---
title: "SilverSummit Healthplan ABA coverage: the intake guide."
url: "https://carelu.com/payers/silversummit-healthplan-nevada"
markdown_url: "https://carelu.com/payers/silversummit-healthplan-nevada.md"
state: NV (Nevada)
payer: SilverSummit Healthplan (Nevada Medicaid)
kind: Medicaid managed care plan (MCO)
parent_program: Nevada Medicaid (Statewide Managed Care)
description: "How SilverSummit Healthplan (Centene) covers ABA for Nevada Medicaid members: ABA on the prior-authorization list, the FA-11E/FA-11F treatment request checklist, CP.BH.104, 2-business-day decisions, no retro authorization, and the state rules underneath."
last_reviewed: October 2026
---

# SilverSummit Healthplan ABA coverage: the intake guide.

_Payer Guide · SilverSummit · Nevada Medicaid · Last updated October 2026 · 18 primary sources_

> Centene’s Nevada Medicaid MCO; ABA on its PA list, FA-11E/FA-11F plus a full treatment plan, CP.BH.104 revised for DOS from 5/30/2026.

SilverSummit Healthplan is Centene’s Nevada Medicaid plan and one of the five health plans NVHA lists for statewide managed care. It lists Applied Behavior Analysis among the provider types in its network and among the behavioral health services that need prior authorization, and in 2026 it published an ABA treatment request checklist built on the state’s own forms: FA-11E for every request and FA-11F with the first. Its medical necessity policy is Centene’s Clinical Policy CP.BH.104, revised for dates of service from May 30, 2026.

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

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment:** Not published / unverified. Verify via: SilverSummit “Pre-Auth Needed?” tool on silversummithealthplan.com or Utilization Management, 1-844-366-2880: check 97151, 97152 and 0362T. [4][7]
- **Prior auth for treatment**: Yes. ABA is on the manual’s behavioral health prior-authorization list; initial requests need FA-11E and FA-11F, and concurrent requests FA-11E with treatment-plan updates (June 2026 checklist) [4][3]
- **Autism diagnosis required?**: Yes: a “Comprehensive diagnostic evaluation supporting an Autism Spectrum Disorder diagnosis by a qualified provider,” with FA-11F signed by a qualified diagnosing practitioner on initial requests [3]

## At a glance

- **Covers ABA?:** Yes (Nevada Medicaid benefit, any age)
- **Prior auth:** Required for ABA treatment; FA-11E + FA-11F (initial), FA-11E + plan updates (concurrent)
- **Criteria:** Clinical Policy CP.BH.104 (revised for DOS from 05/30/2026)
- **Decision clock:** Manual: 2 business days non-urgent; OTR guidance says allow up to 14 business days
- **Retro auth:** Not given for routine sessions; rare exceptions within 180 days
- **Licensure:** Nevada-licensed BCBA/BCaBA, registered RBT (NRS 641D)

## What a SilverSummit ABA request must contain

SilverSummit’s ABA Outpatient Treatment Request Checklist (June 29, 2026) says requests are reviewed “in accordance with Nevada Medicaid MSM Chapter 3700 and PT 85 billing guidelines.” For initial requests, “providers must submit Form FA‑11E (ABA Authorization Request) and Form FA‑11F (Autism Spectrum Disorder Diagnosis Certification),” with FA-11F “completed and signed by a qualified diagnosing practitioner” and needed for initial requests only. But “FA‑11E alone does not replace the requirement for an ABA treatment plan”: send assessment-driven goals with mastery criteria, assessment tool data (VB-MAPP, ABLLS-R, AFLS, EFL or similar) appropriate to age and development, operational definitions and baselines for behaviors targeted for reduction (with an FBA or equivalent), caregiver training goals, a crisis plan when indicated, a generalization plan, titration criteria, the proposed weekly schedule including school, coordination with educational services and IEP status, and the parent’s signature. Concurrent requests need FA-11E plus updated progress, data trends, attendance for member and caregivers, and mastered and modified goals. [3][4][5][8]

The manual lists ABA among behavioral health services requiring prior authorization and says “We do not retroactively authorize treatment.” Behavioral health requests use SilverSummit’s Outpatient Treatment Request forms or the secure portal; network practitioners “should allow up to fourteen (14) business days to process non-urgent requests,” even though the manual’s decision table lists 2 business days for non-urgent pre-service requests. For behavioral health, retro authorizations “will only be granted in rare cases, such as eligibility issues” and must be requested within 180 days of service. Medical necessity is judged against CP.BH.104, which SilverSummit revised for dates of service starting May 30, 2026 (diagnostic documentation, assessment components, caregiver training, continuation and step-down criteria). Nevada’s managed-care rules give members (or a provider acting with the member’s written permission) 60 calendar days from the notice of adverse benefit determination to appeal to the plan, allow one level of internal appeal, and require a standard appeal decision within 30 calendar days (expedited within 72 hours); after the plan’s appeal, the member may request a State Fair Hearing (MSM 3604). [3][4][5][8]

## Can an out-of-state BCBA treat a SilverSummit member, including by telehealth?

Not without a Nevada license. NRS 641D.900 bars anyone from engaging “in the practice of applied behavior analysis unless he or she is licensed or registered as required by the provisions of this chapter.” Telehealth does not get around that: NRS 629.031 counts “A behavior analyst, assistant behavior analyst or registered behavior technician” as a provider of health care, and NRS 629.515 says that before a provider at a distant site “may use telehealth to direct or manage the care or render a diagnosis of a patient who is located at an originating site in this State,” the provider “must hold a valid license or certificate to practice his or her profession in this State.” A BCBA directing a Nevada child’s program from another state is therefore treated as practicing in Nevada and is “subject to the laws and jurisdiction of the State of Nevada.” The fast path is licensure by endorsement under NRS 641D.340: a behavior analyst who holds “a corresponding valid and unrestricted license as a behavior analyst” in another state or D.C. may apply, and unless the Board denies for good cause it must issue the license within 45 days of the application or 10 days after the fingerprint background report, whichever is later. Payers add their own layer: credential the clinician with each plan before billing. [16][17][4]

SilverSummit credentials Nevada Medicaid providers through the state’s centralized credentialing verification organization and says it notifies providers of approvals or denials within 30 calendar days of the CVO’s result. [16][17][4]

## Claim filing and payment rules at SilverSummit

Federal Medicaid rules set the payment floor for every managed care plan: a state’s contract with an MCO "must provide that the organization will meet the requirements of § 447.45(d)(2) and (d)(3)" (42 CFR 447.46) — pay 90 percent of clean claims from practitioners within 30 days of receipt and 99 percent within 90 days — unless the plan and the provider agree in writing to an alternative schedule stipulated in the contract. A "clean claim" is one that "can be processed without obtaining additional information from the provider of the service or from a third party" (42 CFR 447.45(b)). SilverSummit’s 2026 provider manual sends claim instructions to a separate SilverSummit Healthplan Billing Guide, which was not found on its provider resources page for this guide; take the filing limits from that guide or your agreement. [1][2]

## Intake gates

The questions that decide whether a family can start with SilverSummit Healthplan (Nevada Medicaid), and what they have to bring.

- **Age limit**: SilverSummit publishes no ABA age rule and reviews against MSM 3700. No age limit. Nevada Medicaid covers ABA for “Medicaid eligible individuals of all ages” (MSM 3704.1, effective April 1, 2024), with members under 21 also covered through EPSDT. [3][7]
- **Diagnosis recency**: No fixed age for the evaluation, but “Diagnostic documentation must support current medical necessity for ABA services,” and FA-11F is required only with the initial request. [3]
- **Who may diagnose**: FA-11F “must be completed and signed by a qualified diagnosing practitioner acting within their scope of practice”; the state form limits that to a physician, physician assistant, APRN or psychologist. [3][11]
- **Diagnostic tools required**: Diagnosis: FA-11F (ADOS-2, CARS-2, GARS-3, FASD category or documented DSM-5 criteria). Treatment: assessment tool data such as VB-MAPP, ABLLS-R, AFLS or EFL “appropriate for member based on chronological age and developmental level,” noting that “some portions of assessment tools may not meet the coverage criteria.” [3][11]
- **Referral required?**: SilverSummit publishes nothing different. Nevada Medicaid’s rule (MSM 3704.1, FA-11F): ABA “must be rendered according to the written orders of” a physician, physician assistant, psychologist or APRN/NP, who certifies the diagnosis on FA-11F with the first request. [7][11][3]
- **Telehealth**: SilverSummit publishes no ABA telehealth rule. Nevada Medicaid’s rule: MSM 3403 gives telehealth “parity with in-person health care services,” requires the originating site to be in Nevada and lists only personal care, home health and private duty nursing as in-person-only; NRS 422.2721 bars extra prior authorization for telehealth. Bill POS 02 or 10 with modifier 95 (audio-video) or 93 (audio-only). The clinician needs a Nevada license (NRS 629.515). No Nevada ABA document lists which ABA codes may be delivered remotely. [12][13][19][17]
- **Other insurance (who pays first)**: SilverSummit asks members to report other coverage and publishes no ABA-specific rule; Medicaid is the payer of last resort (42 CFR 433.139), and Nevada Medicaid denies what a primary denied for not following its rules. [4][15][20]
- **Prior-auth decision time** _(plan-dependent)_: The 2026 manual lists “Preservice/Non-Urgent 2 business days,” “Preservice/Urgent 72 hours or 2 business days” and concurrent review 24 hours, but tells practitioners using behavioral health Outpatient Treatment Request forms to “allow up to fourteen (14) business days to process non-urgent requests.” The federal managed-care cap is 7 calendar days for rating periods starting on or after January 1, 2026. [4][14]
  - Ask the plan: SilverSummit Utilization Management, 1-844-366-2880: ask which timeframe applies to ABA requests submitted through the portal.

## Delivery and billing rules

Coverage decides whether SilverSummit Healthplan (Nevada Medicaid) 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**: SilverSummit’s checklist asks for the training and treatment plan but sets no supervision ratio of its own; it reviews against MSM 3700. Nevada Medicaid’s rule (MSM 3704.3A, MSM 3704.2A(1)(j)): supervision follows NRS 641D.610, “must be overseen by a Licensed Psychologist, BCBA-D or BCBA who has experience in the treatment of autism,” may be delivered by a BCaBA at their direction, and is capped at 20% of direct therapy hours unless clinical documentation supports more. MSM 3600 requires MCOs to provide services with the same amount, duration and scope as fee-for-service. [3][7][8]
- **Daily limits / MUEs**: SilverSummit publishes no ABA limits of its own and reviews against the PT 85 billing guide. Nevada Medicaid’s limits (MSM 3704.2A(4); PT 85 billing guide): 12 hours of ABA per provider per day, 40 hours per recipient per week; focused 15–25 and comprehensive 25–40 hours a week counting 97153, 97155 and 0373T together; 97151 one 16-unit and 97152/0362T one 4-unit session per 180 days; 97156 4 units a week. Limits may be exceeded with prior authorization and documented medical necessity. [3][7][9]
- **Session-note signature**: Not stated by SilverSummit beyond “Provider signature, per within health plan requirements” on the treatment plan. Nevada Medicaid’s rule (MSM 3704.4G): a progress note for each day of service with the recipient’s name, place of service, date, actual start and end times, the name and credentials of the provider who delivered the service, and “The signature of the provider who delivered the service.” [3][7]
- **Place of service**: SilverSummit publishes no ABA setting rule; its checklist asks for coordination with educational services for school-aged members. Nevada Medicaid’s rule (MSM 3704.1, 3704.2A(8)): ABA may be delivered in a clinic or office, the community or the home, and in “the natural setting (i.e. home, school and community-based settings, including clinics)”; resorts, spas, camps, education services, respite and child care are not covered. Telehealth is billed POS 02 or 10. [3][7]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not addressed in SilverSummit’s manual or checklist, and the state publishes no same-time rule. [4][3]
  - Ask the plan: SilverSummit Provider Services, 1-844-366-2880, or the SilverSummit Provider Billing Manual.

## What intake should collect for SilverSummit Healthplan (Nevada Medicaid)

- **Member ID:** Confirm SilverSummit Medicaid (not Ambetter) on the date of service.
- **FA-11F + diagnostic evaluation:** Signed by a qualified diagnosing practitioner; initial requests only.
- **Full treatment plan:** FA-11E is not enough on its own: goals, assessment data, baselines, caregiver goals, schedule and parent signature.
- **School schedule and IEP:** Coordination with school and IEP status for school-aged members.
- **Other insurance:** Medicaid pays last; bill the primary first.

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

## Common questions

### How fast must SilverSummit pay a clean ABA claim?

Its state contract must hold it to the federal Medicaid standard: 90% of clean practitioner claims paid within 30 days of receipt and 99% within 90 days (42 CFR 447.46, 447.45), unless the provider contract sets an alternative schedule. Its own filing limit comes from the provider manual or your agreement.

### What forms does SilverSummit need for an ABA request?

The state forms: FA-11E for every request and FA-11F with the first, plus a full treatment plan, since SilverSummit says FA-11E alone does not replace it.

### Does SilverSummit authorize ABA retroactively?

Not for routine sessions. Behavioral health retro authorizations are granted only in rare cases such as eligibility issues, requested within 180 days of service with a cover letter.

### How long does SilverSummit take to decide an ABA request?

The manual lists 2 business days for non-urgent pre-service decisions but tells behavioral health practitioners to allow up to 14 business days; federal rules cap standard Medicaid decisions at 7 calendar days for 2026 contracts.

## Primary sources

1. [42 CFR 447.46 — Timely claims payment by MCOs (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-447/subpart-A/section-447.46)
2. [42 CFR 447.45 — Timely claims payment (clean-claim definition; 90% in 30 days, 99% in 90 days) (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-447/subpart-A/section-447.45)
3. [SilverSummit Healthplan — ABA Outpatient Treatment Request Checklist (June 29, 2026)](https://www.silversummithealthplan.com/content/dam/centene/Nevada/Notifications/2026-documents/SSHP_Provider_ABA%20Treatment%20Request%20Checklist_Digital_2026-06-29_FINAL.pdf)
4. [SilverSummit Healthplan — 2026 Provider Manual (updated 01-01-2026)](https://www.silversummithealthplan.com/content/dam/centene/Nevada/Notifications/2026-documents/4%20SSHP%20NV%20Provider%20manual%202025-11-19.pdf)
5. [SilverSummit Healthplan — Notice of revision to Clinical Policy CP.BH.104, Applied Behavior Analysis (June 5, 2026; DOS from 05/30/2026)](https://www.silversummithealthplan.com/content/dam/centene/Nevada/Notifications/2026-documents/ABA%20revisions.pdf)
6. [Nevada Medicaid — Contact a Health Plan (the five Medicaid health plans, updated 04/08/2026)](https://www.nevadamedicaid.nv.gov/medicaid-members/health-plan-home/contact-a-health-plan/)
7. [Nevada Medicaid Services Manual Chapter 3700 — Applied Behavior Analysis (MTL 08/24, effective April 1, 2024; current)](https://www.nevadamedicaid.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/AdminSupport/Manuals/MSM/C3700/MSM_3700_24_04_01.pdf)
8. [Nevada Medicaid Services Manual Chapter 3600 — Managed Care Organization (effective January 1, 2026)](https://www.nevadamedicaid.nv.gov/siteassets/content/resources/adminsupport/manuals/msm/c3600/MSM_3600_26_01-01.pdf)
9. [Nevada Medicaid — Provider Type 85 Billing Guide, Applied Behavior Analysis (updated 10/13/2026)](https://www.medicaid.nv.gov/Downloads/provider/NV_BillingGuidelines_PT85.pdf)
10. [Nevada Medicaid Form FA-11E — Applied Behavior Analysis (ABA) Authorization Request (updated 10/14/2026)](https://www.medicaid.nv.gov/Downloads/provider/FA-11E.pdf)
11. [Nevada Medicaid Form FA-11F — ASD Diagnosis Certification for Requesting Initial ABA Services (updated 06/10/2025)](https://www.medicaid.nv.gov/Downloads/provider/FA-11F.pdf)
12. [Nevada Medicaid Services Manual Chapter 3400 — Telehealth Services (effective November 29, 2023)](https://www.nevadamedicaid.nv.gov/uploadedFiles/dhcfpnvgov/content/Resources/AdminSupport/Manuals/MSM/C3400/MSM_3400_23_11_29_ADA.pdf)
13. [NRS Chapter 422 — NRS 422.27497 (Medicaid ABA services) and 422.2721 (Medicaid telehealth)](https://www.leg.state.nv.us/NRS/NRS-422.html)
14. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-D/section-438.210)
15. [42 CFR 433.139 — Medicaid third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
16. [NRS Chapter 641D — Applied Behavior Analysis (licensure, endorsement, supervision, prohibited acts)](https://www.leg.state.nv.us/NRS/NRS-641D.html)
17. [NRS 629.031 and 629.515 — Provider of health care defined; Nevada license required for telehealth to a patient in Nevada](https://www.leg.state.nv.us/NRS/NRS-629.html)
18. [SilverSummit Healthplan — 2026 Provider Notifications](https://www.silversummithealthplan.com/providers/ProviderNotifications/2026-notifications.html)
19. [Nevada Medicaid — Telehealth Billing Instructions (updated 08/03/2026)](https://www.medicaid.nv.gov/Downloads/provider/NV_Billing_Telehealth.pdf)
20. [Nevada Medicaid and Nevada Check Up Billing Manual (updated July 10, 2026)](https://www.medicaid.nv.gov/Downloads/provider/nv_billing_general.pdf)

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.