Oregon Health Plan (Medicaid) ABA coverage: the intake guide.

Oregon Health Plan covers applied behavior analysis for autism spectrum disorder and for stereotyped movement disorder with self-injurious behavior. The rules are short and specific: OAR 410-172-0760 says who may recommend and deliver ABA, OAR 410-172-0770 lists what the diagnostic evaluation must contain, and HERC’s Prioritized List places ABA (CPT 97151–97158) on funded Line 192 under Guideline Note 75. Most members are enrolled in a coordinated care organization (CCO), which authorizes and pays for ABA; members with open card (fee-for-service) OHP go through OHA and its contractor.

For an agency entering the OHP market, three things matter first. Every clinician who bills directly must hold an Oregon behavior-analysis license (or another Oregon health license whose scope includes ABA); the intake packet is heavier than most states’, because OHA wants a physical exam and a hearing test on file before ABA starts; and the open-card rates are published, so you can model them against each CCO’s contract.

Where ABA sits: the Prioritized List, OAR 410-172, and the member’s CCO

OHP covers condition–treatment pairs on HERC’s Prioritized List, funded through line 470 until December 31, 2026. Guideline Note 75 puts ABA, "represented by CPT codes 97151-97158," on Line 192 AUTISM SPECTRUM DISORDERS. For children 1–12 it includes early intensive behavioral intervention "for up to six months" at a time, with ongoing coverage "based on demonstrated progress towards meaningful predefined objectives" measured on a standardized multimodal assessment no more often than every six months; less intensive ABA (parent training, play-based and joint-attention interventions) is covered when intensive ABA is not indicated, with six-month initial coverage. For members 13 and older, "Intensive ABA is not included on this line," but targeted ABA for problem behaviors is. Guideline Note 126 adds targeted ABA for self-injurious behavior on Line 436.^{[11][12][5][13][16][17][15]}

Two rules soften the age split. OAR 410-172-0770(3) says "Services in excess of the HERC Prioritized List coverage guidance or guideline notes shall be provided when medically appropriate for a particular individual, including individuals age 13 and older," and lists factors such as severity, how recently the diagnosis was made, and comorbidities. And for members under 21, OHA’s EPSDT Provider Guide (March 2026) says OHA, CCOs and providers "Cannot use the Prioritized List, coverage guidance or guideline notes to determine coverage broadly or for an entire age group or population under EPSDT."^{[11][12][5][13][16][17][15]}

Most members belong to a CCO. OHA lists 12 CCOs serving the state by county; PacificSource Community Solutions left Lane County after 2025, and most of its Lane members moved to Trillium Community Health Plan on February 1, 2026. OHA’s behavioral health page sends CCO authorization questions to the CCO and open-card ABA questions to OHA’s contractor.^{[11][12][5][13][16][17][15]}

The front door: evaluation, referral and the open-card request

Before ABA starts, OAR 410-172-0770 requires an evaluation by a physician, psychologist, or developmental-medicine nurse practitioner or physician associate experienced in autism, documenting: an ASD diagnosis on the Prioritized List’s ASD line; "results from a standardized, validated tool, such as the Autism Diagnostic Observation Schedule (ADOS)"; the DSM-5 core features; a parent or caregiver interview; a review of medical records; direct observation; developmental status "using validated assessments ... such as the Vineland" (which the ABA provider may supply); a comprehensive medical exam (a well-child exam counts if within one year for ages 1–6 or two years for ages 6–18); and a hearing test within one year for ages 2–5 or two years for ages 6–18. The exam and hearing test "must be completed before starting ABA but may not be allowed to delay or interrupt ABA services." It ends with a referral for ABA, with or without hours.^{[5][4][6][14][15]}

For open-card members, OHA’s care-coordination contractor (Acentra Health) lists the steps: a specialist evaluates and recommends ABA, the PCP or specialist refers, and "ABA provider submits prior auth request to OHP by faxing to 503-378-5814 or can load request into MMIS themselves," with the EDMS cover sheet; e-mailed requests are not accepted, and "an assessment that refers to a doctor that gave a child a diagnosis of autism is not enough. There must be a documented diagnosis and order from the physician." OHA’s own behavioral health page gives OR1915i@kepro.com for fee-for-service ABA authorizations. Retroactive authorization is possible only in limited cases, requested within 90 days of service (OAR 410-172-0650(6)).^{[5][4][6][14][15]}

Rates, staffing and licensure

OHA’s fee-for-service behavioral health fee schedule (update published 7/1/2026) pays, per 15-minute unit: 97151 $20.85, 97152 $19.81, 97153 $14.70, 97154 $13.72, 97155 $32.07, 97156 $32.07 and 97157 $8.68 (rates effective 7/1/2024). 97158, 0362T and 0373T do not appear on the schedule. The schedule lists rendering provider types per code: 97151 BCBA, physician, psychologist or a legislatively approved licensed health care professional; 97152–97154 add BCaBA and BAI (behavior analysis interventionist); 97155–97157 allow BCBA, BCaBA and the licensed professionals. Every ABA line allows modifier GT for telehealth. CCOs set their own contracted rates; at least one CCO (InterCommunity Health Network) publishes that it keeps ABA rates no lower than the OHA fee-for-service rate under OHA’s behavioral health directed payment.^{[9][34][4][22][23][24][26][27][35]}

Direct payment goes only to a Licensed Behavior Analyst, a licensed health care professional whose scope includes ABA, or an individual holding a declaration of practice; licensed assistant behavior analysts and registered interventionists "are not eligible for direct payment" (OAR 410-172-0760(3)–(4)). Oregon licenses behavior analysts. ORS 676.806 creates the Behavior Analysis Regulatory Board within the Health Licensing Office; under ORS 676.810 it licenses behavior analysts and assistant behavior analysts (a fingerprint-based records check is required, and BACB certification may be), and under ORS 676.815 the Office registers behavior analysis interventionists, who must be 18, hold a diploma or equivalent, pass the fingerprint check, complete "at least 40 hours of professional training," and "receive ongoing training and supervision" by a licensed behavior analyst, licensed assistant behavior analyst or licensed health care professional. A provisional interventionist registration must issue within five business days of a complete application. Only licensees and registrants may use the titles "licensed behavior analyst," "licensed assistant behavior analyst" or "registered behavior analysis interventionist." OAR 824-040-0010 sets the interventionist supervision floor: direct and indirect supervision "for at least 5 percent of the interventionist’s service hours," with direct supervision at least once per calendar month. What that means for an out-of-state BCBA: the Oregon license rule (OAR 824-030-0010) has no reciprocity, temporary-permit or telehealth exemption; it asks applicants for "an affidavit of licensure from any state where the individual holds or has held a license." The payers’ own definitions point the same way. The commercial mandate defines ABA as provided by an Oregon-licensed health care professional, a behavior analyst or assistant licensed under ORS 676.810, or a registered interventionist; OHP pays directly only a Licensed Behavior Analyst, a licensed health care professional, or a declarant; and the telemedicine statute defines a "health professional" as one "licensed, certified or registered in this state." So plan on an Oregon license before treating an Oregon member, including by telehealth. The Health Licensing Office says it does not give individualized advice on how the law applies to a practice. ORS 676.830 lets each health plan set its own ABA credentialing requirements.^{[9][34][4][22][23][24][26][27][35]}

Claims operations: timely filing, payment and other insurance

Open-card claims "must be filed within 12 months of the date of service," and a denied claim filed on time may be resubmitted within 18 months (OAR 410-120-1300). CCO claims run on a shorter clock: OAR 410-141-3565 sets initial claims "within no more than 120 days of the date of service" (365 days for exceptions including retroactive eligibility, Medicare as primary and third-party liability) and requires CCOs to "pay or deny at least 90 percent of valid claims within 30 days of receipt and at least 99 percent of valid claims within 90 days of receipt." A provider enrolled with OHA bills under its OHA provider number or NPI, and using a billing provider does not relieve "the performing provider’s responsibility for the truth and accuracy of submitted information" (OAR 410-120-1280). We did not find an OHA statement applying electronic visit verification to ABA; ask OHA Provider Services (800-336-6016).^{[1][2][3][20][3][21][9]}

For CCO claims the same rule requires each CCO to allow corrections and resubmissions of a timely claim for "a minimum of 180 days after the initial adjudication date," and bars a CCO from requiring providers "to delay claims submission." That rule publishes no weekly payment cycle or submission cutoff.^{[1][2][3][20][3][21][9]}

Federal rules bind OHA’s own fee-for-service payments: the agency "must pay 90 percent of all clean claims from practitioners, who are in individual or group practice or who practice in shared health facilities, within 30 days of the date of receipt" and 99 percent within 90 days, with the date of receipt being the agency’s date stamp and the date of payment the date of the check or other payment (42 CFR 447.45(d)(2), (3), (5), (6)). The same rule makes 12 months from the date of service the outer limit any state may allow for filing (42 CFR 447.45(d)(1)). Managed care plans are held to the same 90/99 percent clean-claim standard through their state contracts (42 CFR 447.46).^{[1][2][3][20][3][21][9]}

Does OHP require a referring provider on the ABA claim?

OHP ABA always has a referrer. OAR 410-172-0770 requires "A referral for ABA treatment with or without specification of hours or intensity" before services. OHA's enrollment rule (OAR 410-120-1260) treats ordering and referring providers as non-billing providers, "whose only relationship with the Authority is to order, refer, or prescribe services for Authority members." It "requires all non-billing and payable providers to be enrolled." Claims "must include an NPI for each provider subject to the NPI requirements," and "Rendering and referring providers may not have the same NPI listed on the claim or encounter."^[5][31]

So make sure the referring physician, psychologist, NP or PA is enrolled with OHA, and report a referring NPI different from the rendering one. OHA's ABA sources read for this guide do not restate a box 17 instruction, and each CCO runs its own claim edits.^[5][31]

Intake gates

The questions that decide whether a family can start with Oregon Health Plan (Medicaid), and what they have to bring. Each maps onto something intake should ask on the first call.

Delivery & billing rules

Coverage decides whether Oregon Health Plan (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.

Common questions

Carelu collects all of this automatically.

Every ID, document, and detail this payer requires — gathered conversationally the moment a family reaches out, with insurance verified before your team touches the file.