Virginia Medicaid, administered by DMAS, covers ABA for children under 21 through the EPSDT benefit — historically labeled "Behavioral Therapy" and now documented as ABA in the Mental Health Services manual's Appendix D. The structure is one of the more intake-friendly in our directory: assessment codes need no service authorization at all, so with an ASD diagnosis in hand you can book the assessment immediately. The rigor arrives at the treatment authorization, which since October 2025 must itemize units per CPT code. All five Cardinal Care MCOs run on the identical DMAS criteria and standardized forms — their guides below cover the per-plan mechanics.
DMAS requires no service authorization for the assessment codes — 97151, 97152, and 0362T — a fact confirmed both in the Mental Health Services manual's Appendix D and in the fee file's own PA flags. For intake, that means the sequence can be: verify eligibility → book the assessment immediately → build the treatment request from the assessment. One post-pandemic constraint: initial assessments must be conducted in person — and that covers the whole initial assessment, including follow-up observations and sessions with additional caregivers, because the Telehealth Services Supplement allows 97151/97152 by telemedicine for reassessments only. DMAS's December 2025 clarifications bulletin makes the in-person initial assessment a condition of Medicaid reimbursement for everything built on it.[1][4][33][34]
All treatment hours require service authorization with a predetermined number of units for each treatment procedure code. Effective for dates of service October 15, 2025 and later, requests — fee-for-service and every Cardinal Care MCO alike — must itemize units per ABA CPT code on the new DMAS standardized preservice form (no more bundling under 97155), so intake and clinical planning need to align on requested intensity code by code. Requests at or above 20 hours/week (80 units) must include an individualized schedule of activities, and continued-stay requests need an updated ISP plus graphical progress data. There is no hard hour cap today — EPSDT medical necessity governs (though a pending FY2027 Appropriation Act item would add a 20-hour/week ceiling; see "Watch" below). Fee-for-service authorizations still run on Acentra Health's Atrezzo Next Generation (ANG) system, but the access path changed twice in 2026: DMAS added an "FFS Service Authorization" tile inside its Medicaid Enterprise System (MES) provider portal effective April 27, 2026, direct login to Atrezzo continued only through May 31, 2026, and effective June 1, 2026 every provider had to reach FFS service authorizations through MES single sign-on and that tile rather than a direct Atrezzo/Kepro login (portal.kepro.com/Login/Login was retired for this purpose). That tile-based path was then itself superseded: a DMAS bulletin issued July 14, 2026 ended even that direct/legacy access to ANG effective July 31, 2026, and effective August 1, 2026 all FFS providers must log into ANG through DMAS Identity, Credentials and Access Management (ICAM) instead. DMAS's bulletins describe the access mechanism for FFS service authorizations generally rather than naming behavioral health/ABA specifically, but the change applies across all FFS service types, ABA included. MCO members continue to follow their plan's own process.[2][1][6][7]
Effective January 1, 2026, the CMS Interoperability and Prior Authorization Final Rule imposes hard decision deadlines on prior-authorization requests — covering behavioral health/ABA — for DMAS FFS and every Cardinal Care MCO alike: 72 hours for expedited requests, and 7 calendar days for standard requests. The 7-day standard clock can extend to 14 days only if the member or provider requests the extension, or if DMAS/the MCO needs additional evidence and the extension is in the member's interest. Build these deadlines into your follow-up cadence — a standard ABA treatment-authorization request sitting past 7 days with no extension notice is worth escalating rather than assuming it's normal.[8]
Item 291.WW.2 of Virginia's 2026 Appropriation Act directs DMAS to impose a cumulative 20-hour-per-week limit on ABA services per recipient (effective July 1, 2026 as drafted, but exceedable based on documented medical necessity under EPSDT) and to require a diagnosis of autism spectrum disorder before authorizing ABA — with children age 5 and younger allowed a one-year provisional ASD diagnosis under a protocol DMAS will designate. DMAS's own SPA notice states plainly that the department is still seeking CMS approval for these changes, and that "the effective date for ABA service changes will be announced in a subsequent notice," with the implementing detail to follow in an update to the Mental Health Services manual. As of October 1, 2026 no such notice or manual update has been published, so none of this is in effect yet — the current Appendix D admission criteria (autism-agnostic, no hard hour cap) remain the operative rule. Treat this as a near-term watch item rather than a live requirement, and re-check before relying on either the current "no diagnosis restriction" or "no hour cap" facts past early 2027. DMAS’s July 28, 2026 bulletin to providers and MCOs says the same, and adds that “no changes will be made to the current authorization process until these changes are approved by CMS and updates to the DMAS Mental Health Services Manual have been finalized.” The Chapter IV revision DMAS posted on October 2, 2026 makes no ABA change.[9][28]
Virginia's fee schedule pays by practitioner licensure tier, flagged with modifiers: no modifier = technician, HN = Licensed Assistant Behavior Analyst (LABA), TF = LMHP, HO = Licensed Behavior Analyst (LBA). Per 15-minute unit (effective 12/1/2021 and still current in the July 2026 fee file): 97153 direct treatment pays $15.00 at the technician tier, $23.48 LABA, $39.40 LMHP, and $46.63 LBA; assessment and QHP codes (97151, 97155, 97156) pay $23.48 / $39.40 / $46.63 at the LABA / LMHP / LBA tiers. Who renders the service is therefore a first-order revenue variable in Virginia. One trap when reading the raw fee file: it also carries generic physician-fee rows for 97151 and 97156 at a few dollars per unit — those are the non-ABA schedule lines, not the ABA program rates.[3][20]
Cardinal Care is the unified brand for Virginia Medicaid managed care, and a new single managed-care contract took effect July 1, 2025 — the same date Molina exited Virginia Medicaid (contract terminated 6/30/2025) and Humana Healthy Horizons entered, absorbing Molina's members. The five active MCOs — Aetna Better Health, Anthem HealthKeepers Plus, Humana Healthy Horizons, Sentara Community Plan, and UnitedHealthcare Community Plan — all apply the identical DMAS criteria and standardized ABA forms, so the per-plan differences are operational: portals, fax lines, credentialing paths, and UHC's Optum carve-out. Providers in every MCO network must also keep their DMAS PRSS enrollment current, and only Board of Medicine-licensed LBAs/LABAs can provide ABA within scope.[18][19]
Virginia does not require the RBT credential. Technician-level Medicaid ABA is delivered by unlicensed personnel working under a Licensed Behavior Analyst (LBA) or Licensed Assistant Behavior Analyst (LABA) per the Board of Medicine's supervision rules (18VAC85-150), and there is no state technician registry — DMAS classifies staff simply as licensed or unlicensed. Scope limits still bind: technicians may give input but cannot develop, review, or update the ISP (an LBA/LABA/LMHP task), and cannot render or bill parent/family training. If you staff with RBTs voluntarily, the BACB floor travels with the credential — age 18+, high-school education, the 40-hour training, a competency assessment, a criminal background check plus abuse-registry check within the 180 days before applying, and ongoing supervision of at least 5% of monthly service hours. VirginiaABA's guidance also holds that technicians must be W-2 employees paid for indirect time (supervision, data analysis), not 1099 contractors — association guidance we couldn't trace to a DMAS document, but worth pricing into the staffing model.[4][10][11][12][13][14][15][16][17]
The screening picture is unusual: ABA agencies sit outside DBHDS licensure (the pre-2012 DBHDS outpatient ABA license became unnecessary once the Board of Medicine took over individual licensure), so Virginia's barrier-crime regime — Va. Code § 37.2-416's CCRE/FBI checks and DSS child-abuse-registry searches — does not bind an ABA-only agency; it applies only if you separately hold a DBHDS license for other services. Employee-level checks instead arrive through the BACB (for RBT-certified hires) and through MCO contracts: Anthem HealthKeepers Plus's provider manual (effective 7/1/2026) requires OIG LEIE exclusion screening before hiring or contracting with any individual, periodic re-checks of current employees and contractors, and immediate reporting of any exclusion — the federal rule behind it (42 CFR 1001.1901) bars payment for anything an excluded person furnishes. At the entity level, Medicaid enrollment consent covers criminal background checks, with fingerprinting only if DMAS or CMS designates the provider high categorical risk (42 CFR 455.434); ABA is not on the federal high-risk provider list, but DMAS's risk-category assignment for ABA isn't published — confirm at enrollment. Revalidation runs at least every five years via PRSS.[4][10][11][12][13][14][15][16][17]
Supervisor licensure runs through the Board of Medicine under Va. Code § 54.1-2957.16: LBA requires current BCBA certification, LABA requires current BCaBA plus documented supervision by an LBA. The supervision floors are qualitative, not ratio-based — 18VAC85-150-120 makes the LBA ultimately responsible for care under his supervision, requires a written supervisory agreement with each LABA, and sets formal LABA supervision at no less than one hour at least every four weeks (informal phone/email contact doesn't count), with no numeric supervisor-to-technician ratio or percent-of-hours observation floor in the licensure regulation itself. DMAS, however, sets its own frequency floors in Appendix D, and they bind regardless: the LBA, LABA or LMHP must “observe the youth and supervise services monthly,” with that supervision documented in the record as a review of progress notes and data plus dialogue with supervised staff, and “supervision of unlicensed staff shall occur at least twice a month by the LBA, LABA or Licensed Clinical Psychologist,” evidenced by the licensed supervisor’s contemporaneously dated signature. Treat those two cadences — monthly on the youth, twice monthly on unlicensed staff — as the audit standard. Two billing consequences: supervision without the client present isn't separately billable (technician rates were built to include it), and each LBA must be individually enrolled in MES and credentialed with each Cardinal Care MCO you accept — a per-supervisor, per-plan administrative load. Two items we couldn't verify directly: the current Appendix D's own staffing text (host unreachable at review) and the LBA continuing-education renewal rule (18VAC85-150-100) — confirm both with DMAS provider enrollment and the Board.[4][10][11][12][13][14][15][16][17]
DMAS's ABA rules say nothing about moving an authorization from one agency to another. Three rules in the Mental Health Services manual decide most handoffs. First, choice: every record must hold "a document signed by the individual verifying freedom of choice of provider was offered and this provider was chosen." Second, gaps: "If there is a lapse in service for more than 31 consecutive calendar days, the provider must discharge the youth from services and notify the FFS service authorization contractor or MCO. If services resume after a break of more than 31 consecutive calendar days, a new service authorization request including a new assessment and ISP must be submitted." Third, readmission: providers "must follow MCO and FFS service authorization contractor guidelines for initial service authorization or registration if individuals are readmitted to a service after the provider has discharged the individual."[21][1]
In practice: avoid a gap longer than 31 days between the outgoing and incoming agency, or the family starts over with a new assessment, ISP and authorization. Ask Acentra (FFS) or the family's Cardinal Care MCO whether the incoming agency needs its own authorization. Some Cardinal Care MCOs publish their own steps for a change of provider or supervisor; see each MCO's guide.[21][1]
DMAS requires the first submission of every claim “within 12 months from the date of service” (42 CFR 447.45(d)). The exceptions cover retroactive and delayed eligibility, and a denied claim that was filed on time can be resubmitted up to 13 months from the denial. When the member has other insurance, bill it first, but the DMAS claim is still due within 12 months of the date of service. Claims go in electronically or by direct data entry in the MES Provider Portal; paper is accepted only when DMAS asks for it.[22][31]
Every claim needs a valid provider taxonomy code. On the CMS-1500, the rendering provider’s NPI goes in 24J, with the taxonomy code in the shaded area under qualifier ZZ. The referring physician’s name and NPI (boxes 17 and 17b) are required where applicable. To ask DMAS to reconsider an NCCI or ClaimsXten edit, email claimcheck@dmas.virginia.gov within 30 calendar days of the denial.[22][31]
Payment clock and cycle: DMAS adjudicates claims in a daily cycle — its Medicaid NCCI edits run “as part of the daily claims adjudication cycle” — and reports results and payment on the provider’s “weekly remittance cycle” (Chapter V). The federal rule DMAS operates under, 42 CFR 447.45(d), requires the state to pay 90% of clean practitioner claims within 30 days of receipt and 99% within 90 days. Chapter V publishes no weekly submission cut-off time.[22][31]
DMAS’s ABA rules (Appendix D) and its billing chapter say nothing about ABA delivered in another state. The federal rule DMAS operates under pays for services furnished in another state only when one of four conditions is met: a medical emergency; the member’s health would be endangered by travelling home; DMAS decides on medical advice that the services are more readily available in the other state; or it is “general practice for beneficiaries in a particular locality to use medical resources in another State” (42 CFR 431.52). For a Cardinal Care member the MCO contract is narrower. The plan “is not responsible for services obtained outside the Commonwealth” except emergency or crisis care, general local practice, medically necessary services not available in-network in Virginia, or a transition-of-care plan. Providers located in another state within 50 miles of the Virginia border may be allowed to enroll with DMAS.[25][24][23][1][26]
The other half is the license. North Carolina makes practicing behavior analysis without an NC license a Class 2 misdemeanor (G.S. 90-746). A behavior analyst licensed or certified in another state can apply for a temporary NC license, but only for “a limited and defined period of service approved by the Board” (G.S. 90-740). Technicians are exempt only while working under the direction of a licensed behavior analyst or other licensed professional (G.S. 90-745). Before scheduling weekend sessions across the border, get written approval from DMAS (fee-for-service) or the member’s MCO and settle NC licensure.[25][24][23][1][26]
Yes, in fee-for-service. DMAS’s CPT fee file (updated October 2026) lists 96112, developmental test administration by a physician or qualified health professional, first hour, at $128.05 on the outpatient row and $109.27 on the inpatient row. Add-on 96113 is $57.36 and $46.10. Both rates took effect July 1, 2026, with no prior-authorization flag and no age limit. 96112 is not among the ABA procedure codes in MHS Appendix D, the appendix that sets ABA licensure modifiers and service authorizations. For a Cardinal Care member, check the MCO’s own rules; Humana Healthy Horizons, for one, puts 96112 on its prior-authorization list.[3][1][35]
DMAS has no ABA-specific rule on 97153 overlapping speech therapy. Appendix D lists which codes may be billed at the same time, and every combination on that list is ABA with ABA (97153 with 97155, 97152 with 97151, two technicians on 97153, group codes for different youth). Speech, occupational and physical therapy are not mentioned, and the Rehabilitation manual that governs those therapies does not mention ABA.[1][22][21][29]
The limit that does apply is the Medicaid National Correct Coding Initiative. Chapter V says DMAS applies the Medicaid NCCI procedure-to-procedure edits by same member, same provider and same date of service: the column-one code pays and the column-two code denies, and only CMS-approved NCCI modifiers can bypass an edit whose indicator allows it. In CMS's Medicaid 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 92508, and OT/PT therapeutic activities 97530 is column one over 97153–97158 and 0373T. All carry modifier indicator 0, so modifier 59 or an X modifier will not unbundle them. In practice: a single provider billing 92507 and 97153 for the same child on the same date of service gets the 97153 line denied.[1][22][21][29]
Because the edits are per provider, a separately enrolled speech therapist seeing the child on the same day is not caught by them. What governs that case is coordination: Chapter IV requires care coordination with all active treating providers, documented in the ISP and progress notes, to prevent duplication of services. The Cardinal Care MCOs administer their own claim editing (see each MCO page); the NCCI table and DMAS's Chapter V describe the fee-for-service side.[1][22][21][29]
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.[1]
Code set: ABA is billed under CPT 97151–97158, 0362T and 0373T, each treatment code authorized with its own predetermined number of units. The only HCPCS codes in Appendix D belong to other services — H2033 for Multisystemic Therapy and H0036 for Functional Family Therapy — not to ABA.[1]
The questions that decide whether a family can start with Virginia Medicaid (DMAS), and what they have to bring. Each maps onto something intake should ask on the first call.
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.[1]
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.[1][4]
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.[1][4]
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.[1][4]
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.[4][1]
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. On the claim the Supplement requires the place of service that reflects the originating site — POS 02 when it is not the member’s home, POS 10 when it is — and modifier GT for telemedicine (93 for audio-only); Table 2 lists 97151–97158 as telemedicine-eligible, with 97151 and 97152 for reassessments only.[1][4][33][34][21]
Standard (non-urgent) requests: decided within 7 calendar days of receipt; expedited: within 72 hours — in force since January 1, 2026 for DMAS FFS (Acentra) and every Cardinal Care MCO alike. The standard clock can extend by up to 14 calendar days if the member or provider requests it, or if the extension is justified in the member's interest to obtain more medical evidence; expedited applies when the standard timeframe "could seriously jeopardize the member's life, physical or mental health, or ability to attain, maintain, or regain maximum function." Before the rule the standard limit was 14 days. When to submit: Appendix D says providers "shall submit service authorization requests by the requested start date of services. If submitted after the required time-frame, the begin date of authorization will be based on the date of receipt" — and the DMAS bulletin adds that days/units not submitted timely are denied. Assessment codes need no authorization, so the clock matters for treatment and every continued-stay request.[8][1][37][38]
Medicaid pays last. DMAS: "The provider must bill other insurance as primary," and "The member can keep private health insurance and still be covered by Medicaid. The other insurance plan pays first." For ABA specifically, the Project BRAVO FAQ answers the secondary-claim question directly: "All claims must first be submitted [to] the youth's commercial plan before being submitted to the youth's Medicaid MCO for secondary coverage consideration." The Medicaid claim must still reach DMAS within 12 months of the date of service even while you wait on the primary, and a claim flagged as having other coverage with no TPL payment needs the EOB/denial attached. Appendix D makes payment for every non-assessment ABA service conditional on service authorization ("Services other than assessment (97151, 97152 and 0362T) must be service authorized by the FFS service authorization contractor or MCO") and names no exemption for a secondary claim, so get the Medicaid authorization even when the commercial plan pays first. 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. Federal law lets a state pay first and chase the third party for claims for preventive pediatric services, "including early and periodic screening, diagnosis and treatment services"; DMAS's mental health billing chapter publishes no such exception for ABA, so bill the commercial plan first.[22][4][1][39][40][41]
Coverage decides whether Virginia Medicaid (DMAS) 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.
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.[1][4][11]
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. 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.[1][4][22][21][29]
No ABA-specific per-day ceiling in Appendix D, but DMAS applies 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. 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. WATCH: FY2027 Appropriation Act Item 291.WW.2 would add a cumulative 20-hour/week cap (exceedable for documented EPSDT medical necessity), but DMAS says this is pending CMS approval with no effective date announced yet as of 10/1/2026.[1][2][9][22][36]
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.[1][4]
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.[1][4]
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.[1][11]
Yes — for members under 21 with autism, under the EPSDT benefit, with no hard hour cap. Assessment codes need no service authorization; all treatment hours are authorized with units itemized per CPT code.
No — 97151, 97152, and 0362T require no service authorization under DMAS rules (confirmed in the manual and the fee file's PA flags). Treatment codes do.
Yes. Appendix D requires the initial assessment to be conducted in person with the youth and the family or caregivers, and DMAS's December 2025 clarifications bulletin makes that a condition of Medicaid reimbursement. The Telehealth Services Supplement (rev. 1/5/2026) allows 97151 and 97152 by telemedicine for reassessments only, and those codes may be billed only as part of the initial assessment or a full reassessment — so follow-up observations and interviews with additional caregivers that complete the initial assessment must be in person too. DMAS sets no separate window that would move them under telehealth rules. Only non-face-to-face work — care coordination, data analysis and treatment-plan preparation without the youth present, billed under 97151 — is exempt. After the initial assessment, QHP observation and protocol work (97155) and caregiver training (97156) may be delivered by telemedicine when the ISP justifies it, and a full reassessment may be too. The same DMAS rule applies to all five Cardinal Care MCOs.
Licensure-tiered rates per 15-minute unit: 97153 pays $15.00 (technician), $23.48 (LABA), $39.40 (LMHP), or $46.63 (LBA); assessment and QHP codes pay the LABA/LMHP/LBA tiers. Modifiers HN/TF/HO flag the tier.
Aetna Better Health, Anthem HealthKeepers Plus, Humana Healthy Horizons (which replaced Molina on July 1, 2025), Sentara Community Plan, and UnitedHealthcare Community Plan — all on identical DMAS criteria and forms.
As of August 1, 2026, through DMAS Identity, Credentials and Access Management (ICAM) to reach Acentra's Atrezzo Next Generation (ANG) system — legacy/direct ANG access ended July 31, 2026. (That followed an earlier move: from June 1, 2026 through July 31, 2026, FFS requests ran through the MES portal's "FFS Service Authorization" tile, after direct login at portal.kepro.com was retired on May 31, 2026.) MCO members still submit through their own plan's portal.
Under the CMS Interoperability and Prior Authorization Final Rule (effective 1/1/2026), DMAS FFS and every Cardinal Care MCO must decide expedited requests within 72 hours and standard requests within 7 calendar days — extendable to 14 days only if the member/provider requests it, or DMAS/the MCO needs more evidence in the member's interest.
Not yet. The 2026 Appropriation Act (Item 291.WW.2) directs DMAS to add a 20-hour/week cumulative cap (exceedable for documented medical necessity under EPSDT) and an ASD-diagnosis requirement (a one-year provisional diagnosis allowed under 6), but DMAS's own SPA notice says the changes are pending CMS approval and that the effective date "will be announced in a subsequent notice." As of October 1, 2026 no effective date has been published, so the current rules — no hard hour cap, no diagnosis restriction — still apply. Check back before assuming either one.
DMAS publishes no transfer rule. If services lapse for more than 31 consecutive days, the provider must discharge the youth and notify Acentra or the MCO, and resuming needs a new service authorization with a new assessment and ISP. A readmitted youth follows the contractor's or MCO's initial-authorization rules. Ask Acentra or the MCO whether the new agency needs its own authorization.
For fee-for-service: 12 months from the date of service (42 CFR 447.45(d)), with exceptions for retroactive and delayed eligibility, and 13 months from the denial to resubmit a timely denied claim. Cardinal Care MCOs set their own limit between 3 and 12 months under the DMAS contract; see each MCO guide.
Only in narrow cases. Federal rules let DMAS pay out-of-state services for emergencies, health risk in travelling home, services more readily available there on medical advice, or general local practice (42 CFR 431.52). Cardinal Care MCOs are not responsible for out-of-state services outside similar exceptions. The clinician also needs North Carolina licensure, and a temporary NC license covers only a Board-approved, limited period (G.S. 90-740, 90-746). Get written approval first.
Fee-for-service, yes: DMAS’s CPT fee file lists 96112 at $128.05 (outpatient row) and 96113 at $57.36, effective 7/1/2026, with no prior-authorization flag. It is not an ABA code under MHS Appendix D. MCOs set their own rules; Humana requires prior authorization.
No. DMAS applies Electronic Visit Verification to personal care, respite and companion services and to home health care services. ABA is not among them.
DMAS publishes no ABA-specific overlap rule: Appendix D's same-time list covers ABA codes only. The limit is the Medicaid NCCI edits, which DMAS applies by same member, same provider and same date of service (MHS manual Chapter V). In the 10/1/2026 CMS Medicaid PTP table, 92507 (speech) bundles 97153–97157 and 0373T, 97153 bundles group speech 92508, and 97530 (OT/PT) bundles 97153–97158 — all with modifier indicator 0, so no modifier overrides them. One provider billing speech and 97153 on the same day loses the column-two line. A different, separately enrolled speech provider is not caught by the edit; DMAS expects coordination with all treating providers, documented in the ISP, to avoid duplicated services.
From November 5, 2026 DMAS regulations (Item 292 QQ of the 2025 Appropriation Act) require provider appeals to be filed through DMAS's online Appeals Information Management System (AIMS, dmas.virginia.gov/appeals) unless a good-cause exception is requested and granted; Chapter II of every provider manual is being revised with the same effective date. DMAS keeps accepting appeals by mail, email and fax through the end of 2026, but submissions by those routes received on or after January 1, 2027 will not be processed without a granted good-cause request — which must itself be sent before the appeal deadline, by mail to the DMAS Appeals Division or by email to appeals@dmas.virginia.gov. (Disagreements with an NCCI or ClaimsXten edit go first to a reconsideration request at claimcheck@dmas.virginia.gov within 30 calendar days of the denial, per MHS manual Chapter V.)
Only when there is one. The Mental Health Services manual's CMS-1500 instructions (Chapter V, rev. 12/5/2025) mark box 17, the referring physician or other source, "REQUIRED if applicable", with the referring physician's NPI in 17b. ABA has no physician-order requirement under DMAS (Appendix D retired it in favour of notifying the youth's PCP), so there is no referring provider by rule; if the child was referred by a physician, report that physician's name and NPI in 17/17b. For DMAS Medicare crossover (Part B) claims, box 17 is not required. Cardinal Care MCOs set their own claim instructions.
Claims adjudicate daily and are paid on a weekly remittance cycle; federal rules require DMAS to pay 90% of clean practitioner claims within 30 days of receipt and 99% within 90. First submission is due within 12 months of the date of service. No weekly cut-off hour is published.
Yes. DMAS Appendix D requires the continued-stay request’s progress summary to include a graphical presentation of progress on each ISP goal and objective, and ongoing documentation must include graphical analysis of goals and objectives. ABA bills under CPT 97151–97158, 0362T and 0373T, not H-codes.
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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