PerformCare is the HealthChoices behavioral health managed care organization for Medicaid members in Cumberland, Dauphin, Lancaster, Lebanon and Perry counties (the Capital Area Behavioral Health Collaborative) and Franklin and Fulton counties (Tuscarora Managed Care Alliance). Pennsylvania Medicaid ABA is delivered as the ABA category of Intensive Behavioral Health Services (IBHS) — for anyone under 21 with a behavioral health diagnosis, started by a written order.
PerformCare publishes its IBHS rules as numbered policies and provider notices. The core is CM-CAS-042 (revised 03/11/26): a 97151 assessment registration with no medical-necessity decision, then a treatment request with the written order, assessment (an FBA is required for ABA), ITP and provider-choice form, approved for up to 12 months. PerformCare has formally adopted the 2019 ABA CPT supplemental guidance, which settles concurrent 97153/97155 billing.
From an ORP-enrolled prescriber (clinic prescribers must include the clinic or medical director MA number). A Best Practice Evaluation can stand in if it meets every written-order requirement. The order is valid 12 months minus one day from the face-to-face.[1][15][16]
The IBHS Individual/ABA Provider Choice Acknowledgment Form is completed with the family when the order is written; if the chosen agency cannot start the assessment within 7 calendar days it must offer a transfer or open a Written Order/BPE Receipt Notification.[1][15][16]
The agency electronically submits an IBHS Assessment Registration Form within 4 calendar days of starting the assessment; PerformCare authorizes 45 calendar days for ABA. The assessment must observe every setting named in the order and include an FBA.[1][15][16]
Within 10 calendar days of completing the ITP: Child/Adolescent Services Request Submission Sheet, provider-choice form, written order/BPE, assessment with FBA, ITP, CANS (Capital/CABHC counties only), and the FFS-to-PerformCare transition form if applicable.[1][15][16]
IBHS 22-102 lays out the bundles: a 97151 registration (no MNC decision) also lets ABA agencies bill 97152/97152 U8; an authorization for 97155 (medical-necessity review) covers 97156/97156 U7; and PerformCare requires separate authorization for 97155 U7 (behavior analyst) and 97153 U8 (assistant behavior consultation-ABA). IBHS 21-105 confirms a BCBA working as BC-ABA bills 97155 U7 at the BA-level rate.[4][5][17][16]
Since 3/1/2023 (IBHS 23-102) agencies may bill 97151 for the reauthorization reassessment, but PerformCare issues no separate authorization or extra units — the hours come out of the clinician’s authorized hours (e.g., a BA authorized for 20 hours can split them across 97155, 97156 and 97151). Periodic ITP updates outside the reauthorization window are billed as 97155. From May 12, 2025, PerformCare "will no longer extend IBHS assessment authorizations under any circumstances".[4][5][17][16]
PerformCare’s manual tells providers to follow 55 Pa. Code § 1101.64 and to "Request prior authorization the same way that they always have from both the BH-MCOs and the private insurance companies", noting that PerformCare authorization is not a guarantee of payment without a primary denial or non-coverage document. Claims for members with commercial or Medicare primary need the primary EOB attached, and providers must be enrolled with the primary plan.[3][8][9]
For ABA and Act 62, IBHS 21-103 requires one denial or non-covered letter per CPT code billed per calendar year; IBHS 23-105 adds that a non-covered letter spanning years must be paired with one EOB denial per CPT code per calendar year. Former exemptions for TRICARE, out-of-state plans and blanket self-funded status no longer apply (self-funded plans are exempt from Act 62 but "may pay for ABA services"). New referrals of privately insured children should go to an in-network provider for that private plan.[3][8][9]
PerformCare pays IBHS at rates set by county-contract rate notices and provider agreements; current ABA rates were not published in the documents reviewed. Ask your PerformCare Account Executive for the current IBHS rate schedule for your county contract.[3]
The questions that decide whether a family can start with PerformCare (HealthChoices BH-MCO, AmeriHealth Caritas family), and what they have to bring. Each maps onto something intake should ask on the first call.
Under 21 — IBHS serves children, youth and young adults under 21 (55 Pa. Code Chs. 1155/5240). No minimum age. PerformCare publishes nothing different.[18][1]
What must be current is the written order/BPE: completed within 12 months of the assessment start date and still valid at submission — it expires 12 months minus one calendar day after the face-to-face (an order written 1/1/2023 expires 12/31/2023). Every reauthorization needs a new written order/BPE.[1]
The written order must come from an ORP-enrolled prescriber based on face-to-face interaction (state rule: licensed physician, licensed psychologist, CRNP or other licensed practitioner whose scope includes diagnosing BH disorders and prescribing BH services). PerformCare’s manual adds that IBHS prescribers must be enrolled as individual MA providers, and clinic-based prescribers must include the clinic or medical director MA number.[1][3][18]
No named instrument is required behind the diagnosis. The tool requirement is in the IBHS assessment: "An FBA must be completed as part of the assessment process (IBHS ABA only)", and a CANS is required in the CABHC (Capital) counties.[1]
A written order (or a BPE meeting all written-order requirements) from an ORP-enrolled prescriber is required to start and again for every reauthorization. The provider-choice form is completed with the family at that time; the order goes to the family’s chosen agency within 4 calendar days if they ask. Agencies that cannot start within 7 calendar days must offer a transfer or open a receipt notification — except for members "who have primary commercial insurance with an ABA benefit", whom providers help coordinate with the commercial plan (IBHS 26-101).[1][11]
Allowed under OMHSAS-22-02. For dates of service on or after 10/1/2022 PerformCare wants POS 10 when the member is at home and POS 02 elsewhere, and modifier FQ (not 95) for audio-only. When PerformCare is secondary, adjust the secondary claim to PerformCare’s billing requirements after the primary processes it.[10][19]
CM-013 (rev. 01/22/26): initial requests decided and the member told at least verbally within 2 business days of the request; concurrent (reauthorization) decisions within 1 business day of complete information; written notice within 2 business days after the decision. Missing information is requested within 48 hours and the provider gets up to 14 days. If the member has no written decision within 21 days of the request, "the service is automatically approved". PerformCare says it follows "the most stringent time frame" of Act 146 and NCQA; the federal floor (42 CFR 438.210(d)) is 7 calendar days standard / 72 hours expedited. Reauth: submit within 60 days before the current authorization ends.[2][1][20]
PerformCare pays last. Its manual tells providers to "Request prior authorization the same way that they always have from both the BH-MCOs and the private insurance companies" — so PerformCare authorization is still needed when commercial is primary — and to bill the private insurer first even if not yet contracted, unless written non-coverage is already on file. Claims need the primary EOB; providers must be enrolled with the primary and file PerformCare within 60 days of the primary’s decision. For ABA/Act 62: one denial or non-covered letter per CPT code per calendar year (IBHS 21-103), plus one EOB denial per code per year when a letter spans years (IBHS 23-105). TRICARE and out-of-state plans are not exempt; self-funded plans are exempt from Act 62 but may cover ABA. Federal law keeps Medicaid behind TRICARE (10 U.S.C. 1079(i)(1)).[3][8][9][21]
Coverage decides whether PerformCare (HealthChoices BH-MCO, AmeriHealth Caritas family) 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.
Follows the state IBHS rule (PerformCare’s IBHS policies set nothing different): under 55 Pa. Code § 5240.82 behavior analytic and BC-ABA staff get 1 hour of individual face-to-face supervision monthly (a second hour if they supervise assistant BC-ABA or BHT-ABA staff) plus 30 minutes of direct observation every 6 months; BHT-ABA staff get 1 hour weekly at 37.5+ hours a week, otherwise 1 hour twice a month, with 1 hour of individual face-to-face supervision each month and 6 hours of onsite supervision before working independently.[13][1]
Allowed when both descriptors are met. IBHS 21-100 says PerformCare "has adopted" the 2019 Supplemental Guidance on Interpreting and Applying the 2019 CPT Codes for Adaptive Behavior Services, which answers "Can I report 97153 and 97155 concurrently?" with "Yes, as long as the criteria in the descriptors of both codes are met. A single QHP may not report 97153 and 97155 concurrently."[6][7]
State rule plus PerformCare’s record standard: 55 Pa. Code § 5240.41 requires each service note to carry the signature of the staff person providing it; PerformCare’s manual requires every entry to be dated with the author identified by "name, title, credentials, and signature (paper) or key identifier (electronic)". ITPs are signed with the family per the IBHS regulations.[3][13]
Home, school, daycare and community per the IBHS rules; CM-CAS-042 requires the assessment to observe the school/daycare/community setting whenever the written order places services there, and the ITP must list hours per setting. PerformCare’s manual says TPL obligations apply at any "location that is recognized as a place of service by the provider". Center-based 1:1 IBHS follows OMHSAS-22-03.[1][13]
The IBHS agency bills as an ABA-approved IBHS provider (PROMISe provider type 11, specialty 592 per IBHS 21-100); the rendering NPI and taxonomy go on the claim when different from the billing NPI (manual, CMS-1500 box 24J / loop 2310B). Credential tiers are carried by modifiers — e.g., a BCBA delivering BC-ABA bills 97155 U7 (IBHS 21-105), assistant BC-ABA bills 97153 U8.[6][17][3]
No per-day unit ceiling is published for PerformCare. Treatment is authorized in hours per service per month, and providers "cannot exceed the hours authorized for the level of clinician" (IBHS 23-102). The state FFS code list’s per-day ranges (OMHSAS-21-03) apply to fee-for-service only.[5][1]
Ask the plan: Your PerformCare provider agreement/fee schedule or your PerformCare Account Executive — ask whether any per-day unit edit applies to 97153/97155 beyond the monthly authorized hours.
It requires a registration, not a medical-necessity decision. The agency submits an IBHS Assessment Registration Form in Jiva within 4 calendar days of starting the assessment, and PerformCare authorizes 45 calendar days for an ABA assessment. Registering 97151 also allows billing 97152.
Yes, when both code descriptors are met. PerformCare adopted the 2019 CPT supplemental guidance for adaptive behavior services, which answers "Yes, as long as the criteria in the descriptors of both codes are met" — but a single QHP may not report both concurrently.
Up to 12 months, starting on the medical-necessity decision date (or the day after the current authorization ends for timely reauths). Reauthorization packets are due within 60 days before the current authorization ends, with a new written order and assessment/ITP updated within 30 days.
No — IBHS ABA is available for a behavioral health diagnosis on the written order. An autism diagnosis matters mainly for coordination with private insurance under Act 62.
Seek authorization from both plans, bill the private plan first, and attach the EOB. For ABA/Act 62, PerformCare needs one denial or non-covered letter per CPT code per calendar year (plus an EOB denial per code per year if the letter spans years) before it pays as primary for the rest of that year.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 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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