---
title: Sentara Community Plan ABA coverage (Cardinal Care MCO).
url: "https://carelu.com/payers/sentara-community-plan"
markdown_url: "https://carelu.com/payers/sentara-community-plan.md"
state: VA (Virginia)
payer: Sentara Community Plan (VA)
kind: Medicaid managed care plan (MCO)
parent_program: Virginia Medicaid (DMAS)
description: "How Sentara Community Plan (formerly Optima/Virginia Premier) administers Virginia Medicaid ABA — the new DMAS units-per-code preservice form, fax and portal channels, the BCBA change-request workflow, and the PAL lookup tool."
last_reviewed: October 2026
vob_data_updated: 2026-10-15
---

# Sentara Community Plan ABA coverage (Cardinal Care MCO).

_Payer Guide · Sentara Community Plan · Last updated October 2026 · 11 primary sources_

> First to post the new DMAS units-per-code form; dedicated BCBA-change workflow, PAL lookup tool.

Sentara Community Plan — the Cardinal Care MCO formed from Optima Family Care and Virginia Premier — runs ABA as a pure pass-through of DMAS forms and criteria, and it was the first plan to post the new DMAS units-per-code preservice form (for dates of service September 1, 2025 onward, ahead of the statewide October 15 mandate). Its plan-specific value is workflow tooling: dedicated fax lines, a PA lookup tool, and a standing BCBA change-request form that most plans lack.

This plan administers the **Virginia Medicaid (DMAS)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Virginia Medicaid (DMAS) guide](https://carelu.com/payers/virginia-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Not required — DMAS rule; Sentara's ABA forms cover treatment codes only [4][2]
- **Prior auth for treatment**: Required — new DMAS preservice form (posted for DOS 9/1/2025+); fax (844) 895-3231 [2][6]
- **Autism diagnosis required?**: NO — not autism-restricted, and not category-restricted either. DMAS Appendix D admits a youth under 21 who meets criteria for a primary ICD diagnosis correlating to a DSM diagnosis, OR who has a provisional psychiatric diagnosis developed by an LMHP when no definitive diagnosis has been made, plus at least two functional-impairment criteria. The ABA criteria name no diagnostic category list and never mention autism [4]

## At a glance

- **Plan type:** Cardinal Care MCO (ex-Optima Family Care / Virginia Premier)
- **Clinical rules:** DMAS criteria + standardized forms, verbatim
- **Assessment auth:** None — DMAS assessment codes are auth-free
- **Submission:** Provider portal or BH fax (844) 895-3231 / (757) 963-9620
- **Supervisor changes:** Dedicated BCBA Change Request Form (upd. 3/2026)
- **PA lookup:** pal.sentarahealthplans.com

## How Sentara runs ABA authorization

Treatment requests use the DMAS preservice service-authorization form — the units-per-code version Sentara posted for dates of service September 1, 2025 and after — plus the matching continued-stay form. The form itself embeds the DMAS rules: units requested per CPT code, and the 20-hours/80-units threshold that triggers the individualized activity schedule. Its worked example models 2 hours/day × 5 days × 24 weeks — roughly 6-month authorization spans as the norm. Non-urgent behavioral-health authorizations fax to (844) 895-3231 or (757) 963-9620 (effective August 2025); behavioral-health provider services runs at (757) 552-7174 / (800) 648-8420, and the PAL lookup tool at pal.sentarahealthplans.com answers code-level questions. [1][2][6]

Two housekeeping notes: directory entries under "Optima" are stale — it's all Sentara Community Plan under Cardinal Care now — and supervisor changes have their own administrative workflow via the BCBA Change Request Form (updated March 2026), so a supervising-BCBA transition is paperwork, not a new authorization battle. [1][2][6]

## What are Sentara Community Plan’s claim deadlines, and must it pay at least the DMAS rate?

Virginia’s Cardinal Care contract (July 2026 – June 2027) lists ABA as a mental health service billed on the CMS-1500. It requires every MCO to pay mental health service providers “no less than the current Medicaid FFS rate,” and puts those services on a minimum fee schedule at 100% of the fee-for-service rate. DMAS’s December 2025 memo removed a broader pay-at-least-FFS line from Chapter V, but the minimum still applies to the contract’s Chapter 12 list, which includes mental health services. The MCO must adjudicate 99% of clean mental health claims within 14 calendar days and all of them within 30. Its timely filing limit must be at least three and at most twelve months from the date of service, counted from the primary payer’s payment or denial when the member has other coverage. [7][8]

## Reauthorization: what a continued-stay request must contain (graphs required)

Follows the Virginia Medicaid (DMAS) rule, which Appendix D addresses to “the FFS service authorization contractor or MCO” alike. Continued-stay (reauthorization) requests must include the Continued Stay Service Authorization Form; the original Comprehensive Needs Assessment with an addendum (it can be a progress note) on new information, progress, interventions to date and the rationale for continuing; an updated ISP that reflects current goals and any use of telemedicine; and a treatment-progress summary that opens with a “graphical presentation of progress on each goal and objective in the ISP,” followed by family involvement, generalization across settings, progress toward discharge (including any planned step-down) and care coordination. Ongoing documentation must also carry “graphical analysis of goals and objectives as defined by the most current ISP.” So yes — Virginia Medicaid requires graphs at reauthorization. [4]

Code set (DMAS rule): ABA is billed under CPT 97151–97158, 0362T and 0373T, each treatment code authorized with its own predetermined number of units; the HCPCS codes in Appendix D (H2033, H0036) belong to MST and FFT, not ABA. [4]

## Intake gates

The questions that decide whether a family can start with Sentara Community Plan (VA), and what they have to bring.

- **Age limit**: 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]
- **Diagnosis recency**: 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]
- **Who may diagnose**: 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]
- **Diagnostic tools required**: 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]
- **Referral required?**: 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]
- **Telehealth**: 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]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: 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]

## Delivery and billing rules

Coverage decides whether Sentara Community Plan (VA) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: 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]
- **Concurrent billing (97153 + 97155)**: 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]
- **Daily limits / MUEs**: 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]
- **Session-note signature**: 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]
- **Place of service**: 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]
- **Bill as provider**: 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]

## What intake should collect for Sentara Community Plan (VA)

- **ASD diagnosis:** Then book the assessment — no authorization needed on assessment codes.
- **Units per CPT code:** Sentara's form is the units-per-code template — plan intensity code by code.
- **Weekly schedule (if ≥20 hrs):** The 80-unit threshold triggers the activity-schedule requirement, embedded in the form.
- **Supervising BCBA on file:** Use the BCBA Change Request Form when supervision changes — don't let claims hit a stale name.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How Sentara Community Plan (VA) ABA benefits route and read on an eligibility check. Data last updated 2026-10-15.

### EDI routing

- **Payer ID (pVerify):** 002478 — pVerify 002478 = "SENTARA HEALTH PLANS" (Medical, Eligibility=Yes); legacy "Optima/Sentara" 00310 also exists. Directory entries under "Optima" are stale.
- **Payer ID (Availity):** 54154 — Payer ID 54154 per the DMAS Sentara MCO Directory (2025-10-29); corroborated by the 2012 Availity row "OPTIMA HEALTH PLAN → 54154."
- **Payer ID (Change Healthcare / Optum):** 54154 — Payer ID 54154 per the DMAS Sentara MCO Directory; legacy Virginia Premier (VP) group runout claims go to CHC ID VAPRM.
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** none (DMAS pass-through; Sentara Health Plans administers ABA in-house)
- **BH administrator payer ID:** 54154
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Not required — DMAS rule: assessment codes 97151, 97152, 0362T need no service authorization | No hard cap — EPSDT medical necessity governs; comprehensive assessment typically authorized in a bounded window per the treatment request per n/a (no SA on assessment codes) | home, office/clinic (11), school (03), community, telehealth (GT) | Reassessments only — the DMAS Telehealth Services Supplement (rev. 1/5/2026) allows 97151 and 97152 by telemedicine (GT) "for reassessments only." The initial assessment, including any follow-up observation or caregiver session billed under 97151/97152 to complete it, must be in person with the youth and caregivers; only care coordination, data analysis and treatment-plan preparation without the youth present (billed under 97151 at the initial assessment) need not be face to face. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97152 | Yes | Not required — DMAS rule: assessment codes 97151, 97152, 0362T need no service authorization | No hard cap — EPSDT medical necessity governs; comprehensive assessment typically authorized in a bounded window per the treatment request per n/a (no SA on assessment codes) | home, office/clinic (11), school (03), community, telehealth (GT) | Reassessments only — the DMAS Telehealth Services Supplement (rev. 1/5/2026) allows 97151 and 97152 by telemedicine (GT) "for reassessments only." The initial assessment, including any follow-up observation or caregiver session billed under 97151/97152 to complete it, must be in person with the youth and caregivers; only care coordination, data analysis and treatment-plan preparation without the youth present (billed under 97151 at the initial assessment) need not be face to face. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97153 | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97154 | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97155 | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97156 | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97157 | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 97158 | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community, telehealth (GT) | Yes — GT modifier, per DMAS state telehealth policy. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 0362T | Yes | Not required — DMAS rule: assessment codes 97151, 97152, 0362T need no service authorization | No hard cap — EPSDT medical necessity governs; comprehensive assessment typically authorized in a bounded window per the treatment request per n/a (no SA on assessment codes) | home, office/clinic (11), school (03), community | No — not on the DMAS Telehealth Services Supplement's telemedicine list (rev. 1/5/2026 lists 97151-97158 only), and Appendix D requires the QHP on site with two or more technicians. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |
| 0373T | Yes | Required — service authorization on the DMAS standardized preservice form; units itemized per CPT code (eff. 10/15/2025) | No hard cap — units requested per code; requests ≥20 hrs/week (80 units) must include an individualized activity schedule per per authorization span (EPSDT medical necessity; ~6-month spans typical) | home, office/clinic (11), school (03), community | No — not on the DMAS Telehealth Services Supplement's telemedicine list (rev. 1/5/2026 lists 97151-97158 only), and Appendix D requires the QHP on site with two or more technicians. | no modifier = technician, HN = LABA, TF = LMHP, HO = LBA |

Code notes:

- **97151:** Behavior-identification assessment (QHP). No service authorization — book the assessment on an ASD diagnosis; build the treatment request from it.
- **97152:** Supporting assessment (technician-adjunct). No service authorization.
- **97153:** Direct one-on-one adaptive-behavior treatment by a technician. Per-code units on the preservice form since 10/15/2025.
- **97154:** Group adaptive-behavior treatment. SA required.
- **97155:** Adaptive-behavior treatment with protocol modification (QHP). SA required; billable alongside 97153 when the QHP directs face-to-face.
- **97156:** Family adaptive-behavior treatment guidance (QHP). SA required.
- **97157:** Multiple-family group guidance. SA required.
- **97158:** Group adaptive-behavior treatment with protocol modification. SA required.
- **0362T:** Behavior-identification supporting assessment (extended/destructive-behavior). No service authorization under the DMAS baseline (note: Humana Healthy Horizons flags 0362T as PA-required — see that guide).
- **0373T:** Extended/destructive-behavior treatment protocol (extra-technician). SA required.

### Medicaid rates

Source: DMAS CPT fee file (cptmedical4.csv for 97151–97158; cptmedical1.csv for 0362T/0373T), read directly from the live file: licensure-tiered per-15-minute ABA rates effective 12/01/2021 (end 12/31/9999), still current in the file that also carries 07/01/2026 rows. Tiers flagged by modifier: no modifier = technician, HN/U1 = LABA, TF/U2 = LMHP, HO/U3/U7 = LBA; ABA rows are the OP (outpatient) place-of-service lines. Trap (confirmed): the file also carries generic "REGULAR & CSB" IP rows for 97151/97152/97156/97157 at a few dollars per unit (e.g. 97151 IP $6.75) — those are the non-ABA physician-fee lines, NOT the ABA program rates. Modifier definitions cross-checked against VirginiaABA's (draft) DMAS billing guidance. No Sentara Community Plan-specific ABA fee schedule is publicly posted. The Cardinal Care Managed Care Contract (July 1, 2026 - June 30, 2027) lists ABA among the mental health services (section 12.2.4.3) that every MCO must pay "no less than the current Medicaid FFS rate" (section 12.2.4; minimum fee schedule at 100% of FFS, section 12.1.14) — so this DMAS table is the contractual floor; the plan's negotiated rate may be higher Effective 2021-12-01.

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | $23.48 (LABA) / $39.40 (LMHP) / $46.63 (LBA) | 15min | HN (LABA): $23.48; TF (LMHP): $39.40; HO (LBA): $46.63 |
| 97152 | $15.00 (technician) / $23.48 (LABA) | 15min | technician: $15.00; HN (LABA): $23.48 |
| 97153 | $15.00 (technician) | 15min | technician: $15.00; HN (LABA): $23.48; TF (LMHP): $39.40; HO (LBA): $46.63 |
| 97154 | $12.77 (technician) — group | 15min | technician: $12.77; HN (LABA): $15.60; TF (LMHP): $13.13; HO (LBA): $15.55 |
| 97155 | $23.48 (LABA) / $39.40 (LMHP) / $46.63 (LBA) | 15min | HN (LABA): $23.48; TF (LMHP): $39.40; HO (LBA): $46.63 |
| 97156 | $23.48 (LABA) / $39.40 (LMHP) / $46.63 (LBA) | 15min | HN (LABA): $23.48; TF (LMHP): $39.40; HO (LBA): $46.63 |
| 97157 | $7.83 (LABA) / $13.13 (LMHP) / $15.55 (LBA) — multi-family group | 15min | HN (LABA): $7.83; TF (LMHP): $13.13; HO (LBA): $15.55 |
| 97158 | $22.83 (LABA) / $28.13 (LMHP) / $30.54 (LBA) — group w/ protocol mod | 15min | HN (LABA): $22.83; TF (LMHP): $28.13; HO (LBA): $30.54 |
| 0362T | $53.47 (LABA) / $69.39 (LMHP) / $76.62 (LBA) — team supporting assessment | 15min | HN (LABA): $53.47; TF (LMHP): $69.39; HO (LBA): $76.62 |
| 0373T | $53.47 (LABA) / $69.39 (LMHP) / $76.62 (LBA) — team treatment | 15min | HN (LABA): $53.47; TF (LMHP): $69.39; HO (LBA): $76.62 |

### Contacts

- **Benefits by phone:** Yes
- **Provider services phone:** 757-552-7174 or 1-800-648-8420 (Behavioral Health Provider Services); eligibility verification: 1-844-512-3172 — Sentara Community Plan Provider Relations and Eligibility Verification
- **Hours:** 8 a.m.-6 p.m. Monday-Friday (Medicaid line)
- **Portal:** [Availity](https://www.availity.com)
- **Fax:** (844) 895-3231 or (757) 963-9620 — ABA-specific, Non-Urgent BH Outpatient fax (eff. 8/1/2025); the general Behavioral Health Provider Services fax (757-552-7499) on Sentara's Contact Us page is a different line and not the one named for ABA forms

Questions to ask on a verification call:

- What places of service are approved under this member's authorization — home, school, community, or telehealth?
- Does Sentara Community Plan pay these ABA codes at the DMAS fee-schedule rate, or is there a plan-specific contracted rate?

### VOB data sources

- https://shc-p-001.sitecorecontenthub.cloud/api/public/content/c4fe04b9052647fb8655708609cc9e7f?v=4adf8dd1 (accessed 2026-07-23)
- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://www.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23)
- https://vamedicaid.dmas.virginia.gov/sites/default/files/2026-07/MES%20EDI%20270-271%20Companion%20Guide_R100_20220509-PK%202.pdf (accessed 2026-07-23)
- https://vamedicaid.dmas.virginia.gov/sites/default/files/2025-07/MHS%20-%20Appendix%20D%20(updated%207.17.25)_Final.pdf (accessed 2026-07-23)
- https://www.dmas.virginia.gov/media/4271/project-bravo-services-faqs-aba.pdf (accessed 2026-07-23)
- https://vamedicaid.dmas.virginia.gov/sites/default/files/2026-01/Telehealth%20Services%20Supplement%20(updated%201.5.26)_Final.pdf (accessed 2026-09-27)
- https://vamedicaid.dmas.virginia.gov/bulletin/applied-behavior-analysis-aba-policy-and-regulatory-clarifications (accessed 2026-09-27)
- https://vamedicaid.dmas.virginia.gov/bulletin/service-authorization-update-applied-behavior-analysis-aba-effective-october-15-2025 (accessed 2026-07-23)
- https://www.dmas.virginia.gov/media/cptcodes/cptmedical4.csv (accessed 2026-07-23)
- https://www.dmas.virginia.gov/media/cptcodes/cptmedical1.csv (accessed 2026-07-23)
- https://virginiaaba.org/wp-content/uploads/2021/11/ABA-Billing-Guidance-from-DMAS-Nov21.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.dmas.virginia.gov/media/cdclvnox/virginia-cardinal-care-managed-care-contract-fy-2026.pdf (accessed 2026-10-07)
- https://www.sentarahealthplans.com/en/providers/contact-us (accessed 2026-07-23)
- https://www.sentarahealthplans.com/en/providers/updates/behavioral-health-authorization-fax-numbers-and-forms (accessed 2026-10-01)
- https://www.sentarahealthplans.com/en/providers/contact-us-sentara-community-plan (accessed 2026-10-14)

## Common questions

### Does Sentara Community Plan cover ABA?

Yes — Virginia's Cardinal Care ABA benefit on DMAS criteria and forms: no authorization on assessment codes, treatment authorized with units per CPT code on the new DMAS preservice form.

### Is Optima Family Care the same as Sentara Community Plan?

Yes — Optima Family Care and Virginia Premier merged into Sentara Community Plan under the Cardinal Care rebrand. Anything still labeled Optima is stale.

### How do I change the supervising BCBA on a Sentara authorization?

Use the plan's dedicated BCBA Change Request Form (updated March 2026) — a standing administrative workflow rather than a new authorization.

### What happens to the authorization when switching ABA providers on Sentara Community Plan?

The DMAS rule applies to the MCO by name: if ABA lapses for more than 31 consecutive days, the provider must discharge the youth and notify the MCO, and resuming needs a new service authorization with a new assessment and ISP. DMAS publishes no rule moving an authorization between agencies, so ask Sentara Community Plan whether the incoming agency needs its own authorization. For a change of supervising BCBA within the same agency, Sentara uses its BCBA Change Request Form.

### Can a Sentara Community Plan member receive ABA while staying across the border in North Carolina, for example on weekends?

Only with the plan’s agreement. The Cardinal Care contract says the MCO “is not responsible for services obtained outside the Commonwealth” except emergency or crisis care, where using another state’s medical resources is general practice in the member’s locality, where medically necessary services are not available in-network in Virginia, or under a transition-of-care plan. The clinician also needs North Carolina licensure to practice there (G.S. 90-746). A temporary NC license covers only “a limited and defined period of service approved by the Board” (G.S. 90-740). Get Sentara Community Plan’s written approval before scheduling sessions in North Carolina.

### What is Sentara Community Plan’s timely filing limit?

We could not read a current Sentara claims document. The Cardinal Care contract requires every MCO’s limit to fall between 3 and 12 months from the date of service, so confirm Sentara’s number in your provider agreement or with Sentara provider services.

### Does Sentara Community Plan require graphs for an ABA reauthorization?

Yes — under DMAS Appendix D, which applies to the MCOs, the continued-stay request must include a graphical presentation of progress on each ISP goal and objective, with an updated ISP and a needs-assessment addendum.

## Primary sources

1. [Sentara — BH prior authorization forms (government plans)](https://www.sentarahealthplans.com/en/providers/claims-authorizations/authorizations/behavioral-health/government)
2. [Sentara — DMAS ABA preservice SA form (DOS 9/1/2025+)](https://shc-p-001.sitecorecontenthub.cloud/api/public/content/c4fe04b9052647fb8655708609cc9e7f?v=4adf8dd1)
3. [DMAS — ABA service authorization update (eff. 10/15/2025)](https://vamedicaid.dmas.virginia.gov/bulletin/service-authorization-update-applied-behavior-analysis-aba-effective-october-15-2025)
4. [DMAS — MHS manual Appendix D (ABA)](https://vamedicaid.dmas.virginia.gov/sites/default/files/2025-07/MHS%20-%20Appendix%20D%20(updated%207.17.25)_Final.pdf)
5. [DMAS — Project BRAVO ABA FAQ](https://www.dmas.virginia.gov/media/4271/project-bravo-services-faqs-aba.pdf)
6. [Sentara — BH authorization fax numbers and forms update (eff. 8/1/2025)](https://www.sentarahealthplans.com/en/providers/updates/behavioral-health-authorization-fax-numbers-and-forms)
7. [DMAS — Cardinal Care Managed Care Contract (July 1, 2026 – June 30, 2027)](https://www.dmas.virginia.gov/media/cdclvnox/virginia-cardinal-care-managed-care-contract-fy-2026.pdf)
8. [DMAS memo — Update to Chapter 5, Correction Regarding MCO Payment Rates (12/4/2025)](https://vamedicaid.dmas.virginia.gov/node/3748)
9. [N.C.G.S. Chapter 90, Article 43 — behavior analyst licensure (G.S. 90-740, 90-745, 90-746)](https://www.ncleg.gov/EnactedLegislation/Statutes/HTML/ByArticle/Chapter_90/Article_43.html)
10. [Sentara Health Plans — Provider Updates (weekly provider email alerts archive)](https://www.sentara.com/en/health-plans/providers/updates/alerts)
11. [Sentara Health Plans — Provider News quarterly newsletter archive](https://www.sentara.com/en/health-plans/providers/updates/newsletters)
12. [DMAS — Mental Health Services Manual, Chapter V: Billing Instructions (rev. 12/5/2025)](https://vamedicaid.dmas.virginia.gov/sites/default/files/2025-12/MHS%20-%20Chapter%205%20%28updated%2012.5.25%29_Final.pdf)
13. [DMAS — Mental Health Services Manual, Chapter IV (rev. 10/2/2026)](https://vamedicaid.dmas.virginia.gov/sites/default/files/2026-10/MHS%20-%20Chapter%204%20%28updated%2010.2.26%29_Final.pdf)
14. [CMS — Medicaid NCCI PTP edits, practitioner services (2026 Q4, active 10/1–12/31/2026)](https://www.cms.gov/files/zip/medicaid-ncci-2026-q4-ptp-edits-practitioner-services.zip)
15. [CMS — Medicaid NCCI MUE edits, practitioner services (2026 Q4, active 10/1–12/31/2026)](https://www.cms.gov/files/zip/medicaid-ncci-2026-q4-mue-edits-practitioner-services.zip)
16. [DMAS — Telehealth Services Supplement (rev. 1/5/2026), Table 2](https://vamedicaid.dmas.virginia.gov/sites/default/files/2026-01/Telehealth%20Services%20Supplement%20(updated%201.5.26)_Final.pdf)
17. [DMAS bulletin — ABA Policy and Regulatory Clarifications (12/16/2025)](https://vamedicaid.dmas.virginia.gov/bulletin/applied-behavior-analysis-aba-policy-and-regulatory-clarifications)
18. [Sentara Health Plans — Virginia Medicaid Program Provider Manual (2026)](https://shc-p-001.sitecorecontenthub.cloud/api/public/content/166702e707ad4460995f61992a6be8e0?v=2c7ff490)
19. [DMAS bulletin — Interoperability and Prior Authorization Final Rule implementation update](https://vamedicaid.dmas.virginia.gov/bulletin/interoperability-and-prior-authorization-final-rule-implementation-update)
20. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/section-438.210)
21. [32 CFR 199.8 — TRICARE double coverage (eCFR)](https://www.ecfr.gov/current/title-32/section-199.8)
22. [38 CFR 17.272 — CHAMPVA benefit limitations; Medicaid exception (eCFR)](https://www.ecfr.gov/current/title-38/section-17.272)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.