-0/download (accessed 2026-07-23; source document older than 18 months)
- https://pverify.com/payer-list/ (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.claim.md/payer/43324 (accessed 2026-07-23)
- https://www.stedi.com/healthcare/network/carelon-behavioral-health (accessed 2026-07-23)
- https://www.carelonbehavioralhealth.com/content/dam/digital/carelon/cbh-assets/documents/global/guides/270-271-companion-guide.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.mass.gov/how-to/eligibility-verification-for-masshealth-providers (accessed 2026-10-14)
- https://www.mass.gov/doc/rates-for-applied-behavior-analysis-effective-october-1-2024-0/download (accessed 2026-07-23; source document older than 18 months)
- https://providers.masspartnership.com/pdf/PerfSpec-ABA.pdf (accessed 2026-07-23)
- https://www.mass.gov/doc/proposed-regulation-date-filed-may-22-2026/download (accessed 2026-07-23)
- https://www.mass.gov/info-details/eligibility-verification-system-overview (accessed 2026-07-23)
- https://www.carelonbehavioralhealth.com/content/dam/digital/carelon/cbh-assets/documents/ma/behavioral-health-policy-and-procedure-manual-for-providers-fallon.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.mass.gov/doc/subchapter-5-administrative-and-billing-instructions-for-all-masshealth-providers/download (accessed 2026-10-14)

## Common questions

### Does MassHealth cover ABA therapy?

Yes — for members under 21 (under 19 on Family Assistance) through EPSDT, with no annual or lifetime dollar or unit caps. Prior authorization is required for all ABA services, submitted to the behavioral-health administrator behind the member's plan.

### Is an autism diagnosis required for MassHealth ABA?

Historically yes — a comprehensive DSM-aligned assessment by a qualified licensed diagnostician. Effective January 1, 2026, Chapter 388 of the Acts of 2024 adds a second pathway: a sole diagnosis of Down syndrome confirmed by genetic testing.

### What does MassHealth pay for ABA?

Single-tier rates per 101 CMR 358.03: 97153 at $16.37 per 15-minute unit (~$65/hour), 97151/97155/97156 at $30.73, 97154 at $13.91 — effective since late September 2024, with an unchanged re-adoption proposed through December 2026. Plans generally pay at or near this schedule, but contracts govern.

### What is the MassHealth 1:10 supervision rule?

MassHealth's CY2024 audit enforced a minimum one hour of 97155 supervision per ten hours of 97153 direct treatment; ratios above that drew partial or full recoupment (letters issued Feb–Mar 2026, currently disputed by provider groups). Staff and schedule to at least 1:10.

### Can the ABA assessment or BCBA supervision be done by telehealth under MassHealth?

Yes. MassHealth's telehealth bulletin (All Provider Bulletin 379) excludes no ABA code, every managed-care plan must be at least as generous (MCE Bulletin 115), and the ABA performance specification allows telehealth at the family's request when clinically appropriate. Bill POS 02 or 10 with modifier 95 (video) or 93 (audio-only). Telehealth must not replace in-person availability.

### What happens to a MassHealth ABA authorization if the family switches providers?

No MassHealth document says whether it transfers, so ask the member's behavioral-health administrator before the switch. The agency the family leaves must give the family an up-to-date treatment plan on the last day of service and send it to the child's other current providers within seven days.

### What is MassHealth’s timely filing limit?

90 days from the date of service, or from the other insurer’s explanation of benefits, for claims billed to MassHealth directly (130 CMR 450.309). Plan- and MBHP-administered ABA follows the administrator’s own limit.

### How fast does MassHealth pay a clean ABA claim?

On claims MassHealth pays directly, federal rule 42 CFR 447.45(d) requires 90 percent of clean practitioner claims paid within 30 days of receipt and 99 percent within 90 days. ABA billed through an ACO, MCO or MBHP follows that plan’s own payment schedule.

### Does MassHealth accept H0031 for ABA?

Yes, as H0031-U2: 101 CMR 358.03 pays it at $30.73 per 15 minutes for assessment and case planning by a licensed professional. 97152, 97158, 0362T, 0373T and H0032 have no MassHealth ABA rate.

## Primary sources

1. [101 CMR 358.00 — Rates for Applied Behavior Analysis (official regulation page)](https://www.mass.gov/regulations/101-CMR-35800-rates-of-payment-for-applied-behavior-analysis-0)
2. [101 CMR 358.03 Rate Provisions (Cornell LII mirror)](https://www.law.cornell.edu/regulations/massachusetts/101-CMR-358-03)
3. [MassHealth ABA Provider FAQ (mass.gov)](https://www.mass.gov/doc/applied-behavioral-analysis-provider-frequently-asked-questions/download)
4. [MA Standard ABA PA Form (MassHealth version, upd. 3/12/2026)](https://www.wellsense.org/hubfs/Forms/Provider_Forms/Applied_Behavioral_Analysis_Prior_Authorization_Form_MassHealth.pdf)
5. [AIRC — MassHealth ABA Coverage factsheet](https://massairc.org/factsheets/masshealth-aba-coverage/)
6. [MassHealth Managed Care Options — plan/BH-vendor map (April 2023)](https://abh.memberclicks.net/assets/docs/KeepingCoverage/2023%20MassHealth%20Accountable%20and%20Managed%20Care%20Options%20031723.pdf)
7. [MassHealth ABA supervision audit & recoupment (Acuity News)](https://acuity.news/regulation/masshealth-aba-supervision-audit-recoupment-litigation-2026/)
8. [MassHealth ABA rate freeze — 101 CMR 358 re-adoption (Acuity News)](https://acuity.news/regulation/masshealth-aba-reimbursement-rate-freeze-101-cmr-358/)
9. [EOHHS — Proposed Regulation, 101 CMR 358.00: Rates for Applied Behavior Analysis (filed 5/22/2026, proposed eff. 12/1/2026) (accessed 10/1/2026)](https://www.mass.gov/doc/proposed-regulation-date-filed-may-22-2026/download)
10. [EOHHS — Staff testimony, Rates for Applied Behavior Analysis, remote public hearing June 17, 2026 (accessed 10/1/2026)](https://www.mass.gov/doc/staff-testimony-for-rates-for-applied-behavior-analysis-presented-at-the-remote-public-hearing-on-june-17-2026-0/download)
11. [Carelon/MBHP Performance Specifications — Applied Behavior Analysis (upd. Feb 15, 2026)](https://providers.masspartnership.com/pdf/PerfSpec-ABA.pdf)
12. [BACB RBT Handbook (upd. 06/2026)](https://www.bacb.com/wp-content/uploads/2025/08/RBTHandbook_260529-2-a.pdf)
13. [101 CMR 15.03 — EOHHS Criminal Offender Record Checks, Scope (Cornell LII)](https://www.law.cornell.edu/regulations/massachusetts/101-CMR-15-03)
14. [262 CMR 8.04 — Standards of Conduct for LABAs/LAABAs (Cornell LII)](https://www.law.cornell.edu/regulations/massachusetts/262-CMR-8-04)
15. [262 CMR 10.03 — Applied Behavior Analyst Licensure (Cornell LII)](https://www.law.cornell.edu/regulations/massachusetts/262-CMR-10-03)
16. [42 CFR 455.436 — Federal database checks (Cornell LII)](https://www.law.cornell.edu/cfr/text/42/455.436)
17. [The Arc of Massachusetts — ABA for Down syndrome expansion (eff. 1/1/2026)](https://thearcofmass.org/post/expansion-of-coverage-of-applied-behavior-analysis-aba-for-individuals-with-down-syndrome/)
18. [Point32Health — ABA policy and coverage updates (Oct 2025)](https://www.point32health.org/provider/applied-behavioral-analysis-policy-and-coverage-updates-102025)
19. [Point32Health — Tufts Health Public Plans Provider Manual, Behavioral Health chapter (2026)](https://www.point32health.org/documents/thpp-08-bh-pm)
20. [MassHealth All Provider Bulletin 379 — Access to Health Services through Telehealth Options (October 2023)](https://www.mass.gov/doc/all-provider-bulletin-379-access-to-health-services-through-telehealth-options-0/download)
21. [MassHealth Managed Care Entity Bulletin 115 — Telehealth for members enrolled in managed care entities (April 2024)](https://www.mass.gov/doc/managed-care-entity-bulletin-115-access-to-health-services-through-telehealth-options-for-members-enrolled-in-managed-care-entities-0/download)
22. [130 CMR 450.309 — Claims: billing deadlines (MassHealth)](https://www.law.cornell.edu/regulations/massachusetts/130-CMR-450-309)
23. [42 CFR 447.45(d) — Medicaid timely claims processing (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-447/subpart-A/section-447.45)
24. [MassHealth — Provider bulletins (index of MassHealth provider bulletins by year)](https://www.mass.gov/masshealth-provider-bulletins)
25. [MassHealth — 2026 provider bulletins (list of all 2026 MassHealth provider bulletins)](https://www.mass.gov/lists/2026-masshealth-provider-bulletins)
26. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/section-438.210)
27. [42 CFR 440.230(e) — State Medicaid agency prior authorization timeframes, from 1/1/2026 (eCFR)](https://www.ecfr.gov/current/title-42/section-440.230)
28. [WellSense — Reduction of prior authorization decision timeframes (provider communication, Oct 31 2025)](https://www.wellsense.org/hubfs/Provider/News/WellSense_Mass_Provider_Communications_PA_Updates_10_31_25.pdf)
29. [Carelon Behavioral Health — Massachusetts Addendum (114_0526 rev.)](https://www.carelonbehavioralhealth.com/content/dam/digital/carelon/cbh-assets/documents/ma/massachusetts-provider-addendum.pdf)
30. [130 CMR 450.303 — MassHealth prior authorization (Cornell LII mirror)](https://www.law.cornell.edu/regulations/massachusetts/130-CMR-450-303)
31. [42 CFR 433.139 — Medicaid payment of claims involving third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/section-433.139)
32. [130 CMR 450.316 — MassHealth third-party liability: requirements (Cornell LII mirror)](https://www.law.cornell.edu/regulations/massachusetts/130-CMR-450-316)
33. [130 CMR 450.317 — MassHealth third-party liability: payment limitations (Cornell LII mirror)](https://www.law.cornell.edu/regulations/massachusetts/130-CMR-450-317)
34. [MassHealth — Coordination of Benefits for MassHealth Providers (upd. 4/12/2024)](https://www.mass.gov/info-details/coordination-of-benefits-for-masshealth-providers)
35. [TRICARE — Using Other Health Insurance](https://tricare.mil/Plans/OHI)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.