Molina Healthcare of South Carolina is one of the five Healthy Connections Medicaid MCOs. Its 2026 provider manual lists autism spectrum disorder services as covered (behavior identification assessment, treatment by protocol, protocol modification and family guidance), and its pre-service review guide effective February 1, 2026 puts ABA for autism behind prior authorization. Molina publishes no South Carolina ABA policy of its own, so expect the SCDHHS ASD manual to be the reference point and confirm details with the plan.
The manual’s covered-services table lists "Autism Spectrum Disorder — Covered": behavior identification assessment, adaptive behavior treatment by protocol, adaptive behavior treatment with protocol modification and family adaptive behavior treatment guidance. The pre-service review guide (effective 02/01/2026) lists "Applied Behavioral Analysis (ABA) – for treatment of Autism Spectrum Disorder (ASD)" under behavioral health services requiring review and tells providers to "Refer to Molina’s Provider Website or Prior Authorization Look-Up Tool for specific codes." Prior authorizations, including behavioral health, go to (855) 237-6178. Molina sets an appointment standard for autism therapy services: routine visits within 15 business days, urgent within 48 hours.[1][2]
Molina says it will process "any non-urgent Prior Authorization requests no later than 7 calendar days following receipt of the request," and urgent requests within 72 hours, each extendable by up to 14 days. Claims are timely within "365 calendar days after the discharge for inpatient services or the Date of Service for outpatient services."[1][2]
Molina’s 2026 South Carolina Medicaid manual: claims are due "within 12 months/365 days after the discharge for inpatient services or the date of service for outpatient services," and "Corrected Claims must be sent within 365 calendar days of date of service of the Claim." When Molina is secondary, "the Provider must submit Claims to Molina within 12 months/365 days from date of service after final determination by the primary payer." Molina "will process the claim for service within 30 calendar days after receipt of Clean Claims," unless the provider agreement sets another schedule. Participating providers must enroll in EFT and ERA. The manual publishes no weekly check-run or cut-off schedule.[1]
The questions that decide whether a family can start with Molina Healthcare of South Carolina, and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the South Carolina Medicaid (SCDHHS) rule: ASD services "must be recommended by a physician or other licensed practitioner of the healing arts within his or her scope of practice under state law." For treatment, the manual recognizes three routes: a physician or LPHA refers a member with a prior-established ASD diagnosis to an ASD-network ABA provider or LIP; the member self-refers on that prior-established diagnosis; or a physician refers a member with presumptive eligibility (Section 8). Referrals "can be done via phone, email, fax and hard copy mail," and the provider's record must contain a "Referral form" alongside the BIA and signed IPOC. In practice the recommendation comes from the diagnosing evaluation: the comprehensive diagnostic assessment must list recommendations based on medical necessity, including a "Referral for applied behavior analysis therapy if indicated." The manual sets no validity period for the referral; the July 2026 ASD manual's initial-request packet carries the diagnostic assessment (or physician documentation of a Medical Care Home assessment or of presumptive eligibility) instead. Molina publishes no ABA-specific referral rule of its own: its 2026 provider manual only lists autism spectrum disorder services as covered, and its pre-service review guide says referrals to network specialists need no prior authorization while ABA itself does.[3][1][2]
Non-urgent requests "no later than 7 calendar days following receipt," urgent within 72 hours; either may be extended by up to 14 calendar days.[1][6]
"Medicaid is always the payer of last resort." If third-party liability exists, bill the primary payer and submit its EOB to Molina for secondary processing.[1][7]
Molina’s manual does not state an age for ABA. The SCDHHS ASD benefit, which the MCOs administer for their members, covers ages 0 through 20.[1][3]
Ask the plan: Molina SC Provider Services, (855) 237-6178.
Not stated by Molina. The SCDHHS manual limits ASD diagnosis to MD/DO, PhD/PsyD or LPES, in person.[1][3]
Ask the plan: Molina SC prior authorizations, (855) 237-6178.
Molina publishes no ABA telehealth rule for South Carolina. The state baseline: Under the SCDHHS ASD manual (July 1, 2026), only two ABA codes may be delivered by telehealth: 97156 (family guidance), with the GT modifier and no extra authorization, and 97155 (protocol modification), only when the QIO approves it during prior authorization, for up to 25% of authorized and rendered 97155 units, for a member receiving in-home ABA in a rural location with limited access. Telehealth must be synchronous audio and video, GT goes in the secondary modifier position, and POS is 02 or 10. "The BIA can not be completed by telehealth," and 97152, 97153, 97154, 97157, 97158, 0362T and 0373T are not deliverable by telehealth. An ASD diagnosis made by telehealth is not valid.[1][3]
Ask the plan: Molina SC Provider Services, (855) 237-6178: ask which ABA codes it pays by telehealth.
Ask the plan: Molina SC prior authorizations, (855) 237-6178: ask how recent the diagnostic evaluation must be.
Not stated by Molina.[1]
Ask the plan: Molina SC prior authorizations, (855) 237-6178: ask which instruments it expects.
Coverage decides whether Molina Healthcare of South Carolina 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.
Molina publishes no ABA supervision rule for South Carolina. The state baseline in the SCDHHS ASD manual: BACB supervision applies: "each RBT must be supervised for a minimum of 5% of the hours spent providing ABA services per month," with at least two face-to-face, real-time contacts a month, one of which observes the RBT with the member; that professional supervision is not billable. Caseload caps: a BCBA may carry 12 cases (16 with a BCaBA), a BCaBA 12, where 30–40 hours a week is one case, 10–25 hours half a case and under 10 hours a quarter case. A behavior technician gets one 90-day grace period to earn the RBT credential, and may work only in a clinic with a BCBA on site during it.[1][3]
Ask the plan: Molina SC Provider Services, (855) 237-6178: ask whether the SCDHHS supervision and caseload rules apply to its network.
Molina publishes no ABA setting rule for South Carolina; the SCDHHS manual allows home, clinic and, with authorization, school and community settings.[1][3]
Ask the plan: Molina SC Provider Services, (855) 237-6178: ask which POS codes it pays for ABA.
Not addressed in the manual or the pre-service review guide. On ABA alongside other therapies, Molina publishes nothing of its own; the state baseline: the SCDHHS ASD manual's non-covered list is explicit — "Concurrent billing of 97153 with any other service or therapy is excluded except as detailed in Section 8," and Section 8's exceptions are ABA-with-ABA only. It also excludes "ABA services while the member is at another medical appointment," and, in the other direction, ABA treatment "that precludes, or requires the member's family to stop engaging with other critical supports … speech therapy, occupational therapy, or IDEA recommended school-based curriculum and supports." So speech and ABA can both continue, but not on the same clock time as a billed 97153 unit. The manual also binds providers to the National Correct Coding Initiative edits and related coding policy unless it says otherwise.[3][1][2]
Ask the plan: Molina SC Provider Services, (855) 237-6178, or your provider agreement.
Molina publishes no ABA unit limits for South Carolina.[1]
Ask the plan: Molina SC prior authorizations, (855) 237-6178: ask whether the SCDHHS section 8 limits apply.
Molina publishes no ABA session-note signature rule for South Carolina.[1]
Ask the plan: Molina SC Provider Services, (855) 237-6178, or the documentation standards in your agreement.
Molina publishes no ABA rendering-provider rule for South Carolina.[1]
Ask the plan: Molina SC Provider Services, (855) 237-6178: ask whether RBT services bill under the supervising BCBA’s NPI.
Initial and corrected claims: 365 days from the date of service. Secondary claims: within 365 days from the date of service after the primary payer’s final determination. Clean claims are processed within 30 calendar days of receipt. No check-run schedule is published.
Yes. Its 2026 manual lists autism spectrum disorder services as covered, and ABA for autism needs prior authorization.
The pre-service review guide lists ABA and points to Molina’s Prior Authorization Look-Up Tool for specific codes; call (855) 237-6178 if in doubt.
Up to 7 calendar days for standard requests and 72 hours for urgent ones, with possible 14-day extensions.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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