Oklahoma Complete Health ABA coverage (SoonerSelect).

Follows the SoonerCare rule: Under 21. OAC 317:30-5-313 requires that "The member is under twenty-one (21) years of age," and OHCA provides ABA "under the EPSDT benefit" (OAC 317:30-3-65.12). No lower age bound is set. (OHCA’s provider application page words it as "ages 21 and younger"; the rule text says under 21.) Oklahoma Complete Health was checked for its own rule on this point and publishes nothing different, so the OHCA rule applies.^{[10][21][20][2][1]}

OK.CP.BH.500 requires disruptive behaviour "within the last 30 days" but, being dated 07/25, does not repeat OHCA’s 9/1/2025 rule that the diagnostic evaluation "should be no older than two (2) years old" at the start of ABA. The plan covers requests under OHCA Part 30, so plan to the two-year limit.^[2][10]

OK.CP.BH.500 (07/25) lists pediatric neurologist or neurologist, developmental pediatrician, licensed psychologist, psychiatrist or neuropsychiatrist, and other licensed physician experienced in ASD. OHCA’s rule as revised 9/1/2025 also accepts an interdisciplinary team (licensed psychologist, physician, PA or APRN) and requires the diagnostician to be in Oklahoma or within 50 miles; the plan’s policy has not caught up, so an interdisciplinary-team diagnosis is worth confirming with the plan before relying on it.^[2][10]

Follows the SoonerCare rule: No single instrument is mandatory. The evaluation must include a complete medical and social history and be "based on criteria outlined in the Diagnostic and Statistical Manual of Mental Disorders (DSM)", and "may also include scores" from formal tests such as the ADI-R, ADOS-2 or CARS "or other tools with acceptable psychometric properties." "Screening scales are not sufficient to make a diagnosis and will not be accepted as the only formal scale." For the ABA clinical assessment itself, OHCA cites validated measures such as the Vineland, and accepts supporting assessments such as the ABLLS-R, AEPS and VB-MAPP with the PA request. Oklahoma Complete Health was checked for its own rule on this point and publishes nothing different, so the OHCA rule applies.^{[10][16][11][2][1]}

Neither OK.CP.BH.500 nor the manual’s ABA entry requires a physician referral; the gate is prior authorization of 97151, 97153, 97155 and 97156. OHCA’s rule requires no referral either.^{[2][1][4][11]}

The manual allows telehealth subject to the same rules as in-person care and defers billing to the billing manual, which has no ABA content; CP.BH.105 requires cameras on and working audio for telehealth sessions and bars 97155 protocol-modification visits by telehealth "unless allowed by state guidelines." OHCA’s rule applies underneath: telehealth justified in the PA, and 97151, 97155 and 97156 (not 97153) on OHCA’s telehealth code list.^{[1][3][11][18]}

The 2026 manual: "Standard Preservice/Non-Urgent Within 7 calendar days," expedited 72 hours, concurrent review 3 calendar days. State law (56 O.S. § 4002.6) sets the same 7 days and 72 hours from receipt of all necessary information and deems the service authorized if a complete portal request is not decided in time. Extensions follow OHCA’s seven-day window. The plan’s 2024 fax form still prints "no later than 72 hours" for standard requests; the manual is newer.^{[1][13][8][12]}

"Oklahoma Complete Health, like all Medicaid programs, is always the payer of last resort." Bill the primary payer first and attach its EOB/EOP; a member with more than one primary insurance needs a paper claim. The manual names pay-and-chase for "Preventive Pediatric services, including Early and Periodic Screening, Diagnostic, and Treatment (EPSDT)" but does not say whether ABA is treated that way, so bill the primary first. OHCA’s rule adds that the state’s authorization meets the primary insurer’s PA requirement.^[1][22]

Case supervision of at least 10% of direct treatment hours from June 30, 2026 ("increasing required case supervision from 5% to 10% of direct treatment hours"), above OHCA’s 5% monthly RBT floor. OHCA’s conditions for concurrent RBT and supervision billing still apply.^[5][14][11]

Follows the SoonerCare rule: Allowed, with conditions. "Providers may only concurrently bill RBT and supervision hours when the following criteria is outlined in the prior authorization request," and the BCBA or licensed psychologist must have directed the RBT in session. "ABA is not allowed to be billed concurrently during any other therapies (i.e., OT, PT speech, etc.)," and "ABA hours approved for one CPT code cannot be used in place of another." Oklahoma Complete Health was checked for its own rule on this point and publishes nothing different, so the OHCA rule applies.^[11][2][1]

No per-day cap on direct treatment beyond OHCA’s authorization limits, but CP.BH.105 limits 97155 protocol-modification visits to eight units (two hours) a day, and group codes are not covered. OHCA’s intensity tiers and 32-unit FBA cap apply.^{[3][6][10][11]}

CP.BH.105: documentation carries the "signature and printed names of the member/enrollee, legal guardian, rendering clinician/technician and supervising practitioner (as applicable)," each note the "Signature of qualified rendering provider/technician," start and stop times, pauses and location; discharge summaries need the rendering provider’s and caregiver’s signatures. OHCA’s treatment-plan signature rule applies underneath.^[3][16]

Follows the SoonerCare rule: Home, community or clinic ("ABA may be provided in a variety of settings, including home, community, or clinical"). "ABA services are not allowed in a daycare setting or school setting, without OHCA approval. If approved, it will be time-limited to three (3) months or less," with a plan to fade support to school staff; private-school transitions are also capped at three months. School or daycare shadowing and aide work is excluded. Telehealth is allowed if justified in the PA (97151, 97155, 97156 on OHCA’s telehealth code list). Oklahoma Complete Health was checked for its own rule on this point and publishes nothing different, so the OHCA rule applies.^{[17][11][18][2][1]}

The plan’s manuals publish only the generic CMS-1500 rule (rendering NPI in box 24J), and OK.CP.BH.500 adopts OHCA’s provider rules, under which BCaBAs and RBTs are not paid directly and payment goes to the supervising BCBA or employing agency. Whether the plan wants the RBT’s NPI as rendering is not stated.^{[1][2][19][20]}

Ask the plan: Oklahoma Complete Health provider services (833-752-1664) or the Availity claim edits: ask whose NPI goes in box 24J for 97153 delivered by an RBT.