The Health Plan (THP) has served West Virginia Medicaid members since September 1, 1996 and WVCHIP members since January 1, 2021, and now serves Mountain Health Trust members in all 55 counties. Its 2026 provider manual says THP "provides behavioral health services as outlined in the Bureau for Medical Services (BMS) practitioner manual," lists Chapter 519 (where the ABA policy sits) among them, and names Applied Behavior Analysis as part of the WVCHIP behavioral health benefit.
The catch is authorization. THP warns that "THP and BMS may have differing prior authorization requirements," and THP’s current PA list does not name a single ABA code. Get THP’s answer in writing before you start.
THP’s Mountain Health Trust chapter says it covers behavioral health services as outlined in the BMS manual chapters, including Chapter 519, and that for WVCHIP members the benefit includes "Applied Behavior Analysis. All practitioners must be fully licensed and credentialed by THP before providing services." It also says THP and BMS "may have differing prior authorization requirements" and sends providers to THP’s PA list.[1][2][5][9][8]
That list, the Medical and Behavioral Health Prior Authorization Requirements effective August 1, 2026, has a Mountain Health Trust column, but none of 97151 through 97158, 0362T, 0373T or H0031 appears on it. The list’s rule for missing codes is "If your valid and active CPT code is not on this list with prior authorization requirements, prior authorization is not required," with an exception for any Mountain Health Trust code "not found on the BMS Fee Schedule" (the ABA codes are on BMS’s ABA fee schedule). BMS Policy 519.23 requires PA on every ABA code, and Chapter 527 says providers must obtain the authorizations "as specified by the MCO." Until THP confirms, treat ABA as requiring a portal authorization; a denied claim cannot be billed to the family under BMS rules.[1][2][5][9][8]
To comply with Senate Bill 267, THP requires prior authorizations for Mountain Health Trust, West Virginia commercial and PEIA members through its secure provider portal; "Effective July 1, 2024, fax and phone prior authorization requests will not be accepted." THP answers complete requests within 5 business days (2 business days urgent) for Mountain Health Trust. For incomplete requests, THP notifies the practitioner of deficiencies within 2 business days, the practitioner has 3 business days to respond, and THP then decides within 2 business days; a peer review is completed within 5 business days and a formal PA appeal decided within 10 business days.[3][11]
For Mountain Health Trust, "Initial, original claims must be submitted within 180 days from the date of service"; corrected claims within 180 days of the original denial or of the service date, whichever is later; and COB claims within 180 days of service or 90 days from the primary carrier’s EOB, whichever is later. THP adjudicates clean claims within 30 days and pays participating practitioners 18% a year interest on Mountain Health Trust claims unpaid after 30 days. EPSDT claims "are paid without any coordination of benefits (COB)" and need the EP modifier, but THP does not say whether it treats ABA as an EPSDT claim. Rates are contracted and unpublished; the BMS ABA fee schedule (97153 $9.90 per 15 minutes) is the public benchmark.[4][1][8]
The questions that decide whether a family can start with The Health Plan of West Virginia (Mountain Health Trust), and what they have to bring. Each maps onto something intake should ask on the first call.
THP publishes no ABA age rule, so the state rule applies. Ages 18 months through 20. Policy 519.23.1 makes ABA available to "Medicaid members ages 18 months through age 20 with a primary diagnosis of Autism Spectrum Disorder (ASD) prior to their eighth birthday" who are referred for diagnostic and treatment services identified during an EPSDT encounter.[1][5]
THP publishes no rule of its own. Within 24 months. The PA request must include "the qualifying diagnostic assessment establishing the ASD diagnosis prior to age eight and completed within the previous 24 months" and "A comprehensive diagnostic assessment completed by a qualifying provider within the previous 24 months" (519.23.6). The first request must also document that the primary diagnosis "was rendered prior to the child’s eighth year of age" (519.23.2).[1][5]
THP publishes no list of its own. Policy 519.23.2 names the "qualified diagnostic provider": a licensed physician "such as a neurologist, pediatric neurologist, developmental pediatrician, psychiatrist, supervising psychologist, or a licensed psychologist, licensed independent social worker, licensed independent counselor." The glossary’s narrower definition of "Diagnostic Assessment" lists only physicians (neurologist, pediatric neurologist, developmental pediatrician, psychiatrist) and licensed psychologists, so a psychologist or physician diagnosis is the safe choice.[1][5]
THP publishes nothing different from the state. Yes. Members must be "referred for necessary diagnostic and treatment services identified during an Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) encounter" (519.23.1), and every PA request must include "The annual physician’s order for ABA Services" (519.23.6).[1][5]
THP publishes no ABA telehealth rule of its own, so the state rule applies. BMS lists every ABA code it pays except 97157 on its telehealth code list: Appendix A to Policy 519.17 (effective 1/1/2025) carries 97151, 97152, 97153, 97154, 97155, 97156 and 97158 with "provisional" status, meaning "temporarily approved for telehealth" and "subject to review." Policy 519.23 says telehealth "must align with" Policy 519.17, which requires real-time audio and video, POS 02 (or POS 10 when the member is at home, since January 1, 2022), written member consent, notes that record the telehealth mode, and HIPAA-compliant platforms. Two cautions: Policy 519.17’s list of distant-site practitioners does not name behavior analysts, and it requires interstate telehealth practitioners to register "with the appropriate board in West Virginia," a board that does not exist for BCBAs. Confirm with BMS or the MCO before building a remote program.[7][6][1]
Complete Mountain Health Trust requests: 5 business days standard, 2 business days urgent. Incomplete: THP flags deficiencies within 2 business days, the practitioner has 3 business days, THP decides within 2 business days of the response. Peer review within 5 business days; PA appeals within 10 business days.[3][11]
Bill the other carrier first: COB claims are due within 180 days of service or 90 days from the primary EOB, whichever is later. THP says EPSDT claims are paid without COB but does not say whether ABA counts as EPSDT, and BMS treats Medicaid as payer of last resort.[4][1][16]
Ask the plan: THP Provider Services: ask whether ABA claims for a member with commercial coverage must carry the primary EOB.
Coverage decides whether The Health Plan of West Virginia (Mountain Health Trust) 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.
THP publishes no ABA supervision rule of its own, so the state rule applies. BMS sets no numeric supervision ratio. Policy 519.23.4 recognizes a BCBA (master’s or BCBA-D), a BCaBA "working under the supervision of a BCBA or who meets Behavior Analyst Certification Board supervisor requirements," and an RBT "working under the supervision of a BCBA or BCaBA who meets the Behavior Analyst Certification Board supervisor requirements," each only while BACB certification is "current and in good standing." The glossary adds that BCaBA "Competency and supervision must be verified annually and submitted to supervisor," and that BMS follows the BACB ethics code. Group skills training is limited to "four members to each staff person."[1][5]
THP publishes no ABA unit cap of its own; Policy 519.23 caps 97151, 97152, 97153, 97154, 97155, 97156 and 97158 in combination at "a maximum of 40 hours per week and/or eight hours within a 24-hour period," with the service week running Sunday 12:00 am through Saturday 11:59 pm. The H0031 assessment is limited to "one per year per member." Group codes 97154 and 97158 may not exceed eight members.[1][5]
THP excludes "School-based services" from its behavioral health benefit (they stay fee-for-service), and BMS says educational services cannot be authorized. THP publishes no other ABA setting rule.[1][5]
THP publishes no ABA concurrent-billing rule; BMS Policy 519.23 requires that "only one staff person’s time is billed for any specific activity."[1][5]
Ask the plan: THP Provider Services or THP payment policies (healthplan.org → Providers → Payment Policies): ask whether 97153 and 97155 may be billed for the same minutes.
Not addressed in the THP manual chapters read.[1]
Blocked on: THP Provider Manual Chapter 4 (Medical Records) or THP Provider Services.
THP "requires credentialing of all licensed behavioral health practitioners operating within a practitioner’s practice," and says unlicensed personnel may not bill behavioral health services except approved supervised psychologists and certain OBMAT exceptions. It does not say how RBT services billed under a BCBA are handled, and BCBAs hold no West Virginia license.[1][5]
Ask the plan: THP Provider Services and credentialing: ask how BCBAs and RBTs are credentialed and which NPI goes on RBT-delivered lines.
Yes. THP covers behavioral health services as outlined in the BMS manual, including Chapter 519, where Policy 519.23 covers ABA, and its manual names ABA in the WVCHIP behavioral health benefit.
Its August 1, 2026 PA list names no ABA code, but BMS policy requires PA on every ABA code and THP warns that THP and BMS rules can differ. Ask THP in writing and keep the answer.
180 days from the date of service for original Mountain Health Trust claims; COB claims 180 days from service or 90 days from the primary EOB, whichever is later.
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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