Meridian Health Plan of Illinois, a Centene company, is a statewide HealthChoice Illinois plan, and its manual lists “Applied behavior analysis (ABA) services” as a covered Medicaid service. It reviews ABA against Centene’s national clinical policy CP.BH.104, which is more prescriptive than HFS’s notices, and from May 1, 2026 it requires notice within 24 hours of an ABA assessment. Meridian also operates YouthCare, the plan for DCFS youth, which has its own guide.
Meridian’s February 26, 2026 notice, issued “in accordance with Illinois Public Act 104-0028”: “Effective May 1, 2026, providers must notify Meridian within 24 hours of conducting ABA assessments (CPT codes 97151 and 97152). Utilization review may begin after the 24-hour notification period. Failure to notify the plan within the 24-hour timeframe will result in a denial of coverage due to lack of timely notification.” Notification “appl[ies] only to ABA initial assessments”; everything else stays under prior authorization or concurrent review. Notify through the secure provider portal, using the same steps as a PA request, or Provider Services at 866-606-3700. The June 2026 manual’s behavioral health table matches: Adaptive Behavior Treatment initial assessment under “Notification required within 24 hours,” and Adaptive Behavior Treatment under “Prior authorization required.”[14][15][2][3][16][17][18][19]
Illinois Public Act 104-0028 (HB 3019) changed behavioral health utilization management from January 1, 2026, and each HealthChoice Illinois plan has read it differently for ABA. Molina says ABA “services are no longer eligible for prior authorization and require concurrent review only” (no authorization for the initial assessment or the first 48 units of therapy a calendar year). Aetna Better Health approves 97151/97152 without medical-necessity review if notified within one business day, then runs concurrent review. Blue Cross Community Health Plans and YouthCare ask for notification within 24 hours of starting ABA services or the initial assessment. Meridian requires notice within 24 hours of 97151/97152 from May 1, 2026 and keeps prior authorization on treatment. CountyCare removed PA from 97151/97152 only. The Act itself added subsection (w) to 215 ILCS 5/370c: from January 1, 2026 “No policy shall require prior authorization for outpatient or partial hospitalization services for treatment of mental, emotional, or nervous disorders or conditions,” such coverage “may be subject to concurrent and retrospective review,” and “A Medicaid managed care organization may set a deadline of 24 hours after the initiation of treatment” for notification (one more business day if it cannot accept the notice). It also lets HFS “adopt rules to implement the applicable provisions” for managed care organizations “and the medical assistance fee-for-service program” (new 305 ILCS 5/5-5.28). The statute does not name ABA, which is why the plans differ; this guide reports each plan’s own written rule.[14][15][2][3][16][17][18][19]
Centene’s ABA policy (last revision 09/25, posted by Meridian in February 2026) requires, to start treatment, a CDE “conducted in the past three years,” or, if it is three to five years old, a diagnostic interview within 12 months of the request; continuation needs a CDE within the past five years. The CDE must use “A minimum of two of the following assessment tools, including at least one primary clinician tool” (STAT, ADI-R, CARS/CARS-2, GARS-3, ADOS/ADOS-2). Hours must be justified by impairment and consider school (“less than 20 hours per week if attending school full-time”), and should “not exceed six hours per day up to a total of 30 hours per week” unless documentation justifies more. Protocol modification (97155) must occur “for at least two hours per week or 10% of the direct service hours provided, whichever is greater” (one to two hours a week is acceptable under 10 hours). Assessments and treatment plans are updated at least every six months, and services may be delivered at home, clinic, school or community, in person or by telehealth.[4]
CP.BH.104’s continuation criteria spell out what a reauthorization must show: an updated behavior assessment and an updated treatment plan “at least every six months (or as clinically appropriate, or as state mandated)”; the percentage of scheduled sessions completed and caregiver participation (attendance below 80% of authorized hours needs a written justification); “Documented progress toward goals since the last authorization,” including “Updated data collected during previous treatment authorization, corresponding to all treatment settings”; behavior-reduction progress “noted in a clear and legible graphic display, including: clear labels on each axis with indicators of treatment changes and environmental variables,” baseline data and progress over time; and skill-acquisition “baseline data and updated progress data for each treatment goal.” CP.BH.105 asks continuation records for “Data and graph representation of mastery of skills noted in the treatment plan” and changes in standardized assessment scores. So yes: graphs are required at reauthorization.[4][5][3][1]
Claims: Meridian’s manual (06.24.26) says “The standard submission for professional and institutional Medicaid claims for both in-network and out-of-network providers is 180 days from the date of service to submit an initial claim,” with two exceptions (retroactive eligibility, 180 days from notice of the change; third-party liability delays, 90 days from the TPL processing date). Illinois law sets the payment clock for every HealthChoice Illinois plan: under 305 ILCS 5/5-30.1(g), “The MCO shall pay a claim within 30 days of receiving a claim that contains all the essential information needed to adjudicate the claim,” must notify the billing party within 30 days when it cannot adjudicate a claim, and owes a late-payment penalty at least equal to the Insurance Code’s timely-payment interest, calculated and paid within 30 days after the claim is paid, without the provider having to ask for it. No plan document we read publishes a weekly submission cutoff or check-run day; ask the plan’s provider services for its payment cycle.[4][5][3][1]
The questions that decide whether a family can start with Meridian (Meridian Health Plan of Illinois), and what they have to bring. Each maps onto something intake should ask on the first call.
Under 21: HFS covers ABS for children 0 through 20; Meridian publishes no different limit.[20][3]
CP.BH.104: for treatment initiation the CDE must be from the past three years, or, if three to five years old, supplemented by a diagnostic interview within 12 months of the request; continuation needs a CDE within five years.[4]
CP.BH.104: “a licensed physician, psychologist, or other licensed professional with specialized training in diagnosis and treatment of ASD, or a provider otherwise authorized under state law to diagnose autism.” HFS’s ABS standard is a physician or clinical psychologist.[4][6]
CP.BH.104: at least two tools, including at least one primary clinician tool: STAT, ADI-R, CARS/CARS-2, GARS-3 or ADOS/ADOS-2.[4]
Meridian publishes no separate referral rule; HFS’s ABS benefit requires a physician order and referral, valid one year.[3][6]
CP.BH.104 allows telehealth as a modality; for billing, HFS’s fee schedule governs. HFS’s ABS fee schedule (updated 05/14/2026) marks four codes for remote delivery: 97151 (assessment), 97155 (protocol modification), 97156 (family guidance) and 97157 (multiple-family group). The footnote reads: “Only use the GT or 93 modifier when providing allowable service remotely as a distant site telehealth service along with Place of Service (POS) 02 or 10, as applicable, on the specific service line of the claim.” 97152, 97153, 97154, 97158, 0362T and 0373T carry no telehealth modifier, so technician-delivered treatment is billed as in-person.[4][8]
Meridian’s manual (06.24.26) prints a turnaround table for all prior authorization requests: standard pre-service review “Within 5 days of receipt of the request,” urgent pre-service (expedited) within 48 hours, urgent/concurrent review within 72 hours of receipt, and retrospective review (only for certain service types) within 30 days of the provider’s request, with notice given in the same time frames. ABA assessments are notification-only (within 24 hours of 97151/97152) since May 1, 2026. The federal ceiling is 7 calendar days for standard requests (42 CFR 438.210(d), rating periods from January 1, 2026).[3][2][10]
“If Meridian is not the only insurance coverage for the member, Meridian should be billed as the secondary payer for all services rendered and is responsible only for the difference between what the primary insurance pays and the allowable Medicaid fee schedule.”[3][11]
Coverage decides whether Meridian (Meridian Health Plan of Illinois) 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.
CP.BH.104: Adaptive Behavior Treatment with Protocol Modification “occurs for at least two hours per week or 10% of the direct service hours provided, whichever is greater” (one to two hours a week is acceptable below 10 hours a week), and treatment must be “delivered or supervised by an ABA-credentialed professional.” HFS adds that RBTs “must receive supervision from a BCBA.”[4][7]
CP.BH.104: treatment hours “Do not exceed six hours per day up to a total of 30 hours per week” unless clinical documentation justifies more, and should be under 20 hours a week for a child in school full-time. HFS’s fee schedule daily unit maximums also apply to claims.[4][8]
CP.BH.105 requires every session note to carry the “Rendering clinician/technician’s name, credentials, and dated signature,” the start and end time, any pauses, location, service code, participants and a session summary; treatment plans record the “Signature, credential, and role of each person who reviewed and signed the plan.”[5]
CP.BH.104: “Services may be provided in various settings (e.g., home, clinic, school, community) and modalities (e.g., in-person, telehealth),” and a school-based plan has its own documentation requirements. HFS limits remote billing to 97151, 97155, 97156 and 97157.[4][8]
Its provider manual says standard pre-service requests are decided within 5 days of receipt, expedited requests within 48 hours and concurrent reviews within 72 hours.
Yes. CP.BH.104 asks for behavior-reduction progress in “a clear and legible graphic display” with labelled axes and phase lines, baseline and updated data for every skill goal, an updated assessment and treatment plan at least every six months, and attendance and caregiver-participation figures. CP.BH.105 asks for data and graphs of skill mastery.
No PA, but notification: from May 1, 2026 you must notify Meridian within 24 hours of 97151 or 97152, or coverage is denied for late notice.
Yes. Adaptive Behavior Treatment is on Meridian’s prior authorization list and is reviewed against Centene policy CP.BH.104.
CP.BH.104 wants a CDE from the last three years to start treatment, or a new diagnostic interview within 12 months if the CDE is three to five years old.
Up to 6 hours a day and 30 a week unless documentation justifies more, and under 20 hours a week for a child in school full-time (CP.BH.104).
180 days from the date of service.
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