WellCare of Kentucky is Centene’s Kentucky Medicaid MCO. Its quarterly prior authorization list is the place to check ABA codes: on the Q4 2026 list every ABA code needs authorization, including 97157, which WellCare had released on February 1, 2026 and put back on the list from October 1, 2026.
WellCare’s Kentucky Medicaid Prior Authorization List for Q4 2026 (published October 2026) shows 97151, 97152, 97153, 97154, 97155, 97156 and 97158 with a "Date Requiring Auth" of 1/1/2019 and no release, 0362T and 0373T from 9/15/2018, and 97157 among the codes requiring authorization from 10/1/2026. The Q3 2026 list had shown 97157 as "No Auth Required," "Authorization released 2/01/2026," so a 97157 session on or after October 1, 2026 needs an authorization. WellCare notes that the list is not all-inclusive and that its secure provider portal is "the most accurate method" of checking requirements. DMS’s August 2025 chart lists the ways to submit a WellCare behavioral health PA: Availity Essentials or the WellCare provider portal, phone 1-877-389-9457, or fax 1-877-544-2007 marked ATTENTION TO: BHO for outpatient behavioral health. WellCare’s manual says it "has adopted utilization review criteria developed by InterQual® products to determine medical necessity for healthcare services."[1][3][2]
The 2025–2026 manual (state approved October 10, 2025) requires claims "within 12 months (or six months from the Medicaid or primary insurance payment date, whichever is later) from the date of service," unless the provider contract says otherwise, and accepts a clearinghouse acceptance report or a detailed electronic submission sheet as proof of timely filing. "Claim payment appeals must be submitted to WellCare in writing within 24 months of the date of denial of the EOP." Medicaid is the payor of last resort, and WellCare cost-avoids claims when it knows of other coverage.[2]
That clock covers every claim type: the manual names claims "(initialed, corrected and voided)," and "Corrected and/or voided claims are subject to timely claims submission" rules (frequency 7 to replace, 8 to void). A claim billed after the primary payer pays must show the primary payment, and when WellCare knows of other coverage it denies and redirects the claim to that payer first. A claim subject to coordination of benefits is not a "Clean Claim." On payment the manual says "Refer to the Provider Contract" and that WellCare complies with Kentucky’s prompt-pay statute (KRS 304.17A-700 to -730); it publishes no check-run schedule.[2]
The questions that decide whether a family can start with WellCare of Kentucky, and what they have to bring. Each maps onto something intake should ask on the first call.
No ABA referral requirement appears in WellCare’s documents or the state regulation; prior authorization is the gate.[1][6]
WellCare’s manual lists telehealth as a $0-copay covered service and publishes no ABA telehealth rule, so the state rule applies. 907 KAR 3:170 makes its telehealth policies "supersede any in-person requirement established within KAR Title 907" (unless a law, licensing board, professional criteria or the billing code itself requires in-person), applies them to fee-for-service and to MCO coverage alike, and defines place of service as wherever the patient is, "including … the patient’s home or office, or a clinic, school, or workplace." A service is reimbursable by telehealth when it is appropriate and safe for the technology, not prohibited by the provider’s licensing board, and delivered by an enrolled provider; reimbursement is at least 100 percent of the in-person rate (an MCO may negotiate otherwise), telehealth must be denoted "by place of service or other means," and referral rules are the same as in person. Neither DMS nor any Kentucky MCO document read publishes an ABA-specific telehealth code list or modifier. The licensing board requires a Kentucky license for anyone delivering ABA by telehealth to a client located in Kentucky (201 KAR 43:100, Section 2).[2][7][14]
Kentucky’s MCO contract (§ 18.6) is stricter than the federal floor: a standard prior authorization is decided "no later than five (5) Days after receiving the necessary information" (contract "Day" means calendar day; "necessary information" is as defined in KRS 304.17A-607), extendable up to 14 days at the provider’s or enrollee’s request; expedited decisions within 24 hours of all necessary information; and "an untimely service authorization constitutes a Denial" that can be appealed. Federal law caps standard MCO decisions at 7 calendar days from the request for rating periods starting on or after January 1, 2026.[5][9]
WellCare’s manual quotes the contract: if WellCare is aware of other coverage it "shall avoid payment by ‘cost avoiding’ (denying) the claim and redirecting the provider to bill the other Third Party Resource as a primary payer." Medicaid pays last. The MCO contract (§ 14.2) says Medicaid "shall be used as a source of payment for Covered Services only after all other sources of payment have been exhausted," and when another resource is known the plan "shall avoid payment by ‘cost avoiding’ (denying) the Claim and redirecting the provider to bill the other Third Party Resource as a primary payer" (42 CFR 433.139). So bill the commercial plan first and follow its ABA prior authorization.[2][5][10]
Not stated by WellCare.[2]
Ask the plan: WellCare of Kentucky behavioral health UM, 1-877-389-9457.
Not stated by WellCare. Kentucky law excludes diagnosis from the practice of ABA (KRS 319C.010(8)).[2][13]
Ask the plan: WellCare of Kentucky behavioral health UM, 1-877-389-9457.
Not stated by WellCare; InterQual is licensed.[2]
In licensed criteria: WellCare of Kentucky behavioral health UM, 1-877-389-9457.
Coverage decides whether WellCare of Kentucky 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.
WellCare publishes no ABA supervision rule of its own; the state rule applies. 907 KAR 15:010, Section 3(3)(r)4 says ABA "shall be provided by" a licensed behavior analyst, a licensed assistant behavior analyst, or an approved behavioral health practitioner (or one under supervision) "with documented training in applied behavior analysis," and that "a registered behavior technician under the supervision of an appropriate practitioner" may provide "support services." No numeric supervision ratio is set. The documentation rules carry the supervision: notes by a practitioner working under supervision must be co-signed and dated by the supervising professional within 30 days, with a monthly supervisory note on the case. 907 KAR 15:005 defines the RBT by BACB training, competency assessment and exam, within six months of hire.[2][6][12]
WellCare publishes no ABA-specific note rule; the state rule applies. Under 907 KAR 15:010, Section 6, service notes must be made within 48 hours of each visit, say whether the service was face-to-face or telehealth, state a start and end time, and be "recorded and signed by the rendering behavioral health practitioner" with the practitioner’s professional title; "initials, typed signatures, or stamped signatures shall not be accepted" (compliant electronic signatures are allowed under Section 9). Notes by a practitioner under supervision are co-signed by the supervisor within 30 days, and the plan of care is reviewed at least every six months.[2][6]
WellCare publishes no ABA concurrent-billing rule. DMS allows 97155 concurrently with 97153 from December 2, 2025 when the patient is present and the professional is directing the technician.[8][2]
Ask the plan: WellCare of Kentucky Provider Services, 1-877-389-9457.
WellCare publishes no ABA unit limit; units are set by the authorization.[1][2]
Ask the plan: WellCare of Kentucky behavioral health UM, 1-877-389-9457.
WellCare publishes no ABA setting rule; the state regulation sets none.[2][6]
Ask the plan: WellCare of Kentucky Provider Services, 1-877-389-9457: ask which place-of-service codes it pays for ABA.
WellCare publishes no ABA-specific rendering rule.[2]
Ask the plan: WellCare of Kentucky Provider Services, 1-877-389-9457: ask whether RBT services bill under the supervising licensed behavior analyst with modifier UC as on the DMS fee schedule.
All of them on the Q4 2026 list: 97151–97158, 0362T and 0373T. 97157 was released on February 1, 2026 but needs authorization again from October 1, 2026.
Its manual says it uses InterQual for medical necessity. InterQual is licensed and not published.
12 months from the date of service, or six months from the primary payment date if later; claim payment appeals within 24 months of the denial.
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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