Montana Medicaid pays for applied behavior analysis itself. There are no Medicaid managed care plans standing between the family and the state for ABA: the ABA manual describes services "administered by the Department," the Developmental Disabilities Program (part of DPHHS’s Behavioral Health and Developmental Disabilities Division) takes the start-of-care paperwork, Mountain-Pacific Quality Health reviews requests for more units in its Qualitrac portal, and the BCBA bills the state on a CMS-1500. So there is one rulebook to learn, the Montana Medicaid Applied Behavior Analysis Services Manual (updated September 2025).
The benefit is unusual in two ways. It is not limited to autism: members up to 20 with a provisional ASD diagnosis, members found eligible for state developmental disabilities services, and children with a listed serious emotional disturbance can all qualify if they meet functional impairment criteria. And the first 180 days (or 1,260 units) need no prior authorization at all, only an Intent to Initiate form and a prescription; prior authorization starts with the second span.
The ABA manual describes "Montana Medicaid Applied Behavior Analysis (ABA) services administered by the Department," and every step of the process it lays out runs through the state. The Intent to Initiate form and the Provider Transfer Request go to the Developmental Disabilities Program at DDPServiceRequest@mt.gov through the state’s secure file transfer service; requests for additional units are uploaded to "the Medicaid Utilization Review Portal" run by Mountain-Pacific Quality Health (Qualitrac); and BCBAs bill the Department "electronically" or "on a CMS-1500 claim form." DPHHS lists an ABA Program Officer at (406) 444-3878 and sends prior-authorization and continued-stay questions to Mountain-Pacific at 1-800-219-7035. None of the ABA sources we read mentions a managed care plan, and the forms carry no plan field, so the first intake question is simply whether the child has active Montana Medicaid.[1][3][5][6][8][20]
Mountain-Pacific is a utilization review contractor, not a payer: the manual sends Additional Units of Service requests "to the Department or other designated reviewer," Mountain-Pacific’s Qualitrac portal, while DPHHS pays the claims. That is why this directory has one Montana Medicaid guide and no separate plan guides.[1][3][5][6][8][20]
Initial eligibility has three doors: a provisional qualifying diagnosis of ASD and "no older than 20 years of age"; DD eligibility (found eligible for state developmental disabilities services under ARM 37.34.201) and no older than 20; or a provisional SED diagnosis at 17 or younger, or up to 20 if enrolled in an accredited secondary school. The SED list is long (it includes major depressive disorder, generalized anxiety disorder, PTSD, OCD, oppositional defiant disorder and others; ADHD only alongside another SED diagnosis). Every category must also meet the Functional Impairment Criteria: impairment "for at least 180 calendar days or that is reasonably predicted to last at least 180 calendar days," shown by two or more of six listed problems, from failing to maintain peer relationships to behavior that disrupts the family’s ability to keep work.[1][3][5]
A physician, licensed mental health professional, nurse practitioner or psychologist must deem ABA medically necessary and write a prescription "stating the diagnosis for which the member is being referred and that the referral is for ABA services." Members receiving ABA are exempt from cost sharing.[1][3][5]
The BCBA starts care by sending the Intent to Initiate Treatment form and the prescription; the first date of service "may pre-date the Date of Submission." DPHHS emails back the billing span, and "No PA will be required during this billing span." The initial package is 1,260 units over 180 calendar days for all codes combined, used "as the BCBA provider sees fit," and unused units expire at day 180. Within 30 calendar days of starting, the provider must complete a behavior identification assessment and an individualized treatment plan.[1][5][6][7][10][19]
To continue, the BCBA submits the Additional Units of Service Request "at least 14 calendar days prior to the intended onset of continued service delivery," uploaded to Qualitrac, and "the Department may not give providers reimbursement retroactively for failure to submit timely, complete, and required documentation." The first such request needs the diagnostic evaluation that confirms the diagnosis, the initial BIA and the current treatment plan; later ones need a current BIA (within one year), a current treatment plan (within six months), proof of continuing functional impairment and, for SED, an annual clinical reassessment. Approvals run 180 calendar days and may not exceed 1,260 units. Requests missing information are pended, and a late response becomes a technical denial. Members can request an administrative review of a denial. DPHHS’s Required Document Components Checklist (updated 01.01.2026), "required for review for re-authorization," asks for the assessment tool’s results with "accompanying grids, tables, or graphs," the date the tool was given and a summary of findings, in both the treatment plan and the BIA; problem behaviors and at least three skill deficits "objectively identified and measured" with a baseline; at least three measurable skill-acquisition goals and three parent or generalization goals; and coordination-of-care, transition and discharge plans. "The same tool should be utilized for the entire treatment span" (VB-MAPP, ABLLS-R, AFLS or ABAS preferred). In Qualitrac the request is Review Type "Behavioral Health Outpatient," Place of Service "99 – Other Place of Service," Type of Service "ABA SED" or "ABA DD"; Mountain-Pacific’s user guide lists "Charts/graphs" among the clinical documentation that supports an extension and gives its review turnaround as 2 business days.[1][5][6][7][10][19]
The July 1, 2025 ABA fee schedule is the latest one DPHHS posts for ABA, per 15-minute unit: 97151 $40.41 (BCBA) or $29.91 with the TC modifier (BCaBA); 97152 $11.36; 97153 $11.36; 97154 $3.78; 97155 $20.46 (BCBA) or $15.17 with TC (BCaBA); 97156 $20.46; 97157 and 97158 $6.84. 0362T and 0373T are not on the schedule. Codes: "Providers bill using standard Current Procedural Terminology (CPT) procedure codes"; the ABA fee schedule lists only 97151–97158, with no HCPCS H-code. ABA is paid from the Department’s RBRVS system, "Applied Behavior Analysis Services do not require co-pay," and "All services are billed under the BCBA’s provider NPI." For state fiscal year 2027 DPHHS announced no legislatively authorized rate increases but did implement the 2026 RBRVS relative values, with pricing elements adjusted to stay budget neutral, and its July 1, 2026 fee-schedule notice lists ABA among the affected provider types; check the current RBRVS schedule before quoting a rate.[4][1][2][13][14]
Clean claims must reach Montana Healthcare Programs within twelve months of the date of service (or of a retroactive eligibility determination), or within six months of a Medicare EOB or a third-party adjustment notice when those come later. Bill other insurance first; if 90 days pass with no response from the other carrier, Medicaid can be billed with proof the claim was sent. Commercial payers are processed as third-party liability at the claim level on the CMS-1500. Telehealth ABA needs approval in advance on the ABA Telehealth Exception Request, which asks why video delivery is medically necessary, which goals are unsuitable and how the home setting is assessed for safety. Neither the ABA manual nor its forms mention electronic visit verification; DPHHS describes its EVV system as covering personal care, home health and other home and community-based services. "Montana Healthcare Programs payment and remittance advices are available weekly," paid by EFT; no submission cut-off is published.[11][16][9][21][1][17][18]
Corrections: a denied claim cannot be adjusted, only resubmitted. When the new Montana Healthcare Claims System starts (adjustment changes effective March 31, 2027), paper adjustments use a clean claim form with resubmission code 7 (replace) or 8 (void) and the original ICN in CMS-1500 box 22, the old Individual Adjustment Request form is retired, and "Claim adjustments must meet the timely filing requirements in" ARM 37.85.406, the same 12-month clock as new claims; a late adjustment is denied and the original payment is not reissued. The new system will also reject any claim without an affiliation between the rendering provider and the billing provider in the MES Provider Services Module, so link each RBT and BCBA to the group now.[11][16][9][21][1][17][18]
Providers who disagree with a Department decision can request an administrative review in writing within 30 days of the date the decision was mailed, and a fair hearing within 30 days of the review decision.[11][16][9][21][1][17][18]
Montana licenses behavior analysts through the Board of Psychologists (MCA 37-17-403), and Montana Medicaid’s forms are built around that license: the Intent to Initiate and Additional Units forms ask for the provider’s license number and have the "licensed Board Certified Behavior Analyst (BCBA)" attest to the service requirements, and the telehealth request asks for "BCBA NPI and License Number." State law lets "a person licensed under this title" deliver services by telehealth (MCA 37-2-305) and offers no registration for clinicians licensed only elsewhere. A BCBA outside Montana who wants to serve Montana Medicaid members, including by telehealth, should get a Montana behavior analyst license and Montana Medicaid enrollment first.[22][24][5][6][9][25]
The questions that decide whether a family can start with Montana Medicaid, and what they have to bring. Each maps onto something intake should ask on the first call.
ASD or DD-eligible: "no older than 20 years of age." SED: 17 or younger, or up to 20 if enrolled in an accredited secondary school.[1][3]
A provisional diagnosis is enough to start. The confirming diagnostic evaluation is required only with the first Additional Units request; after that the clocks run on the BIA (within one year) and treatment plan (within six months). SED requires a reassessment within 12 months of the last determination, and DD eligibility proof must be dated within 365 days.[1][6][7]
To continue past the first span, the diagnosis must be established by one of: child and adolescent psychiatrist; general psychiatrist; psychiatric mental health NP; developmental pediatrician; neurologist; neuropsychologist or psychologist; pediatrician; family physician; family or pediatric NP; physician assistant; clinical professional counselor; or clinical social worker. The form adds child and adolescent experience for general psychiatrists and psychiatric NPs.[1][6]
No instrument is named. The diagnostic evaluation must establish the diagnosis "through interview, observation, and formal assessment tools appropriate to the condition." For treatment progress, DPHHS asks for one tool across the whole span and prefers VB-MAPP, ABLLS-R, AFLS or ABAS.[1][7]
Yes. A physician, licensed mental health professional, nurse practitioner or psychologist must document medical necessity in a prescription "stating the diagnosis for which the member is being referred and that the referral is for ABA services," submitted with the Intent to Initiate form.[1][5]
Only with prior approval. The BCBA must file the ABA Telehealth Exception Request, which is "for prior authorization of services to be delivered via telehealth," explaining why telehealth is medically necessary, which treatment goals are unsuitable for it, how effectiveness will be monitored and how the home is checked for safety; DPHHS accepts or declines. DPHHS’s telehealth policy pays telehealth at the in-person rate when the service is medically necessary, clinically appropriate and allowed by the provider manual, and requires the appropriate CPT code, place of service and modifier. No ABA-specific telehealth code list, POS or modifier is published.[9][12][1]
Two business days. Mountain-Pacific’s Qualitrac Behavioral Health Provider User Guide (revised 06/24/2026) lists the ABA extension request (the Additional Units of Service request) with a "TAT for UM review of Ext Req" of "2 business days"; the initial span needs no PA ("TAT for UM review of PA: NA"). Submit "At least 14 calendar days before end of current auth period"; requests that arrive after the authorized period has expired "will be reviewed for MNC from the date of submission moving forward," so late requests lose the gap. Approved extensions cover 1,260 units over 180 calendar days. The federal ceiling for state fee-for-service prior authorization since January 1, 2026 is a standard decision "in no case later than 7 calendar days" (extendable up to 14) and an expedited one within 72 hours.[19][1][26]
Medicaid pays after other insurance: "In most cases, providers must bill other insurance carriers before billing Montana Healthcare Programs," and payment from all sources may not exceed the Medicaid fee. If another insurer has not responded in 90 days, bill Medicaid with proof the claim was sent. Commercial coverage and Medicare Advantage are processed as third-party liability at the claim level, with the primary EOB attached. Federal rule: 42 CFR 433.139.[11][16][27]
Coverage decides whether Montana Medicaid 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.
Services "must be directed by a BCBA or a BCBA-D," and an RBT practices "under the direction and close supervision of a BCBA," who "is responsible for all work RBTs perform" and "assumes full professional responsibility for all services provided by a BCaBA or RBT." No numeric supervision ratio is published. State licensure law adds that a BCaBA or behavior technician must be supervised by a licensed behavior analyst or an ABPP-certified behavioral psychologist (MCA 37-17-405).[1][4][23]
Each span is a package of 1,260 units over 180 calendar days for all ABA codes combined, used as the BCBA sees fit; unused units expire at the end of the span. DPHHS training lists "Billing more units per date of service than allowed" as a common denial, but neither the manual nor the fee schedule publishes a per-day unit limit.[1][4][10]
The person who provided the service signs and dates it. The General Information for Providers manual’s record-keeping list requires "Each medical record entry must be signed and dated by the person ordering or providing the service," with the date and time of service, the name and title of the person providing it (other than the billing practitioner), and the description and length of treatment. The ABA manual adds that direct treatment, supervision, parent training and progress be documented "in a manner consistent with practice guidelines." It sets no deadline for signing; the underlying rule, ARM 37.85.414, was not opened.[11][1]
The manual sets no home, clinic or school restriction. ABA can run alongside PHP, day treatment, CSCT, therapeutic group home, home support services, therapeutic foster care, extraordinary needs aide and SED case management if billed outside those programs’ authorized hours with documented coordination, but not alongside CBPRS, PRTF, acute inpatient or IOP. Telehealth delivery needs an approved Telehealth Exception Request.[1][9]
"All services are billed under the BCBA’s National Provider Identifier (NPI)." The Additional Units and Transfer forms ask for both a group NPI and the rendering NPI, and rendering providers must be affiliated to the billing NPI in the portal.[1][4][6][8][10]
Not addressed. The manual’s "Concurrent Services" section is about other children’s mental health programs (ABA must be billed outside their authorized hours), not about billing 97153 and 97155 for the same clock time.[1]
Blocked on: DPHHS ABA Program Officer, (406) 444-3878, or Montana Provider Relations, (800) 624-3958: ask for written guidance on billing 97155 during a 97153 session.
Yes, for members up to age 20 with ASD or DD eligibility, and for children with certain serious emotional disturbances (up to 17, or 20 if in secondary school), when they meet the functional impairment criteria. DPHHS runs the benefit directly.
A physician, licensed mental health professional, nurse practitioner or psychologist, who documents medical necessity "in the form of a prescription stating the diagnosis for which the member is being referred and that the referral is for ABA services." The prescription goes in with the Intent to Initiate form. For a child whose qualifying diagnosis is SED, later requests for more units need an annual clinical re-assessment by one of those professionals.
No. DPHHS administers ABA itself: the Developmental Disabilities Program receives the start paperwork, Mountain-Pacific Quality Health reviews additional units, and the BCBA bills the state.
No. The first 180 days or 1,260 units, assessment included, start on an Intent to Initiate form and a prescription with no PA. Prior authorization applies to every span after that.
Per 15 minutes on the July 2025 schedule: 97151 $40.41, 97153 $11.36, 97155 and 97156 $20.46, 97152 $11.36, 97154 $3.78, 97157/97158 $6.84; BCaBA lines with the TC modifier pay less. Everything is billed under the BCBA’s NPI.
Plan on a Montana license first. Montana licenses behavior analysts, Medicaid’s forms ask for the license number, Montana’s telehealth statute covers people licensed under Montana law, and ABA telehealth also needs an approved Telehealth Exception Request.
Its Qualitrac user guide gives 2 business days for the ABA extension request. Submit at least 14 calendar days before the current span ends; a request that arrives after the span has expired is reviewed only from the date it was submitted.
Yes. The Required Document Components Checklist asks for the assessment tool results with accompanying grids, tables or graphs, baselines for problem behaviors and skill deficits, and the same tool across the whole span; Mountain-Pacific also lists charts and graphs as supporting documentation.
No. ABA is billed with standard CPT codes, and the ABA fee schedule lists only 97151–97158.
Twelve months from the date of service, or six months from a Medicare EOB or third-party adjustment notice when that is later.
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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