---
title: "Neighborhood Health Plan of Rhode Island ABA coverage: the intake guide."
url: "https://carelu.com/payers/neighborhood-health-plan-rhode-island"
markdown_url: "https://carelu.com/payers/neighborhood-health-plan-rhode-island.md"
state: RI (Rhode Island)
payer: Neighborhood Health Plan of Rhode Island
kind: Medicaid managed care plan (MCO)
parent_program: Rhode Island Medicaid (RIte Care managed care)
description: "How Neighborhood Health Plan of Rhode Island covers ABA for RIte Care members: ABA as a subset of HBTS, its admission criteria, HCPCS coding with XP and U1 modifiers, in-house behavioral health since September 2025, 180-day filing, and its commercial exchange ABA rule."
last_reviewed: October 2026
---

# Neighborhood Health Plan of Rhode Island ABA coverage: the intake guide.

_Payer Guide · Neighborhood Health Plan of RI · Last updated October 2026 · 14 primary sources_

> RI Medicaid plan; ABA is a subset of HBTS (HCPCS codes), managed in-house since 9/1/2025; its exchange plans cover ABA to age 20.

Neighborhood Health Plan of Rhode Island holds one of the three EOHHS Medicaid managed care contracts. Its Autism and Developmental Services Payment Policy (posted July 2026) describes HBTS as including "Applied Behavioral Analysis, Personal Assistance Services and Supports (PASS), Respite," and its clinical policy BH-001 sets separate ABA criteria "for Medicaid Members (subset of HBTS)."

Two changes matter for agencies that worked with Neighborhood before. Behavioral health moved in-house: providers should have sent Optum claims for dates of service before September 1, 2025, and behavioral health providers now contract and credential directly with Neighborhood. And the plan’s commercial exchange products cover ABA on CPT codes, but only for members under age 20.

This plan administers the **Rhode Island Medicaid (RIte Care managed care)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Rhode Island Medicaid guide](https://carelu.com/payers/rhode-island-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment:** Not published / unverified. Verify via: Neighborhood Utilization Management, 401-459-6060, or Provider Services, 1-800-963-1001: ask whether the ABA assessment (H2014 or H0046 lines) needs authorization. [1][6]
- **Prior auth for treatment:** Not published / unverified. Verify via: Neighborhood Utilization Management, 401-459-6060 (fax 401-459-6023): confirm whether T1024 and H0046 need prior authorization for RIte Care members. [1][2][6]
- **Autism diagnosis required?**: Yes, but not only autism: Medicaid ABA eligibility requires a member "Diagnosed with a cognitive, developmental and/or an Autism Spectrum Disorder within the last three years" with significant social, behavioral and communication challenges, and the diagnostic report must state "the diagnosis, and the evidence used to make that diagnosis" [2][1]

## At a glance

- **Covers ABA?:** Yes: Medicaid members under 21, as a subset of HBTS; exchange plans under age 20
- **Medicaid codes:** T1024 (U1 = 15-min unit), H0046 lead therapy / -HO / -HP supervision, H2014, T1016, T1013, S9446; XP when 2 agencies
- **Authorization:** Criteria in CMP BH-001; auth line 1-800-963-1001, fax 401-459-6023; code list not published
- **Decision clock:** Medicaid standard 7 calendar days; expedited 3 days
- **Timely filing:** 180 days from date of service; Medicaid clinical appeals within 60 days
- **Behavioral health:** Managed in-house since 9/1/2025 (formerly Optum)
- **Licensure:** Credentials Licensed Applied Behavioral Analysts (LBA)

## Medicaid ABA: criteria and coding

Neighborhood’s Medicaid ABA criteria require all of: a comprehensive diagnostic and/or functional assessment "(e.g., ABLLS-R, Vineland-II, ADIR, ADOS-G, CARS2, VB-MAPP, or Autism Behavior Checklist)"; atypical or disruptive behavior that "significantly interferes with daily functioning" or poses risk; an "Initial evaluation from a Licensed Applied Behavior Analyst" supporting the request; and a diagnostic report that states the diagnosis and its evidence. Continuation requires measurable progress shown by "behavioral graphs, progress notes, and daily session notes," parent involvement, care coordination and no duplication of IEP services. ABA is non-covered for Medicaid members 21 and older. [1][2]

The payment policy lists the Medicaid HBTS codes: H0046 lead therapy, H0046-HO and H0046-HP clinical supervision (30-minute units, or 15-minute units with U1), H2014 treatment consultation (with HO or HP), S9446 social skills group, T1013 interpretation (up to 8 hours a month), T1016 treatment coordination, and T1024 home-based therapy (30-minute unit, or 15-minute with U1). Append XP "When 2 agencies are supporting the same member"; treatment consultation "cannot be duplicated across agencies." Services must be "ordered by a practitioner," and ABA must be "overseen by a Board-Certified Behavior Analyst (BCBA) or a licensed trained professional (e.g., Psychologist)." [1][2]

## Network, claims and appeals

Behavioral health providers join Neighborhood directly: submit the network application, sign the contract, and pass the Credentialing Committee, which "may take up to 45 days"; Licensed Applied Behavioral Analysts are on the list of credentialed behavioral health clinicians. The rendering provider field is mandatory ("or the claim will be denied"), and fee schedules are requested from bhcontracting@nhpri.org. Neighborhood’s supervisory-billing policy (U5 modifier) "does not apply to ABA services." Complete claims must reach Neighborhood "within one hundred eighty (180) days from the date of service," clean electronic claims are paid within 30 days and paper within 40, and for Medicaid Neighborhood "is the payer of last resort," with 180 days from the primary carrier’s EOB to bill a secondary balance. Medicaid clinical claim appeals "must be filed within 60 days of receiving the initial denial." [4][3][5]

## Licensure and out-of-state BCBAs

Rhode Island licenses behavior analysts, so a BCBA licensed elsewhere cannot simply treat a Rhode Island child. Under R.I. Gen. Laws § 5-86-21(g), an analyst "licensed or certified in another state" may practice in Rhode Island without a Rhode Island license "for up to ten (10) calendar days per calendar year with no more than five (5) days of this activity occurring consecutively." Beyond that, the clinician needs a Rhode Island license (LBA) from the Department of Health board, which requires passing the BCBA exam and keeping active BACB status (§ 5-86-9). Chapter 5-86 has no telehealth exception and no reciprocity section. For Medicaid telehealth, EOHHS is explicit: an out-of-state provider may serve Medicaid members by telehealth only with "an active and unrestricted license in the state of Rhode Island" and Rhode Island Medicaid enrollment; "Out-of-state licensure alone does not confer eligibility." [10][11][9]

## Intake gates

The questions that decide whether a family can start with Neighborhood Health Plan of Rhode Island, and what they have to bring.

- **Age limit**: Medicaid: under 21 ("Noncovered for members 21 years old and older"). Commercial exchange plans: "ABA is covered up to age 20" (non-covered at 20 and older). [1][2]
- **Diagnosis recency**: Diagnosis "within the last three years" for Medicaid ABA; the HBTS criteria likewise need a diagnosis "made within 3 years" and an evaluation by a licensed mental health professional within three years. [2][1]
- **Who may diagnose**: A "qualified licensed health care professional" for the diagnosis, and a licensed mental health professional for the three-year evaluation (CMP BH-001, HBTS criteria). The ABA initial evaluation must come from a Licensed Applied Behavior Analyst. [1]
- **Diagnostic tools required**: A comprehensive diagnostic and/or functional assessment, "e.g., ABLLS-R, Vineland-II, ADIR, ADOS-G, CARS2, VB-MAPP, or Autism Behavior Checklist." [1]
- **Referral required?**: Yes: "Services must be ordered by a practitioner." For children under 3 in early intervention, a valid PCP referral to early intervention is required. The licensing law also has a licensed analyst provide ABA only when prescribed by a child psychiatrist, behavioral developmental pediatrician, child neurologist or child-trained licensed psychologist (R.I. Gen. Laws § 5-86-2(8)). [2][1][15]
- **Prior-auth decision time**: Prior authorization decisions: Medicaid standard requests "seven (7) calendar days after receiving the request," commercial 14 calendar days; expedited requests three calendar days for both; post-service 30 days. [3][12]
- **Other insurance (who pays first)**: "For Medicaid, Neighborhood is the payer of last resort. If a member is known to have other primary insurance coverage, all claims must be filed to the primary insurer first," and COB claims must be submitted electronically. Contracted providers have "180 days from the date on the primary carrier’s EOB to submit for any secondary balances," and Neighborhood pays as secondary only for covered benefits. [3][13]
- **Telehealth** _(plan-dependent)_: Neighborhood covers services "delivered through telemedicine/telephone, as defined by Rhode Island laws," when the patient is present, the service is medically necessary and clinically appropriate, the exchange is sufficient to meet the in-person service’s requirements, and it meets the same standard of care; "For coding related to telehealth services, please see applicable payment policies." The ABA payment policy publishes no telehealth codes or modifier. Its EOHHS contract bars stricter prior authorization or lower behavioral health rates for telemedicine. [3][2][7]
  - Ask the plan: Neighborhood Provider Services, 1-800-963-1001: ask which HBTS/ABA components may be delivered by telehealth and the POS/modifier to bill.

## Delivery and billing rules

Coverage decides whether Neighborhood Health Plan of Rhode Island 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**: The ABA treatment plan "is developed by a Licensed, Applied Behavior Analyst"; sessions are "typically provided by behavioral technicians or paraprofessionals" and "The technician is supervised by the Licensed, Applied Behavior Analyst." Neighborhood publishes no numeric ratio. Its contract with EOHHS requires monthly in-home observation of each worker by the clinical supervisor, and ABA "overseen by a Board-Certified Behavior Analyst (BCBA) or a licensed trained professional." [1][2][7]
- **Daily limits / MUEs**: HBTS hours must be justified by medical necessity "up to 20 hours per week (excluding ABA programs), or more as clinically indicated." No ABA unit cap is published; T1013 interpretation is limited to 8 hours a month. [1][2]
- **Place of service**: ABA covered by Neighborhood is "typically in a home or community setting." "Services provided in a school setting are distinct and separate," and services in a school setting as part of the IEP are excluded. [1][2]
- **Bill as provider**: Behavioral health providers "must fill in the rendering provider field, or the claim will be denied." The U5 supervisory-billing route "does not apply to ABA services"; the commercial ABA codes take a degree modifier (HN bachelor’s, HO master’s, HP doctorate). Billing and supervising providers must be screened and credentialed. [4][5][2]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not addressed in Neighborhood’s ABA policies. The payment policy lets two agencies bill for one member (XP modifier) but bars duplicating treatment consultation across agencies. [2]
  - Ask the plan: Neighborhood Provider Services, 1-800-963-1001, or your behavioral health contract (bhcontracting@nhpri.org).
- **Session-note signature** _(ask the plan)_: Continuation requires progress "evidenced by behavioral graphs, progress notes, and daily session notes," and documentation must support the service billed; Neighborhood "follows CMS standards for proper documentation requirements." It does not say who signs session notes or by when. [1][2]
  - Ask the plan: Neighborhood Provider Services, 1-800-963-1001: ask for the documentation standard for HBTS/ABA session notes.

## What intake should collect for Neighborhood Health Plan of Rhode Island

- **Member ID and product:** RIte Care (Medicaid) versus an exchange plan: the codes, age limit and rules differ.
- **Diagnostic report:** A cognitive, developmental or autism diagnosis within the last three years, stating the evidence; a named instrument (ADOS, CARS2, Vineland and others).
- **LBA initial evaluation:** An initial evaluation by a Licensed Applied Behavior Analyst supporting the request.
- **Practitioner order:** Neighborhood requires services to be ordered by a practitioner.
- **Current IEP:** Providers must obtain and keep a current copy of the IEP; services may not duplicate it.

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

## Common questions

### Does Neighborhood Health Plan of Rhode Island cover ABA?

Yes. For Medicaid (RIte Care) members under 21, ABA is a subset of Home Based Therapeutic Services. Its commercial exchange plans cover ABA for members under 20.

### Does Neighborhood still use Optum for behavioral health?

No. Neighborhood manages behavioral health in-house as of September 1, 2025; Optum claims for earlier dates could be followed up with Neighborhood until August 31, 2026.

### Which codes does Neighborhood use for Medicaid ABA?

The HBTS HCPCS codes: T1024 (direct service), H0046 (lead therapy; HO/HP for clinical supervision), H2014, T1016, T1013 and S9446, with U1 for 15-minute units and XP when two agencies serve one child. Its commercial plans use CPT 97151–97158.

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

180 days from the date of service, unless your contract says otherwise; 180 days from the primary carrier’s EOB for secondary claims.

## Primary sources

1. [Neighborhood Health Plan of RI — Clinical Medical Policy BH-001, Behavioral Health: Home and Community Based Services (last reviewed 08/20/2025)](https://www.nhpri.org/blobnhpri08e0944faa/wp-content/uploads/2025/08/2025.09.01-CMP-BH-001-Behavioral_Health_Home_and_Community_Based_Services.pdf)
2. [Neighborhood Health Plan of RI — Autism and Developmental Services Payment Policy (posted 7/10/2026)](https://www.nhpri.org/blobnhpri08e0944faa/wp-content/uploads/2026/07/Autism-and-Developmental-Services-Payment-Policy-7.10.26.pdf)
3. [Neighborhood Health Plan of RI — Provider Manual (effective 1/1/2026)](https://www.nhpri.org/wp-content/uploads/2023/08/Provider-Manual.pdf)
4. [Neighborhood Health Plan of RI — Behavioral Health provider page and FAQ (in-house since September 1, 2025)](https://www.nhpri.org/providers/provider-resources/behavioralhealth/)
5. [Neighborhood Health Plan of RI — Behavioral Health Supervisory Billing Payment Policy (03.13.2026; excludes ABA)](https://www.nhpri.org/wp-content/uploads/2026/03/Behavioral-Health-Supervisory-Billing-Payment-Policy-03.13.2026.pdf)
6. [Neighborhood Health Plan of RI — Prior Authorization Reference Guide page (RIte Care guide last updated 2/1/2021)](https://www.nhpri.org/providers/policies-and-guidelines/prior-authorization-reference/)
7. [EOHHS–Neighborhood Health Plan of RI Medicaid Managed Care Contract, Amendment 21 (full contract, effective July 1, 2026)](https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2026-08/NHPRI_Amend_21_executed_Fully%20Executed_20260624.pdf)
8. [RI EOHHS — Certification Standards for Providers of Home Based Therapeutic Services (inclusive of ABA), July 2016](https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2021-03/HBTSJuly2016.pdf)
9. [RI EOHHS — Telemedicine Billing Guidance (July 2025, effective September 1, 2025)](https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2025-07/Telemedicine%20Billing%20Guidance.pdf)
10. [R.I. Gen. Laws § 5-86-21 — Persons and practices exempt (out-of-state analysts: 10 calendar days a year)](https://webserver.rilegislature.gov/Statutes/TITLE5/5-86/5-86-21.htm)
11. [R.I. Gen. Laws § 5-86-9 — Qualifications and examinations for licensing (BCBA exam, active BACB status)](https://webserver.rilegislature.gov/Statutes/TITLE5/5-86/5-86-9.htm)
12. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-D/section-438.210)
13. [42 CFR 433.139 — Medicaid third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
14. [Neighborhood Health Plan of RI — Provider Newsletter archive (Neighborhood News)](https://www.nhpri.org/providers/communication/provider-newsletter/)
15. [R.I. Gen. Laws § 5-86-2 — Definitions (practice of ABA; services provided only when prescribed by listed specialists), as amended effective June 30, 2025](https://webserver.rilegislature.gov/Statutes/TITLE5/5-86/5-86-2.htm)

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.