Priority Health is a Michigan-based carrier. Its ABA rules live in one medical policy, No. 91615 "Autism Spectrum Disorders" (revision R8, effective March 1, 2026), which sets the diagnostic standard, sends authorization decisions to Behavioral Health InterQual, and sets its own supervision floor. Priority Health also runs a Medicaid plan, but its policy notes that autism services for Priority Medicaid and Healthy Michigan Plan members "are paid through Michigan’s Department of Community Mental Health" — see our Michigan Medicaid guide for those members.
Initial diagnostic evaluation, including psychological testing, is medically necessary, and the diagnosis must match the DSM standard at the time of evaluation. The evaluation must show a multimodal assessment (caregiver reports, records, collateral reports, standardized psychological tools and an observational assessment), and Priority Health "may require a second diagnostic opinion from a contracted, licensed PhD psychologist with specialized training in autism spectrum disorders."[3][4]
ABA authorization "is determined by the clinical findings and ABA indications recommended by Behavioral Health InterQual®," continued stays require documented measurable progress against InterQual criteria, the plan must be supervised by a BCBA, and line-staff supervision should be at least "1 hour of supervision for every 15 hours of treatment." The coding section marks every ABA code, 97151 included, "prior authorization required," in center, office or home; speech, physical and occupational therapy for autism need no PA. Exclusions include services that are a school program’s legal responsibility, services by family or household members, and unproven treatments (among them secretin, chelation, facilitated communication, sensory-based treatments, RDI, Floortime/DIR, and equine therapies).[3][4]
Michigan’s autism mandate has two parallel statutes: MCL 500.3406s for insurers (added by 2012 PA 100, amended by 2016 PA 276, applying to policies delivered, issued or renewed beginning 180 days after its April 18, 2012 enactment) and MCL 550.1416e for health care corporation group and nongroup certificates. Both require coverage "for the diagnosis of autism spectrum disorders and treatment of autism spectrum disorders," including behavioral health treatment such as applied behavior analysis, and bar the carrier from limiting the number of visits, from denying coverage because treatment "is educational or habilitative in nature," and from applying dollar limits, copays, deductibles or coinsurance that do not apply to physical illness generally.[5][6]
Unlike newer mandates, Michigan’s still carries age and dollar ceilings the carrier may choose to apply: coverage for treatment may be limited "through 18 years of age" and to a maximum annual benefit of $50,000 through age 6, $40,000 from 7 through 12, and $30,000 from 13 through 18. Treatment must be "prescribed or ordered" by a licensed physician or licensed psychologist who finds it medically necessary, behavioral health treatment must be "provided or supervised by a board certified behavior analyst or a licensed psychologist," and the diagnosis means assessments "including the autism diagnostic observation schedule, performed by a licensed physician or a licensed psychologist." While a member is in treatment the carrier may require a treatment plan and treatment review, request the ADOS results, request that the ADOS be repeated no more than once every three years, and request an annual development evaluation. Utilization review, medical-necessity review, network requirements and coordination of benefits still apply. Exempt: self-funded ERISA employer plans (outside state insurance law), exchange qualified health plans to the extent the coverage exceeds essential health benefits, and, under 500.3406s, short-term policies of six months or less.[5][6]
Michigan licenses behavior analysts through LARA’s Board of Behavior Analysts under Part 182A of the Public Health Code (Michigan’s licensure law dates from 2016). A license requires current BACB certification in good standing sent directly from the BACB, a criminal background check, human-trafficking and implicit-bias training, and renews every four years; assistant behavior analysts have their own LARA license and supervision verification. Technicians are not licensed by the state. Priority Health does not publish commercial ABA rates; they are set in the participating-provider agreement.[7][8][9]
Michigan’s prompt-pay statute, MCL 500.2006(8), governs insured health plans (it excludes administrative-services-only arrangements): "A clean claim must be paid within 45 days after receipt of the claim by the health plan," with 12% simple annual interest after that; the plan must flag defects within 30 days, and the provider gets 45 days to fix them. A provider "must bill a health plan within 1 year after the date of service" for the claim to be a clean claim.[17][1][2]
Priority Health’s own deadline matches the statute: its provider manual says “You must complete billing, including resolving all claim discrepancies, within 12 months of the date of service. After that date, we will deny corrected or augmented information as provider responsibility.” A claim that does not appear in the Claims Inquiry tool or on a rejection report may be resubmitted “within 45 days of your original submission.” On the claim, Priority Health’s behavioral health billing page says field 24J (rendering provider) “must show the individual NPI number of the practitioner who directly provides the service being billed,” with exceptions only for limited licensees billed under their supervisor. The manual names no weekly submission cutoff or check-run day.[17][1][2]
What changes on Jan. 1, 2027. CMS records that at its September 2025 meeting the AMA CPT Editorial Panel "deleted CPT codes 0362T" and "0373T," "revised eight existing CPT codes" (97151 through 97158) and "created six new CPT codes" for adaptive behavior services; the AMA released the CPT 2027 code set on Sept. 9, 2026, with changes in effect on January 1. The ABA Coding Coalition’s 2027 guidance gives the final numbers: 97148 and add-on +97149 (behavior identification supporting assessment of harmful behavior, delivered by two technicians, additional technicians on the add-on), 97159 and add-on +97160 (adaptive behavior treatment of harmful behavior, same two-technician structure), 97173 (adaptive behavior treatment with analysis by a physician or other QHP, face-to-face with one patient) and 97180 (non-face-to-face services personally performed by the QHP, such as data review and modifying protocols). "Protocol modification" becomes "analysis" in the descriptors, and "since there is no grace period, 0362T and 0373T are invalid for dates of service on or after January 1, 2027." No state "approves" the codes themselves: they are Category I CPT codes that HIPAA requires on electronic claims, but, as the Coalition notes, HIPAA "does not, however, govern whether a payer covers a code / service, what a payer pays for a code / service, or what a payer requires to authorize" it, so each payer has to load them, price them and say how authorizations that list 0362T or 0373T carry over.[18][19][20][16][2]
Priority Health had published no 2027 adaptive-behavior code guidance as of Nov. 1, 2026: its provider news page (which does announce other Jan. 1, 2027 changes, such as the new provider portal) and its behavioral health billing page say nothing about the ABA codes. Ask Priority Health how it will load and price the new codes and whether authorizations that list 0362T or 0373T carry over.[18][19][20][16][2]
Priority Health’s provider manual: “When we receive your complete credentialing information, it can take us up to 80 calendar days to process your request,” and each step in the process “has a unique timeline that falls within the 80 days,”, credentialing being “the most time consuming.” Requests for missing information come through prism. “If your request has exceeded 80 calendar days, email us at exceedsprocessingtime@priorityhealth.com,” with the inquiry ID; Priority Health asks providers not to post status-update comments, which “will only delay your processing time.” “You shouldn’t see Priority Health members seeking in-network care until you get your network effective date from us,”, so add a new BCBA well before their first Priority Health session.[21]
The questions that decide whether a family can start with Priority Health (Michigan), and what they have to bring. Each maps onto something intake should ask on the first call.
No recency window. The policy requires the diagnosis to be "consistent with the standards of the Diagnostic and Statistical Manual of Mental Disorders at the time of evaluation" and "Priority Health may require a second diagnostic opinion from a contracted, licensed PhD psychologist with specialized training in autism spectrum disorders." Under the mandate a fully insured plan may request the ADOS be repeated no more than once every three years.[3][5]
The policy does not list specialties; it requires a multimodal diagnostic evaluation and reserves the right to a second opinion from a contracted, licensed PhD psychologist with autism training. For fully insured plans the mandate defines the diagnosis as assessments, including the ADOS, "performed by a licensed physician or a licensed psychologist."[3][5]
"The diagnostic evaluation must include evidence of a multimodal assessment that contains caregiver(s) reports, records (e.g., medical, school, other evaluations), collateral reports (e.g., teachers, other treatment providers), data gathered from utilization of standardized psychological tools, and an observational assessment." No specific instrument is named; AI and app-based diagnostic devices (e.g., Canvas Dx) are excluded.[3]
Priority Health’s policy states no referral or order requirement for ABA beyond prior authorization. For a fully insured Michigan policy the mandate adds an order requirement: covered treatment is care "prescribed or ordered for an individual diagnosed with 1 of the autism spectrum disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary," and the treatment plan is developed "when the treatment of an autism spectrum disorder is first prescribed or ordered." Self-funded ERISA plans sit outside the statute.[3][5]
Priority Health’s autism policy sets no age limit. Michigan’s mandate lets a fully insured carrier limit autism treatment coverage to members "through 18 years of age" and cap it at $50,000 a year through age 6, $40,000 for ages 7–12 and $30,000 for ages 13–18; whether a given plan uses those limits is in its certificate. Self-funded ERISA plans set their own terms.[3][5][6]
Ask the plan: Live benefits verification in Prism: fully insured vs. self-funded, and whether the certificate applies the mandate’s age-18 and annual-dollar limits.
Turns on how the plan is funded. Fully insured Michigan insurance and HMO plans follow MCL 500.2212e: after May 31, 2024 a non-urgent prior authorization request "is considered granted" if the insurer does not grant it, deny it, or ask for more information "within 7 calendar days after the date and time of submission," and again within 7 calendar days after additional information is submitted; a request the provider certifies as urgent is considered granted if not acted on within 72 hours. An approved authorization "is valid for not less than 60 calendar days or for a duration that is clinically appropriate, whichever is later." The statute’s "health benefit plan" covers individual and group insurance, HMO contracts, and self-funded plans of the state or local governments, not private self-funded employer plans, which follow ERISA: pre-service decisions "not later than 15 days after receipt of the claim," one 15-day extension, urgent claims within 72 hours.[10][11]
Ask the plan: At benefits verification ask whether the plan is fully insured (Michigan-regulated) or self-funded (ERISA), then confirm the Priority Health turnaround and reauthorization lead time (Priority Health provider services or the Prism provider portal).
Which plan pays first is set by Michigan’s Coordination of Benefits Act for state-regulated plans: for a dependent child whose parents are married or living together, "The plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (same birthday: the plan covering the parent longer); for divorced or separated parents a court order assigning health coverage controls, then the order in MCL 550.253. The autism mandate adds that a member with two policies covering autism gets benefits "subject to the limits of this section when coordinating benefits." If the child also has Michigan Medicaid, Priority Health pays first: Medicaid is payer of last resort and "is not liable for payment of services denied because coverage rules of the primary health insurance were not followed," so get Priority Health’s authorization even when Medicaid (the PIHP) will pay secondary. TRICARE pays after other coverage except Medicaid (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[12][5][13][14][15]
Ask the plan: Ask Priority Health at benefits verification for the member’s coordination-of-benefits order (Priority Health provider services or the Prism provider portal); self-funded plans set their own COB terms in the plan document. Record every other coverage the child has.
Not addressed in Policy 91615.[3]
Ask the plan: Priority Health provider manual telehealth policy or provider services — ask which ABA codes are payable via telehealth and with which POS/modifier.
Coverage decides whether Priority Health (Michigan) 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.
"An ABA treatment plan must be supervised by a BCBA who oversees the treatment and coordinates with other medical professionals," and "Supervision of line staff by the BCBA should occur at a minimum of 1 hour of supervision for every 15 hours of treatment with the member." That is a lower floor than the 1-per-10 many payers use.[3]
ABA treatment services are covered "in center, office, or home" with prior authorization. Excluded: "Services or treatment that are the legal responsibility of a school program such as evaluations completed in an educational setting," and services provided by family or household members.[3]
Priority Health’s autism policy describes 97155 as "Administered by BCBA, which may include simultaneous direction of technician" but does not state whether 97153 and 97155 may be billed for the same clock time; the policy points to Billing Policy No. 054 Behavioral Health for billing rules, which we did not retrieve.[3]
Blocked on: Priority Health Billing Policy No. 054 (Behavioral Health) in the provider manual, or Priority Health provider services.
No hour or unit limit is published in the policy. Authorization, and continued-stay approval, is decided on Behavioral Health InterQual criteria, which are licensed and viewable only through Priority Health’s Prism portal (Authorizations > Authorization Criteria Lookup).[3]
In licensed criteria: Prism > Authorizations > Authorization Criteria Lookup (InterQual Behavioral Health), or the authorization determination.
Not addressed in Policy 91615; documentation standards for behavioral health are not in the published policy.[3]
Blocked on: Priority Health provider manual (documentation standards) or Billing Policy No. 054.
The policy lists the ABA CPT codes (97151–97158) with technician codes "Administered by technician under the direction of a BCBA," but does not say whose NPI goes on the claim; that is set in Billing Policy No. 054, which we did not retrieve.[3]
Blocked on: Priority Health Billing Policy No. 054 (Behavioral Health) or provider services.
Up to 80 calendar days from receipt of complete credentialing information, per Priority Health’s provider manual. Past 80 days, email exceedsprocessingtime@priorityhealth.com with the inquiry ID. Do not see members in network until you have your network effective date.
Billing, including fixing every claim discrepancy, must be complete within 12 months of the date of service; after that Priority Health denies corrected information as provider responsibility. Clean claims from insured plans must be paid within 45 days under MCL 500.2006.
Yes. Policy 91615 lists 97151 through 97158 under "ABA treatment services – in center, office, or home – prior authorization required."
A BCBA must supervise the treatment plan, with line-staff supervision of at least one hour for every 15 hours of treatment.
No. Priority Health’s policy notes that these services for Priority Medicaid and Healthy Michigan Plan members are paid through the state’s community mental health system (the PIHP).
Within 45 days of receipt for a clean claim on an insured plan (MCL 500.2006(8)), with 12% interest after that. Self-funded plans are not covered.
Not as of Nov. 1, 2026. Its provider news and behavioral health billing pages say nothing about the 2027 ABA codes. CPT 2027 deletes 0362T and 0373T and adds 97148/97149, 97159/97160, 97173 and 97180, so ask Priority Health how it will price them and handle existing authorizations.
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.
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