---
title: "Ohio Medicaid ABA coverage: the intake guide."
url: "https://carelu.com/payers/ohio-medicaid"
markdown_url: "https://carelu.com/payers/ohio-medicaid.md"
state: OH (Ohio)
payer: Ohio Medicaid
kind: State Medicaid program
description: "How Ohio Medicaid covers ABA (adaptive behavior services) under OAC 5160-34-02 — prior authorization, 6-month reviews, published fee-schedule rates by credential tier, COBA/BCBA credentialing, and why OhioRISE never pays for ABA."
last_reviewed: October 2026
vob_data_updated: 2026-10-15
---

# Ohio Medicaid ABA coverage: the intake guide.

_Payer Guide · Ohio Medicaid · Last updated October 2026 · 25 primary sources_

> OAC 5160-34: all-PA ABA, 6-month reviews, published rates, and the OhioRISE carve-out myth.

Ohio Medicaid covers ABA — "adaptive behavior services" — for the assessment and treatment of autism spectrum disorder under Ohio Administrative Code rule 5160-34-02. Ohio runs heavily through its Next Generation managed-care plans, several of which layer genuinely distinct clinical policies on the state rule, so the per-plan guides below matter more here than in most states. Two facts worth knowing cold: OhioRISE (Aetna) never pays for ABA — the member's MCO does, even for OhioRISE-enrolled youth — and ODM has a pending rewrite of the ABA chapter that would loosen assessment PA.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment:** Not published / unverified. Verify via: OAC 5160-34-02 does not exist as an in-force rule: codes.ohio.gov returns “No Ohio Administrative Code rule number corresponds to ‘5160-34’” (re-confirmed 10/1/2026), the chapter is absent from the Title 5160 index, and ODM’s draft rewrite (ERF188422B) is still marked “DRAFT — NOT FOR FILING” with no JCARR filing (per ODM’s 7/30/2026 stakeholder presentation). Confirm current practice with Rules@Medicaid.Ohio.gov or JCARR, or the member’s MCO.
- **Prior auth for treatment:** Not published / unverified. Verify via: OAC 5160-34-02 does not exist as an in-force rule: codes.ohio.gov returns “No Ohio Administrative Code rule number corresponds to ‘5160-34’” (re-confirmed 10/1/2026), the chapter is absent from the Title 5160 index, and ODM’s draft rewrite (ERF188422B) is still marked “DRAFT — NOT FOR FILING” with no JCARR filing (per ODM’s 7/30/2026 stakeholder presentation). Confirm current practice with Rules@Medicaid.Ohio.gov or JCARR, or the member’s MCO.

## At a glance

- **Covers ABA?:** Yes — adaptive behavior services for ASD (OAC 5160-34-02)
- **Prior auth:** Required for all covered ABA codes (current rule)
- **Reviews:** Medical necessity at baseline, then every 6 months
- **Rates (per 15 min):** No in-force published ABA schedule; ODM’s unfiled draft lists 97153 $16.04 (RBT) · 97155 $27.28 · 97151 $30.49 (COBA/BCBA tier)
- **Credentialing:** COBA or BCBA/BCBA-D as independent practitioner; ODM Provider Type 19
- **OhioRISE:** Does NOT pay ABA — bill the member's MCO (or FFS), always
- **Staff screening:** COBA: BCI + FBI fingerprint check (OAC 4783-4-03) · RBTs: BACB background + abuse-registry check within 180 days

## Coverage & the state rule

OAC rule 5160-34-02 covers adaptive behavior services for the assessment and treatment of ASD, with prior authorization required for all covered ABA codes at both initial and ongoing stages and medical-necessity review at baseline and at least every six months. The ASD diagnosis must come from a documented comprehensive diagnostic evaluation by a licensed physician, psychologist, or other clinician qualified to diagnose autism, demonstrating DSM-5-TR criteria. Independent practitioners are Certified Ohio Behavior Analysts (COBA, under ORC Chapter 4783) or BACB BCBAs/BCBA-Ds, enrolled with ODM as Provider Type 19, Specialty 190; BCaBAs and RBTs work under supervision. [1][2][3]

Watch the pending rewrite: ODM has drafted new rules 5160-34-01 through -03 that would, among other changes, require assessment PA only beyond 10 hours per 180 days and remove specific diagnostic-condition requirements. The broken codes.ohio.gov citation flagged in earlier reviews now has a documented cause: per ODM's own 7/30/2026 provider stakeholder presentation, the ABA rule package was paused in 2025 for reevaluation — a mix of state budget pressure, national scrutiny of ABA spending, and state OIG audit findings elsewhere citing improper-payment takebacks ($56.5M in Indiana, $17.3M in Massachusetts, $18.5M in Wisconsin, $42.6M in Colorado, cited by ODM for context on why ABA rules are under review nationally). The chapter is under active revision again, with provider comments on the current draft due 8/5/2026, but no JCARR (Joint Committee on Agency Rule Review) filing exists yet — it remains pre-filing, not adopted law, so nothing below has changed. codes.ohio.gov's live page for rule 5160-34-02 still returns "no rule number corresponds" as of this review, and the entire 5160-34 chapter is still missing from the Title 5160 master chapter index; confirm current rule status with Rules@Medicaid.Ohio.gov or JCARR before relying on the codes.ohio.gov citation below. [1][2][3]

Forward-looking only — DRAFT, NOT YET ADOPTED, do not treat as current policy: draft rule 5160-34-01 would require full RBT certification (dropping today's exam-eligible pathway), CARF or Joint Commission organizational accreditation, and a dedicated ABA provider type. Draft rule 5160-34-03 would introduce a two-tier intensity structure — Comprehensive (10–25 hrs/week) vs. Focused (1–20 hrs/week) — restrict eligibility to ASD only, require a diagnosing/referring practitioner who is independent of (not employed by) the ABA provider, require 4 hours/month of parent participation, and explicitly ban billing ABA under non-ABA/behavioral-health codes. None of this governs coverage today; re-check when (and if) the chapter files with JCARR. [1][2][3]

## Rates: what Ohio Medicaid pays for 97153 and the other ABA codes

Ohio Medicaid has no in-force, published ABA rate table to quote. ODM’s main non-institutional fee schedule (Appendix DD to OAC 5160-1-60, revised January 1, 2026) has no rows for 97151–97158, 0362T or 0373T, and the ABA rule chapter 5160-34 is not in the Ohio Administrative Code (codes.ohio.gov, rechecked October 7, 2026). The only ODM table for these codes is Appendix A to the draft rule 5160-34-03 in package ERF188422B, headed “Fee schedule for Applied Behavior Analysis” with a “current maximum payment amount” column, on pages marked “DRAFT - NOT YET FILED”: 97153 (RBT) $16.04 per 15-minute unit; 97151 $30.49 (independent practitioner: COBA/BCBA/BCBA-D) or $22.67 (BCaBA); 97152 $17.00; 97154 $7.61; 97155 $27.28 / $20.63; 97156 $30.09 / $22.37; 97157 and 97158 $14.46 / $10.62; 0362T and 0373T $33.54. Treat those as ODM’s draft figures and confirm the amount on a paid fee-for-service remittance or with ODM before modelling revenue. [2][26][27][28][29]

Most members are in an MCO, which pays under its own provider contract, and no Ohio MCO publishes its ABA rates. House Bill 453 (introduced September 15, 2025; in the House Insurance Committee since October 1, 2025) would set MCO payment rates for 97151–97158 at “one hundred per cent of the fee-for-service rate” for fiscal year 2027 and require commercial payers to pay at least 100% of the Medicaid fee schedule. It is a pending bill, not law. [2][26][27][28][29]

## The OhioRISE carve-out myth

A recurring point of confusion in Ohio: OhioRISE — the Aetna-run specialty plan for youth with complex behavioral-health needs — does not cover ABA. ODM's Mixed Services Protocol states explicitly that claims for ABA services (97151–97158, 0362T, 0373T) for ASD are the responsibility of the member's Medicaid MCO or fee-for-service, even when the youth is enrolled in OhioRISE. If an intake team hears "we're on OhioRISE," the follow-up question is which MCO holds the medical benefit — that's who authorizes and pays for ABA. [4]

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

Ohio layers no separate technician license or state registry on top of the BACB — behavior technicians are RBTs, so the BACB's own bar is the employee-level floor: applicants must be at least 18 with a high-school education, complete the 40-hour training and initial competency assessment, and pass both a criminal background check and an abuse-registry check no more than 180 days before applying (the BACB itself doesn't require fingerprinting). The pending rule rewrite (draft 5160-34-01) would formalize this — defining the RBT as a BACB-certified paraprofessional under close, ongoing supervision of a COBA, BCBA, or BCBA-D — and would add a 90-day "exam-eligible RBT" window: a technician who has finished the coursework and competency assessment could render supervised services for 90 days from exam eligibility, documented on form ODM 10391, then must be certified or stop rendering. As of the May 2025 clearance package that chapter was still marked draft and not yet filed — hire to the BACB requirements today and re-check when it files. [8][2][9][10][11][12][13][6]

Screening runs at two levels, and it pays to keep them straight. At the supervisor level, COBA applicants must complete a fingerprint-based BCI criminal-records check that includes an FBI check (OAC 4783-4-03) — the Board of Psychology accepts results only directly from BCI, won't issue the certificate without acceptable results, and the applicant bears the cost (the board doesn't currently publish COBA application fees in a retrievable form — confirm directly). At the organization level, OAC 5160-1-17.8 runs the database battery at enrollment and revalidation: the provider and every 5%-or-greater owner or managing agent are screened against the HHS-OIG exclusion list, SAM, the Medicare Exclusion Database, other states' Medicaid termination lists, the ODH nurse aide registry, and the DODD abuser registry — a hit disqualifies the provider agreement (the appendix assigning ABA Provider Type 19's screening risk level wasn't retrievable; high-risk types add owner fingerprinting). One trap: Ohio's ARCS registry-check mandates (OAC 5123-2-02) bind DODD-system and waiver staff, not state-plan ABA — no Ohio rule mandates employee-level fingerprints for state-plan-only RBTs, so the BACB 180-day check plus mirroring the OIG/SAM exclusion checks on all staff is the operative standard. [8][2][9][10][11][12][13][6]

Supervision is where Ohio is unusual: OAC 4783-6-02 requires the COBA to build a written supervision plan into each client's treatment plan — naming every supervisee, their relationship to the client, and their responsibilities, with the amount and type of training and supervision specified — and mandates consultation before plan initiation and before any modification plus periodic direct observation, but sets no fixed ratio; frequency and intensity are the COBA's documented judgment, and client assessment, treatment-plan development, and efficacy review can never be delegated. The quantitative floor comes from the plans instead: Optum/UHC's Ohio Medicaid criteria (effective 7/1/2026) require 1–2 hours of direct case supervision per 10 hours of direct treatment per week, citing CASP standards, and CareSource's MM-0028 requires supervision records retained 5 years (COBAs) or 7 years (BCBAs/RBTs) after supervision ends — with claims tied to documentation discrepancies subject to recoupment. Staff to the strictest contracted plan, not the state rule. [8][2][9][10][11][12][13][6]

## Is Ohio Medicaid's ABA network open to new providers?

Ohio has no ABA-specific enrollment moratorium we can cite, and the front door is centralized. Certified Ohio Behavior Analysts are on the list of practitioners for whom “credentialing by ODM is mandatory” (OAC 5160-1-42), through ODM’s CAQH-based process with recredentialing every 36 months. Contracting is still per plan: AmeriHealth Caritas Ohio’s January 2026 manual tells providers to start contracting with each MCO while enrolling and being credentialed at ODM, that the plan interest can be flagged in ODM’s PNM system when applying, and that a provider is not participating until both credentialing and contracting are complete. Whether a given MCO’s ABA panel is open is that plan’s contracting decision. One policy signal: ODM paused its ABA rule rewrite in 2025 citing budget shortfalls and national concern over ABA growth and spending, and its draft would create an ABA-specific organizational provider type — a draft that governs nothing yet. [19][20][3]

## Ohio Medicaid ABA claims: filing deadline, referring provider, payment clock and EVV

Filing deadline: a fee-for-service claim is timely if ODM receives it within 365 days of the date the service was provided, and a denied claim resubmitted for payment has the same 365 days from the date of service; underpaid claims should be adjusted within 365 days too (OAC 5160-1-19(D)). Paper claims are not accepted. The Medicaid MCOs’ manuals apply the same 365-day limit by reference to this rule. [21][22][23]

Rendering, supervising and referring providers: “Claims for items and services that necessitate a rendering or supervising provider, order, prescription, referral, or certification will be denied if” they do not carry that provider’s NPI and legal name, or the provider has no active Medicaid provider agreement (5160-1-19(C)). [21][22][23]

Payment clock: federal rules require ODM to pay 90% of clean practitioner claims within 30 days of receipt and 99% within 90 days (42 CFR 447.45(d)). [21][22][23]

EVV does not apply to ABA in Ohio. OAC 5160-32-01 lists the services subject to Ohio’s EVV program — named waiver services in the home care, MyCare, PASSPORT and developmental-disability waivers, plus state-plan home health, private duty nursing and RN assessment and consultation — and makes managed care entities responsible for applying it; ABA is not on the list, and services delivered by telehealth are exempt. [21][22][23]

## Intake gates

The questions that decide whether a family can start with Ohio Medicaid, and what they have to bring.

- **Who may diagnose**: The ASD diagnosis must come from a documented comprehensive diagnostic evaluation by a licensed physician, psychologist, or other clinician qualified to diagnose autism, demonstrating DSM-5-TR criteria. Optum’s Ohio Medicaid supplemental criteria, which defer to the Ohio Administrative Code on practitioner requirements, restate the same bar: a valid ASD diagnosis issued by a state licensed physician, psychologist, or other state licensed clinician qualified to make such a diagnosis under DSM-5-TR. Several MCOs narrow it further — CareSource restricts the diagnosis to a child or adolescent psychiatrist, psychologist, child neurologist, or developmental pediatrician. [1][13][6]
- **Prior-auth decision time**: Two layers. The statute covers ODM and its designees, including the MCOs: for requests submitted electronically, they must “respond to all prior authorization requests within forty-eight hours for urgent care services, or ten calendar days for any prior authorization request that is not for an urgent care service, of the time the request is received” (R.C. 5160.34). An incomplete request must get a reply naming “the specific additional information that is required.” Stricter rules now override the 10 days. For MCO members (most ABA families), OAC 5160-26-03.1 has required 7 calendar days standard and 48 hours expedited since 1/1/2026. For fee-for-service requests, the federal rule caps standard decisions at 7 calendar days and expedited at 72 hours from 1/1/2026 (42 CFR 440.230(e)). Together: 7 calendar days standard, 48 hours urgent. An adverse decision can be reconsidered: ODM decides “within ten calendar days of receipt,” or within 48 hours for urgent care services (OAC 5160-1-31). None of the rules read here sets an ABA reauthorization lead time. [30][31][32][33]
- **Other insurance (who pays first)**: Ohio Medicaid pays last. OAC 5160-1-08: “The medicaid program must be the last payer to receive and adjudicate the claim,” and the provider must get the other insurer’s details from the family and “bill the insurance company prior to billing ODM.” Ask about other coverage at every visit, whether or not the Medicaid card shows it. ODM pays only after “reasonable measures”: a remittance from the other payer showing a valid reason for non-payment; three submissions within ninety days and no reply within ninety days of the last one; a partial payment with its remittance; or written proof from the other payer that the service is not covered. Valid reasons include “the service is not covered,” charges applied to the deductible or copays, and a benefit maximum reached. Payment “will not exceed the medicaid maximum payment for the service … less all third party payments.” Exception: “Medicaid pays before any TPL and medicare for preventive pediatric services identified in 42 C.F.R. 433.139.” Medicaid also pays before the children with medical handicaps program and the crime-victims reparations program. Neither 5160-1-08 nor the PA rule (5160-1-31) exempts a secondary Medicaid claim from Ohio Medicaid prior authorization. [34][33]

## Delivery and billing rules

Coverage decides whether Ohio 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**: Ohio is unusual in setting no fixed ratio at the state level. OAC 4783-6-02 requires the Certified Ohio Behavior Analyst to build a written supervision plan into each client’s treatment plan — naming every supervisee, their relationship to the client and their responsibilities, with the amount and type of training and supervision specified — and mandates consultation before plan initiation and before any modification plus periodic direct observation, while leaving frequency and intensity to the COBA’s documented judgment. Client assessment, treatment-plan development and efficacy review can never be delegated. The quantitative floors come from the plans instead: Optum’s Ohio Medicaid criteria (eff. 7/1/2026) require 1–2 hours of direct case supervision per 10 hours of direct treatment per week, citing CASP; Buckeye’s CP.BH.104 puts 97155 at a minimum of 2 hours a week or 10% of direct hours, whichever is greater, capped at 20% unless justified; and CareSource requires supervision records retained 5 years for COBAs or 7 years for BCBAs and RBTs. Staff to the strictest contracted plan, not the state rule. [12][13][15][6]
- **Daily limits / MUEs**: The per-day ceiling is a claim edit, not an ABA rule. Ohio’s claim-submission rule says claims “should be submitted pursuant to the national correct coding initiative” (OAC 5160-1-19(B)), and the CMS Medicaid NCCI practitioner MUE table active 10/1–12/31/2026 sets 97151 at 32 units, 97152 at 16, 97153 at 32, 97154 at 18, 97155 at 24, 97156 at 16, 97157 at 16, 97158 at 16, 0362T at 16 and 0373T at 32 units per date of service. No in-force Ohio ABA rule sets an hours-per-day or hours-per-week cap that we can read: codes.ohio.gov still returns “No Ohio Administrative Code rule number corresponds to ‘5160-34’” (re-checked 10/18/2026) and ODM’s draft rewrite (ERF188422B, “DRAFT — NOT FOR FILING”) does not govern, so any weekly ceiling comes from the prior authorization itself. Managed care plans set their own limits — see each plan’s guide. [21][24]
- **Bill as provider**: Independent practitioners are Certified Ohio Behavior Analysts (COBA, under ORC Chapter 4783) or BACB BCBAs and BCBA-Ds, enrolled with ODM as Provider Type 19, Specialty 190; BCaBAs and RBTs work under supervision. Optum’s Ohio Medicaid criteria add the claim-level detail: COBA providers must be enrolled with Ohio Medicaid as Provider Type 19, Specialty Type 190 and hold a National Provider Identifier for both the rendering provider and the group provider, and a provider not enrolled with Medicaid needs a single case agreement. The routing rule that trips Ohio intake teams is separate and firm: OhioRISE does not pay for ABA — ODM’s Mixed Services Protocol assigns claims for 97151–97158, 0362T and 0373T to the member’s Medicaid MCO or fee-for-service even when the youth is enrolled in OhioRISE. [1][13][4]
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: Rules@Medicaid.Ohio.gov for the in-force rule; otherwise a written coding determination from the member’s MCO (CareSource UM (800) 488-0134, Buckeye UM (800) 224-1991). [1]

## What intake should collect for Ohio Medicaid

- **Member ID & Next Gen MCO:** CareSource, Buckeye, Molina, Anthem, UHC, AmeriHealth Caritas, or Humana — several run materially different ABA policies.
- **OhioRISE status + underlying MCO:** OhioRISE never pays ABA — identify the MCO that does.
- **ASD diagnosis (DSM-5-TR):** The comprehensive diagnostic evaluation, the licensed clinician who completed it, and the date — some MCOs restrict which specialties qualify.
- **Rendering practitioner tier:** COBA/BCBA vs. BCaBA vs. RBT determines the rate line — staffing is a revenue decision.
- **Review cadence:** Baseline and 6-month medical-necessity reviews — the intake baseline sets the terms.

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

## Verification of benefits (VOB) data

How Ohio Medicaid ABA benefits route and read on an eligibility check. Data last updated 2026-10-15.

### EDI routing

- **Payer ID (pVerify):** 00165
- **Supports 270/271 eligibility:** Yes
- **Real-time eligibility:** Yes
- **Behavioral health administrator:** none — ABA is a medical benefit of the member's MCO (or FFS); OhioRISE (Aetna) is enrolled-but-never-the-ABA-payer
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No
- **Where the 271 carries MCO enrollment:** Loop 2110C EB01='MC' flags MCO enrollment; the MCO entity is named in Loop 2120C NM1 (NM101='PR', name free-text in NM103); EB05 carries the coded 'Plan Coverage Description' (defined in ODM's separate 271 Code Crosswalk). MCO routing is also identifiable via the fixed ODM trading-partner codes in ISA06/ISA08 and the 2100A NM109 MCE-payer-ID table (see mcoCarrierCodes). OhioRISE (Aetna) is separately visible (trading partner 0021914 / MCE payer 60054) — but per ODM's Mixed Services Protocol OhioRISE never pays ABA; identify the underlying medical MCO, which is the ABA payer.
- **Eligibility span granularity:** Monthly — EB06 Time Period Qualifier '34' (Month); coverage reported through the last day of the queried month. Transaction supports real-time and batch.

Managed-care codes returned in the 271:

| Code | Meaning |
| --- | --- |
| 60054 | Aetna OhioRISE — 2100A NM109 MCE claims payer ID (OhioRISE, not ABA) |
| 61103 | Humana Ohio Medicaid — 2100A NM109 MCE claims payer ID |
| 88337 | UnitedHealthcare Ohio Medicaid — 2100A NM109 MCE claims payer ID |
| 842435374 | AmeriHealth Caritas Ohio — 2100A NM109 MCE claims payer ID |
| MMISODJFS | ODM Fee-for-Service (ISA06/08 trading partner) |
| 0021920 | AmeriHealth Caritas Ohio (ISA trading partner) |
| 0002937 | Anthem BCBS Ohio — medical MCE (ISA trading partner / 2100A NM109 payer ID) |
| 0004202 | Buckeye Health Plan (ISA trading partner / MCE payer ID) |
| 0003150 | CareSource (ISA trading partner / MCE payer ID) |
| 0021919 | Humana Health Plan of Ohio (ISA trading partner) |
| 0007316 | Molina Healthcare of Ohio (ISA trading partner / MCE payer ID) |
| 0007610 | UnitedHealthcare Community Plan of Ohio (ISA trading partner) |
| 0021914 | Aetna OhioRISE (ISA trading partner) — NEVER pays ABA; the member's medical MCO does |

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes — covered for Medicaid individuals under 21 following a comprehensive diagnostic evaluation (OAC 5160-34; OhioRISE Mixed Services Protocol lists all 10 codes as MCO/FFS-paid) | Required — current OAC 5160-34-02 all-PA rule. The pending (not-yet-filed) 5160-34-03 rewrite would exempt assessment/reassessment up to 10 hrs per 180 days. | 32 units/day (CMS NCCI MUE ceiling, enumerated in CareSource PY-1638, eff. 9/1/2026 — formerly in MM-0028, split out effective 9/1/2026 with figures unchanged) per day | — | — | Priced by practitioner tier (Independent COBA/BCBA/BCBA-D · BCaBA · RBT), not by a billing modifier in the ODM fee appendix — confirm any claim-level tier modifier with ODM/the MCO |
| 97152 | Yes — covered for Medicaid individuals under 21 following a comprehensive diagnostic evaluation (OAC 5160-34; OhioRISE Mixed Services Protocol lists all 10 codes as MCO/FFS-paid) | Required — current OAC 5160-34-02 all-PA rule. The pending (not-yet-filed) 5160-34-03 rewrite would exempt assessment/reassessment up to 10 hrs per 180 days. | 16 units/day (CMS NCCI MUE ceiling, enumerated in CareSource PY-1638, eff. 9/1/2026 — formerly in MM-0028, split out effective 9/1/2026 with figures unchanged) per day | — | — | Priced by practitioner tier (Independent COBA/BCBA/BCBA-D · BCaBA · RBT), not by a billing modifier in the ODM fee appendix — confirm any claim-level tier modifier with ODM/the MCO |
| 97153 | Yes — covered for Medicaid individuals under 21 following a comprehensive diagnostic evaluation (OAC 5160-34; OhioRISE Mixed Services Protocol lists all 10 codes as MCO/FFS-paid) | Required — at treatment initiation and again for continuation beyond the initial 180-day authorization (current rule; draft 5160-34-03 retains treatment PA). | 32 units/day (CMS NCCI MUE ceiling, enumerated in CareSource PY-1638, eff. 9/1/2026 — formerly in MM-0028, split out effective 9/1/2026 with figures unchanged) per day | — | — | Priced by practitioner tier (Independent COBA/BCBA/BCBA-D · BCaBA · RBT), not by a billing modifier in the ODM fee appendix — confirm any claim-level tier modifier with ODM/the MCO |
| 97154 | Yes — covered for Medicaid individuals under 21 following a comprehensive diagnostic evaluation (OAC 5160-34; OhioRISE Mixed Services Protocol lists all 10 codes as MCO/FFS-paid) | Required — at treatment initiation and again for continuation beyond the initial 180-day authorization (current rule; draft 5160-34-03 retains treatment PA). | 18 units/day (CMS NCCI MUE ceiling, enumerated in CareSource PY-1638, eff. 9/1/2026 — formerly in MM-0028, split out effective 9/1/2026 with figures unchanged) per day | — | — | Priced by practitioner tier (Independent COBA/BCBA/BCBA-D · BCaBA · RBT), not by a billing modifier in the ODM fee appendix — confirm any claim-level tier modifier with ODM/the MCO |
| 97155 | Yes — covered for Medicaid individuals under 21 following a comprehensive diagnostic evaluation (OAC 5160-34; OhioRISE Mixed Services Protocol lists all 10 codes as MCO/FFS-paid) | Required — at treatment initiation and again for continuation beyond the initial 180-day authorization (current rule; draft 5160-34-03 retains treatment PA). | 24 units/day (CMS NCCI MUE ceiling, enumerated in CareSource PY-1638, eff. 9/1/2026 — formerly in MM-0028, split out effective 9/1/2026 with figures unchanged) per day | — | — | Priced by practitioner tier (Independent COBA/BCBA/BCBA-D · BCaBA · RBT), not by a billing modifier in the ODM fee appendix — confirm any claim-level tier modifier with ODM/the MCO |
| 97156 | Yes — covered for Medicaid individuals under 21 following a comprehensive diagnostic evaluation (OAC 5160-34; OhioRISE Mixed Services Protocol lists all 10 codes as MCO/FFS-paid) | Required — at treatment initiation and again for continuation beyond the initial 180-day authorization (current rule; draft 5160-34-03 retains treatment PA). | 16 units/day (CMS NCCI MUE ceiling, enumerated in CareSource PY-1638, eff. 9/1/2026 — formerly in MM-0028, split out effective 9/1/2026 with figures unchanged) per day | — | — | Priced by practitioner tier (Independent COBA/BCBA/BCBA-D · BCaBA · RBT), not by a billing modifier in the ODM fee appendix — confirm any claim-level tier modifier with ODM/the MCO |
| 97157 | Yes — covered for Medicaid individuals under 21 following a comprehensive diagnostic evaluation (OAC 5160-34; OhioRISE Mixed Services Protocol lists all 10 codes as MCO/FFS-paid) | Required — at treatment initiation and again for continuation beyond the initial 180-day authorization (current rule; draft 5160-34-03 retains treatment PA). | 16 units/day (CMS NCCI MUE ceiling, enumerated in CareSource PY-1638, eff. 9/1/2026 — formerly in MM-0028, split out effective 9/1/2026 with figures unchanged) per day | — | — | Priced by practitioner tier (Independent COBA/BCBA/BCBA-D · BCaBA · RBT), not by a billing modifier in the ODM fee appendix — confirm any claim-level tier modifier with ODM/the MCO |
| 97158 | Yes — covered for Medicaid individuals under 21 following a comprehensive diagnostic evaluation (OAC 5160-34; OhioRISE Mixed Services Protocol lists all 10 codes as MCO/FFS-paid) | Required — at treatment initiation and again for continuation beyond the initial 180-day authorization (current rule; draft 5160-34-03 retains treatment PA). | 16 units/day (CMS NCCI MUE ceiling, enumerated in CareSource PY-1638, eff. 9/1/2026 — formerly in MM-0028, split out effective 9/1/2026 with figures unchanged) per day | — | — | Priced by practitioner tier (Independent COBA/BCBA/BCBA-D · BCaBA · RBT), not by a billing modifier in the ODM fee appendix — confirm any claim-level tier modifier with ODM/the MCO |
| 0362T | Yes — covered for Medicaid individuals under 21 following a comprehensive diagnostic evaluation (OAC 5160-34; OhioRISE Mixed Services Protocol lists all 10 codes as MCO/FFS-paid) | Required — current OAC 5160-34-02 all-PA rule. The pending (not-yet-filed) 5160-34-03 rewrite would exempt assessment/reassessment up to 10 hrs per 180 days. | 16 units/day (CMS NCCI MUE ceiling, enumerated in CareSource PY-1638, eff. 9/1/2026 — formerly in MM-0028, split out effective 9/1/2026 with figures unchanged) per day | — | — | Priced by practitioner tier (Independent COBA/BCBA/BCBA-D · BCaBA · RBT), not by a billing modifier in the ODM fee appendix — confirm any claim-level tier modifier with ODM/the MCO |
| 0373T | Yes — covered for Medicaid individuals under 21 following a comprehensive diagnostic evaluation (OAC 5160-34; OhioRISE Mixed Services Protocol lists all 10 codes as MCO/FFS-paid) | Required — at treatment initiation and again for continuation beyond the initial 180-day authorization (current rule; draft 5160-34-03 retains treatment PA). | 32 units/day (CMS NCCI MUE ceiling, enumerated in CareSource PY-1638, eff. 9/1/2026 — formerly in MM-0028, split out effective 9/1/2026 with figures unchanged) per day | — | — | Priced by practitioner tier (Independent COBA/BCBA/BCBA-D · BCaBA · RBT), not by a billing modifier in the ODM fee appendix — confirm any claim-level tier modifier with ODM/the MCO |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** The in-force/draft ODM ABA rule sets NO per-code daily unit cap of its own — only an assessment PA threshold (10 hrs/180 days) and a 1:8 group-session ratio (97154/97158). The daily cap shown is the CMS NCCI MUE ceiling. POS settings and telehealth mechanics are not enumerated in the draft rule package and could not be read from the JS-gated in-force OAC text this pass — shipped unverified. A rewrite of OAC 5160-34 is under active revision (ODM office-hours presentation, 7/30/2026) but not yet filed with JCARR — treat draft 5160-34-01/-03 detail as pending, not current. Verify via: ODM telehealth rule (OAC 5160-1-18) and the member's MCO policy.

### Medicaid rates

Source: ODM ABA fee appendix (Appendix A to draft rule 5160-34-03, package ERF188422B.pdf) — "CURRENT MAXIMUM PAYMENT AMOUNT," per 15-min unit, by practitioner tier. DRAFT (not-yet-filed) filing with a blank effective-date column; the only published ODM ABA fee document and the one ohio.ts prose already quotes. No billing-modifier column — priced by practitioner-tier descriptor. Rechecked 2026-10-07: ODM’s Appendix DD to OAC 5160-1-60 (revised 1/1/2026) has no ABA rows and chapter 5160-34 is still absent from the OAC, so no in-force schedule replaces these draft figures.

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | Tiered — see modifierTiers (assessment) | 15min | Independent (COBA/BCBA/BCBA-D): $30.49; BCaBA: $22.67 |
| 97152 | $17.00 per 15-min unit (RBT tier) | 15min | RBT: $17.00 |
| 97153 | $16.04 per 15-min unit (RBT tier) | 15min | RBT: $16.04 |
| 97154 | $7.61 per 15-min unit (RBT tier, group) | 15min | RBT: $7.61 |
| 97155 | Tiered — see modifierTiers | 15min | Independent (COBA/BCBA/BCBA-D): $27.28; BCaBA: $20.63 |
| 97156 | Tiered — see modifierTiers (family guidance) | 15min | Independent (COBA/BCBA/BCBA-D): $30.09; BCaBA: $22.37 |
| 97157 | Tiered — see modifierTiers (multi-family group) | 15min | Independent (COBA/BCBA/BCBA-D): $14.46; BCaBA: $10.62 |
| 97158 | Tiered — see modifierTiers (group w/ protocol modification) | 15min | Independent (COBA/BCBA/BCBA-D): $14.46; BCaBA: $10.62 |
| 0362T | $33.54 per 15-min unit (single rate) | 15min | — |
| 0373T | $33.54 per 15-min unit (single rate) | 15min | — |

### Contacts

- **Benefits by phone:** Yes
- **Provider services phone:** (800) 686-1516
- **Hours:** Not posted on the PNM contact page — confirm at time of call
- **Portal:** [ODM PNM (Provider Network Management) Module](https://ohpnm.omes.maximus.com/OH_PNM_PROD/Account/Login.aspx)

Questions to ask on a verification call:

- For members under 21, is PA still required on assessment codes 97151/97152/0362T, or has the 5160-34-03 rewrite's assessment-PA exemption (up to 10 hrs/180 days) taken effect yet?
- What place-of-service settings (home, school, clinic, telehealth) are currently approved for ABA billing?
- Is telehealth allowed for any ABA code, and if so which codes and under what modifier?
- Do ABA claims need a practitioner-tier billing modifier (Independent COBA/BCBA/BCBA-D vs. BCaBA vs. RBT), or is tier reflected some other way on the claim?
- This member shows OhioRISE enrollment on the eligibility response — can you confirm ABA claims should route to their underlying medical MCO (or FFS), not OhioRISE?

### VOB data sources

- https://dam.assets.ohio.gov/image/upload/medicaid.ohio.gov/Providers/MITS/HIPAA%205010%20Implementation/CompanionGuide/OMES/FFS/Ohio270-271.pdf (accessed 2026-07-23)
- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://dam.assets.ohio.gov/image/upload/medicaid.ohio.gov/Stakeholders,%20Partners/LegalandContracts/Rules/ERF188422B.pdf (accessed 2026-07-23)
- https://dam.assets.ohio.gov/image/upload/v1743449666/managedcare.medicaid.ohio.gov/OhioRISE/OhioRISE_Mixed_Services_Protocol_20250401.pdf (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.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23)
- https://codes.ohio.gov/ohio-administrative-code/rule-5160-34-02 (accessed 2026-07-23)
- https://dam.assets.ohio.gov/image/upload/medicaid.ohio.gov/BH/provider/Presentations/7.30_ABA_Presentation.pdf (accessed 2026-09-01)
- https://www.caresource.com/documents/medicaid-oh-policy-reimburse-py-1638-20260901 (accessed 2026-09-01)
- https://ohpnm.omes.maximus.com/OH_PNM_PROD/Process/ContactUs.aspx (accessed 2026-07-23)
- https://dam.assets.ohio.gov/image/upload/medicaid.ohio.gov/Providers/MyCareOhio/Next_Generation_MyCare_Program_Provider_Help_Desk_One-Pager.pdf (accessed 2026-10-14)

## Common questions

### Does Ohio Medicaid cover ABA therapy?

Yes — as adaptive behavior services for ASD under OAC 5160-34-02, with prior authorization on all covered ABA codes and medical-necessity reviews at baseline and every six months.

### Does OhioRISE cover ABA?

No — ODM's Mixed Services Protocol assigns ABA claims to the member's Medicaid MCO (or FFS) even for OhioRISE-enrolled youth. Always identify the underlying MCO.

### What does Ohio Medicaid pay for ABA?

No in-force schedule is published. ODM’s only ABA rate table is in its unfiled draft rule (ERF188422B): per 15-minute unit, 97153 at $16.04 (RBT), 97155 at $27.28 and 97151 at $30.49 at the COBA/BCBA tier, with lower BCaBA-tier amounts. MCOs pay their own contracted rates, which are not published.

### Who can provide ABA under Ohio Medicaid?

Independent practitioners are COBAs (Ohio Board of Psychology, ORC 4783) or BCBAs/BCBA-Ds enrolled as ODM Provider Type 19, Specialty 190; BCaBAs and RBTs deliver under supervision.

### Is Ohio Medicaid accepting new ABA providers?

There is no ABA enrollment moratorium we can cite. Behavior analysts (COBAs) are credentialed once, centrally, by ODM under OAC 5160-1-42, but you still contract with each MCO separately, and whether a plan's ABA panel is open is its own decision. Start MCO contracting while your ODM enrollment and credentialing are in process.

### What does Ohio Medicaid pay for 97153?

There is no in-force published rate to quote. ODM’s main fee schedule (Appendix DD, revised 1/1/2026) has no ABA rows, and the ABA rule chapter 5160-34 is not in the Ohio Administrative Code. ODM’s only table is the appendix to its unfiled draft rule (ERF188422B), which lists 97153 at $16.04 per 15-minute unit (RBT) under a “current maximum payment amount” heading on pages marked “DRAFT - NOT YET FILED.” MCOs pay their own contracted rates and do not publish them. House Bill 453 would set MCO ABA rates at 100% of the fee-for-service rate for fiscal year 2027, but it is still in committee.

### What is Ohio Medicaid’s timely filing limit for ABA claims?

365 days from the date of service, including resubmissions of denied claims (OAC 5160-1-19). The Ohio Medicaid MCOs apply the same 365 days.

### Does Ohio Medicaid require the referring or supervising provider on the claim?

Yes, when the service needs one: ODM denies claims that lack the NPI and legal name of the required rendering, supervising, ordering, referring or certifying provider, or where that provider has no active Medicaid agreement (OAC 5160-1-19(C)).

### Does Ohio Medicaid require EVV for ABA?

No. OAC 5160-32-01 limits EVV to listed waiver services and state-plan home health, private duty nursing and RN visits; ABA is not included, and telehealth services are exempt.

## Primary sources

1. [Ohio Administrative Code — rule 5160-34-02](https://codes.ohio.gov/ohio-administrative-code/rule-5160-34-02)
2. [ODM — ABA rule package + Appendix A fee schedule (draft filing)](https://dam.assets.ohio.gov/image/upload/medicaid.ohio.gov/Stakeholders,%20Partners/LegalandContracts/Rules/ERF188422B.pdf)
3. [ODM — Provider Stakeholder Office Hours: ABA Proposed Rule Review (7/30/2026)](https://dam.assets.ohio.gov/image/upload/medicaid.ohio.gov/BH/provider/Presentations/7.30_ABA_Presentation.pdf)
4. [ODM — OhioRISE Mixed Services Protocol](https://dam.assets.ohio.gov/image/upload/v1743449666/managedcare.medicaid.ohio.gov/OhioRISE/OhioRISE_Mixed_Services_Protocol_20250401.pdf)
5. [Ohio Medicaid Managed Care Health Plan Comparison (2026) — confirms current 7-plan roster](https://ohfiles.blob.core.windows.net/public/OhioMHWebsite/Documents/Ohio%20Medicaid%20Managed%20Care%20Health%20Plan%20Comparison%202026.pdf)
6. [CareSource — Ohio Medicaid ABA policy (MM-0028, eff. 9/1/2026)](https://www.caresource.com/documents/medicaid-oh-policy-medical-mm-0028-20260901)
7. [CareSource — Ohio Medicaid ABA reimbursement policy (PY-1638, eff. 9/1/2026)](https://www.caresource.com/documents/medicaid-oh-policy-reimburse-py-1638-20260901)
8. [BACB — RBT Handbook (background-check and supervision requirements)](https://www.bacb.com/rbt-handbook)
9. [Ohio Administrative Code — rule 4783-4-03 (COBA criminal records check)](https://www.law.cornell.edu/regulations/ohio/Ohio-Admin-Code-4783-4-03)
10. [Ohio Administrative Code — rule 5160-1-17.8 (provider screening)](https://www.law.cornell.edu/regulations/ohio/Ohio-Admin-Code-5160-1-17-8)
11. [Ohio Administrative Code — rule 5123-2-02 (DODD background investigations)](https://www.law.cornell.edu/regulations/ohio/Ohio-Admin-Code-5123-2-02)
12. [Ohio Administrative Code — rule 4783-6-02 (COBA supervision responsibilities)](https://www.law.cornell.edu/regulations/ohio/Ohio-Admin-Code-4783-6-02)
13. [Optum/UHC Community Plan — Ohio Medicaid supplemental clinical criteria (eff. 7/1/2026)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/optumLOCG/ohlocg/ohMedcadLOCG.pdf)
14. [Anthem OH Medicaid — provider manual (10/2025)](https://providers.anthem.com/docs/gpp/OH_CAID_ProviderManual.pdf)
15. [Buckeye — CP.BH.104 Applied Behavior Analysis (rev. 2/2026)](https://www.buckeyehealthplan.com/content/dam/centene/Buckeye/policies/clinical-policies/CP.BH.104.pdf)
16. [Anthem OH Medicaid — Clinical UM Guidelines list (CG-BEH-02)](https://providers.anthem.com/docs/gpp/OH_CAID_FEB23CUMG.pdf)
17. [ODM — Telehealth Billing Guidelines (FFS, DOS on or after 1/1/2026)](https://dam.assets.ohio.gov/image/upload/medicaid.ohio.gov/Providers/Billing/BillingInstructions/Telehealth_Billing_Guidelines_updates_for_2026_final.pdf)
18. [OAC 5160-1-18 — Telehealth](https://codes.ohio.gov/ohio-administrative-code/rule-5160-1-18)
19. [OAC 5160-1-42 — Medicaid provider credentialing](https://codes.ohio.gov/ohio-administrative-code/rule-5160-1-42)
20. [AmeriHealth Caritas Ohio — Provider Manual (v6, January 2026)](https://www.amerihealthcaritasoh.com/content/dam/amerihealth-caritas/acoh/pdf/provider/provider-manual.pdf)
21. [OAC 5160-1-19 — Claim submission and payment (timely filing), codes.ohio.gov](https://codes.ohio.gov/ohio-administrative-code/rule-5160-1-19)
22. [42 CFR 447.45(d) — timely processing of Medicaid fee-for-service claims (eCFR)](https://www.ecfr.gov/current/title-42/section-447.45)
23. [OAC 5160-32-01 — Electronic visit verification: programs and services subject to EVV, codes.ohio.gov](https://codes.ohio.gov/ohio-administrative-code/rule-5160-32-01)
24. [CMS — Medicaid NCCI MUE edits, practitioner services (2026 Q4, active 10/1–12/31/2026)](https://www.cms.gov/files/zip/medicaid-ncci-2026-q4-mue-edits-practitioner-services.zip)
25. [Ohio Department of Medicaid — News for Providers (index of ODM Press provider bulletins and notices)](https://managedcare.medicaid.ohio.gov/news/news-for-providers)
26. [ODM — Appendix DD to OAC 5160-1-60, non-institutional fee schedule (updates for 1/1/2026, XLSX)](https://dam.assets.ohio.gov/raw/upload/medicaid.ohio.gov/Providers/FeeScheduleRates/OutpatientHospital/5160-1-60-_App_DD-_Updates_for_01_01_2026-_FINAL.xlsx)
27. [codes.ohio.gov — Chapter 5160-34 lookup (“No Ohio Administrative Code rule number corresponds,” checked October 7, 2026)](https://codes.ohio.gov/ohio-administrative-code/chapter-5160-34)
28. [Ohio House Bill 453 (136th General Assembly), as introduced — ABA coverage and payment rates](https://search-prod.lis.state.oh.us/api/v2/general_assembly_136/legislation/hb453/00_IN/html/)
29. [Ohio Legislature — HB 453 status (introduced 9/15/2025; referred to House Insurance 10/1/2025)](https://www.legislature.ohio.gov/legislation/136/hb453/status)
30. [R.C. 5160.34 — Ohio Medicaid prior authorization requirements](https://codes.ohio.gov/ohio-revised-code/section-5160.34)
31. [OAC 5160-26-03.1 — MCO utilization management and authorization timeframes (eff. 1/1/2026)](https://codes.ohio.gov/ohio-administrative-code/rule-5160-26-03.1)
32. [42 CFR 440.230(e) — Medicaid fee-for-service prior authorization timeframes, from 1/1/2026 (eCFR)](https://www.ecfr.gov/current/title-42/section-440.230)
33. [OAC 5160-1-31 — Medicaid prior authorization (eff. 6/30/2024)](https://codes.ohio.gov/ohio-administrative-code/rule-5160-1-31)
34. [OAC 5160-1-08 — Medicaid coordination of benefits](https://codes.ohio.gov/ohio-administrative-code/rule-5160-1-08)

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.