Sentara Community Plan ABA coverage (Cardinal Care MCO).

Follows the Virginia Medicaid (DMAS) rule: under 21 — Appendix D's ABA admission criteria state it as the first requirement, and the benefit rides EPSDT, so there is no hard hour cap beneath it.^[4][2]

Follows the Virginia Medicaid (DMAS) rule: no recency window on the diagnosis. Appendix D admits on a current primary ICD diagnosis correlating to a DSM diagnosis, or on a provisional psychiatric diagnosis developed by an LMHP where no definitive diagnosis has been made — and DMAS states there is no timeframe for the use of a provisional psychiatric diagnosis, expecting the LBA to follow up with the youth's physician or other LMHPs as more information is gathered. What must stay current is the assessment: it is reviewed and updated at least annually by the LBA, LABA or LMHP, and continued-stay criteria test symptoms within the past 30 days.^[4][5][2]

Follows the Virginia Medicaid (DMAS) rule: two different questions, and Appendix D answers both. The diagnosis: the youth must currently meet criteria for a primary ICD diagnosis that correlates to a DSM diagnosis, or have a provisional psychiatric diagnosis as developed by an LMHP — Appendix D does not restrict the benefit to autism or name a specialty list of diagnosing clinicians. The ABA assessment: it must be completed by an LBA, LABA or LMHP acting within scope (an LMHP-R, LMHP-RP or LMHP-S with completed education and training in ABA may complete it under the supervising LMHP), conducted in person with the youth and the family or caregivers, and an assessment completed by an LABA may be used only for ABA, not as a Comprehensive Needs Assessment for other services.^[4][5][2]

Follows the Virginia Medicaid (DMAS) rule: the initial assessment must include a functional assessment using validated tools, completed by the LBA, LABA or LMHP within scope, and documentation must describe any assessment tools used. DMAS publishes no approved list — the QHP may use clinical judgement to choose the best assessments for the youth — so what is audited is that a validated instrument was used and named, not which one.^[4][5][2]

Follows the Virginia Medicaid (DMAS) rule: no physician order. DMAS retired the requirement for an order or letter recommending services signed by a physician, nurse practitioner or physician assistant — what replaced it is a notification duty: the QHP must notify the youth's primary care physician that the child is receiving ABA, providers must communicate the results of the assessment and treatment planning to the PCP, and care coordination with the PCP must be documented in the youth's record.^[5][4][2]

Follows the Virginia Medicaid (DMAS) rule, which DMAS's December 2025 ABA clarifications bulletin addresses to Acentra and the Cardinal Care MCOs alike as the service-authorization contractors: initial assessments must be conducted in person with the youth and the family or caregivers, by the LBA, LABA or LMHP — and DMAS's December 2025 ABA clarifications bulletin makes that a condition of payment: "Initial assessments must be conducted in person by an LBA, LABA or LMHP in order for ABA services to be reimbursable by Medicaid," and services built on an assessment that does not meet DMAS requirements are non-reimbursable. No part of the initial assessment has a telehealth path. The Telehealth Services Supplement (rev. 1/5/2026, Table 2) allows 97151 and 97152 by telemedicine "for reassessments only," and Appendix D lets 97151, 97152 and 0362T be billed only "as part of the initial assessment or full reassessments" — so follow-up observations and sessions with additional caregivers that are part of completing the initial assessment are initial-assessment time and must also be in person. DMAS defines no separate assessment window that would move them under telehealth rules. The one exception is non-face-to-face work: care coordination, data analysis and treatment-plan preparation without the youth present may be billed under 97151 at the time of the initial assessment, and care coordination billed under 97151 or 97155 does not have to be face to face. Once the initial assessment is complete, further QHP observation, data review and protocol changes bill as 97155 and caregiver sessions as 97156, both on the Supplement's telemedicine list (0362T and 0373T are not), and a full reassessment may be done by telemedicine. Any telemedicine delivery must be justified in the ISP submitted with the initial and continued-stay authorization: a schedule of when services are delivered by telemedicine and when in person, clinical evidence that telemedicine is appropriate, and how in-person needs will be met — and the provider must document that the youth and caregiver can take part meaningfully and safely. Chapter IV adds that an assessment done by telemedicine cannot serve as the assessment for a service that requires an in-person one. Edge cases go to DMAS's Behavioral Health Division at enhancedbh@dmas.virginia.gov. MCO-contracted providers must consult their contracted MCO for that plan's telehealth policies.^{[4][5][2][16][17][13]}

Virginia Medicaid rule, applied by Sentara Community Plan: since January 1, 2026 DMAS requires FFS and every Cardinal Care MCO to decide standard (non-urgent) requests within 7 calendar days of receipt and expedited requests within 72 hours; the 7-day clock can extend up to 14 calendar days if the member or provider asks, or if the extra time is justified in the member's interest to obtain more medical evidence. Sentara's 2026 manual states the same: standard decisions "not to exceed seven calendar days following receipt of the request for service," expedited "no later than 72 hours after receipt of the request." Timing from Appendix D: submit treatment requests (initial and continued stay) by the requested start date — "If submitted after the required time-frame, the begin date of authorization will be based on the date of receipt," so a late reauthorization leaves an unpaid gap.^{[18][19][4][20]}

Medicaid pays last. Sentara's manual: "If a Sentara Health Plans program member is identified as having a commercial product, the provider must send the initial claim to the commercial plan for payment… Medicaid is always the payor of last resort." Sentara is the one Virginia MCO that writes down the secondary-authorization rule: "Sentara Health Plans does not require service authorization when acting as the secondary payer except" when the primary payer does not cover the service, or the member has exhausted the primary's benefit — in either case Sentara becomes the primary payer and its service authorization is required. So: covered by the commercial plan → the commercial plan's authorization, no Sentara SA; commercial plan excludes ABA or the benefit is used up → Sentara SA before services. TRICARE and CHAMPVA both pay ahead of Medicaid: TRICARE rules state "Medicaid is not a double coverage plan. In any double coverage situation involving Medicaid, CHAMPUS is always the primary payer," and CHAMPVA "assumes primary payer status" over Medicaid.^{[18][5][21][22]}

Follows the Virginia Medicaid (DMAS) rule: three separate floors. The LBA, LABA or LMHP must at a minimum observe the youth and supervise services monthly, with supervision documented as a review of progress notes and data plus dialogue with supervised staff about progress and the effectiveness of the ISP. Supervision of unlicensed staff must occur at least twice a month by the LBA, LABA or Licensed Clinical Psychologist, demonstrated by the contemporaneously dated signature of the licensed supervisor. Clinical supervision is required for services rendered by an LABA, LMHP-R, LMHP-RP or LMHP-S, consistent with the scope of practice set by the applicable Virginia Department of Health Professions board — on the nature of supervision DMAS defers to that board and to the BACB. Supervision time without the individual present is not billable; the technician rates were built to include it.^[4][5][2]

Follows the Virginia Medicaid (DMAS) rule: Appendix D publishes the combinations that may be billed at the same time: 97152 with 97151 (except 97152 HN together with 97151 HN); 97153 with 97155 (except 97153 HN together with 97155 HN) — DMAS adds that 97155 and 97153 may be billed together for supervision activities when the QHP is directing the technician in delivering treatment and the QHP, technician and youth are all present; 97154 and 97158 at the same time for different youth in the same group, with identical professional-level modifiers; 97153 at the same time for two technicians when the reason is documented in a service-authorized ISP; and services with the youth alongside family or group family training when delivered by different qualified staff. What is barred: an additional technician-level code alongside 97158 or 97154. Separately, ABA may not be authorized concurrently with Intensive In-Home, Mental Health Skill Building, Psychosocial Rehabilitation, Partial Hospitalization or Assertive Community Treatment, though short-term authorization overlaps are allowed during transitions. For DMAS fee-for-service claims, ABA at the same time as speech, occupational or physical therapy: DMAS publishes no ABA-specific overlap rule — Appendix D's same-time list names ABA codes only, and neither the MHS manual nor the Rehabilitation manual addresses ABA alongside a therapy session. What reaches it is the claim-edit layer. Chapter V says DMAS runs the Medicaid NCCI edits on the "same member, same provider, and same date of service": the column-one code pays, the column-two code denies, and only CMS-listed NCCI modifiers can bypass an edit that allows one. In the CMS Medicaid NCCI practitioner PTP table active 10/1–12/31/2026, speech treatment 92507 is column one over 97153, 97154, 97155, 97156, 97157 and 0373T; 97153 is column one over group speech treatment 92508; and therapeutic activities 97530 (OT/PT) is column one over 97153–97158 and 0373T — every pair with modifier indicator 0, so no modifier unbundles it. One provider billing 92507 and 97153 for the same child on the same date of service will see the 97153 line deny. The edits key on the same provider, so they do not by themselves stop a separately enrolled speech therapist from seeing the child the same day; for that, Chapter IV requires care coordination with all active treating providers, documented in the ISP and progress notes, to prevent duplication of services. Sentara's ABA medical-necessity criteria publish no ABA-with-therapy rule, so whether its claim editor applies the same NCCI pairs and MUEs is a question for Sentara provider services.^{[4][5][2][12][13][14]}

Follows the Virginia Medicaid (DMAS) rule: no ABA-specific per-day ceiling in Appendix D. Assessment codes 97151, 97152 and 0362T carry no service authorization and no unit limit, but may only be billed as part of an initial assessment or a full reassessment. Since dates of service 10/15/2025 every treatment code is authorized with its own predetermined number of units rather than bundled under 97155. Requests at or above 20 hours (80 units) a week must include an individualized schedule of activities that distinguishes therapeutic from recreational time — a general schedule of clinic-based activities is not sufficient. Group sizes follow CPT guidelines. In Residential Treatment Services settings, including therapeutic group homes and PRTFs, the payable ABA set narrows to 97151, 97154 (with modifier HN, HO or TF only), 97155, 97156 and 97157. Sentara was the first plan to post the DMAS units-per-code preservice form, for dates of service 9/1/2025 onward, ahead of the statewide 10/15/2025 mandate; its worked example models 2 hours a day across 5 days for 24 weeks, which puts roughly 6-month authorization spans as the practical norm. DMAS fee-for-service claims also run the Medicaid NCCI medically unlikely edits per member, per servicing provider, per date of service — units above the MUE deny the claim (Chapter V). The CMS Medicaid 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. Whether Sentara Community Plan enforces the same per-day MUEs on its own claims is a question for its provider services line.^{[2][4][3][12][15]}

Follows the Virginia Medicaid (DMAS) rule: documentation must carry the initial assessment completed by the LBA, LABA or LMHP including the assessment instruments used, dates of service and face-to-face contacts, staff and participant names, and staff credentials and signatures. Treatment progress must be documented through daily data collection plus a weekly summary note, with graphical analysis of goals and objectives for those dates of service. Supervision is demonstrated by the contemporaneously dated signature of the licensed supervisor. The ISP must be reviewed at least every 30 calendar days — a progress note satisfies the review if it documents the discussion, any alterations, and the individual's response; the individual's signature is not required, and the 30-day review is held for audit rather than submitted.^[4][5][2]

Follows the Virginia Medicaid (DMAS) rule: ABA may be provided in home or community settings where the targeted behaviors are likely to occur, and in clinic settings — the setting must be justified in the ISP. School is the constrained one: ABA may only be provided in the school setting when the purpose is observation and collaboration by the QHP related to behavior and skill acquisition, not direct therapy, and only when authorized by the school, the parent and the provider and included in the ISP. Technician-level codes may not be billed for school observation and collaboration, and DMAS interprets school as any education setting, private or public; additional school ABA may be available under school health services through the local education agency. Services rendered primarily by a relative or guardian who is legally responsible for the youth's care are not covered.^[4][5][2]

Follows the Virginia Medicaid (DMAS) rule: ABA providers must be enrolled with DMAS under the ABA provider types (PCT 156 or 456 with PS 903; PCT 020 or 023; PCT 256 with PS 104), licensed by the applicable Virginia Department of Health Professions board, and credentialed with the youth's Medicaid MCO for managed-care members. Every CPT code is billed with the staff modifier that identifies the professional providing the service: HN for an LABA, HO for an LBA, TF for an LMHP. QHP-level codes must be provided by an LBA or LMHP, with an LABA able to act as a QHP as determined by the supervising LBA under 18VAC85-150-120, and LMHP-Rs, LMHP-RPs and LMHP-Ss with completed ABA education and training able to provide them under the supervising LMHP. Technician-level codes may be delivered by an LMHP-R/RP/S under supervision, an LABA under an LBA, personnel supervised by an LBA or LABA under 18VAC85-150-10 et seq., personnel supervised by a Licensed Clinical Psychologist under § 54.1-3614, or by an LBA or LMHP acting as the technician — LBAs may bill technician-level codes with the appropriate modifier. Unlicensed personnel include but are not limited to RBTs; Virginia does not require the RBT credential. Sentara runs supervisor changes as paperwork rather than a new authorization: it maintains a dedicated BCBA Change Request Form (updated 3/2026), which is the opposite of the NPI-matching rule at Aetna Better Health.^[2][4]