Wellmark Blue Cross and Blue Shield of South Dakota is the state’s Blue plan, an independent licensee of the Blue Cross and Blue Shield Association alongside Wellmark’s Iowa companies. For ABA, the public record is thin. Wellmark’s A–Z medical-policy index, as posted September 30, 2026, has no applied behavior analysis or autism policy, and its code-level medical Authorization Table lists none of the ABA codes (checked October 2026), though some group plans add behavioral health precertification. That leaves South Dakota’s autism mandate as the documented floor for the plans it reaches.
Establish plan type on every benefits check. The mandate binds insured large-group and grandfathered plans and local-government self-funded plans. It does not bind self-funded ERISA employer plans that Wellmark administers, the State of South Dakota employee plan, or ACA individual and small-group plans.
Wellmark’s provider medical-policy page lists its policies alphabetically, from ablative nerve procedures to Zevaskyn. No policy on applied behavior analysis, intensive behavioral intervention or autism appears. The same page says Wellmark uses InterQual criteria "to evaluate whether a medical procedure or equipment is medically necessary." It does not say whether ABA is reviewed on InterQual or on an internal guideline, and InterQual is licensed and not public. Code-level pre-service review requirements sit in the Wellmark medical Authorization Table. In October 2026 none of the ABA codes was on it: 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T and 0373T each came back "not listed on the authorization table therefore there is no medical policy/criteria or preservice requirement at this time," and a keyword search for "behavior analysis" found nothing either.[1][2][3][4]
That is not a blanket "no authorization." Wellmark’s guide to authorization types says "Some group plans may require additional precertification (e.g., behavioral health). Please log in to the Provider Portal to view member benefits." Prior approval is never required when Medicare is the member’s primary coverage. The Behavioral Health and Chemical Dependency section of the Wellmark Provider Guide (August 2026) is behind the provider login, so its ABA documentation rules are not stated here. Check the member’s benefits before the first session.[1][2][3][4]
South Dakota’s autism mandate is SDCL 58-17-154 to 58-17-162 (SL 2015, ch 250), in force for plan years beginning on or after January 1, 2016. Every policy it reaches "shall provide coverage for applied behavior analysis for the treatment of autism spectrum disorders" (58-17-157). "Treatment" means evidence-based care "prescribed or ordered for a person diagnosed with an autism spectrum disorder by a licensed physician or psychologist" (58-17-154(4)). The carrier may use "pre-authorization, prior approval, and other care management requirements," visit limits, deductibles, copayments and coinsurance that apply to other medical services, and it may cap the benefit, but the annual maximum "may not be less than" $36,000 through age 6, $25,000 from age 7 through 13, and $12,500 from age 14 through 18 (58-17-158). The statute sets no benefit floor for anyone 19 or older. Anyone who performs or supervises ABA must be a physician or psychologist licensed in South Dakota with documented ABA training, or a licensed behavior analyst (58-17-159). The carrier may review the treatment "not more than once every three months" unless the insurer and the treating physician or psychologist agree to more frequent review, and the carrier pays for that review (58-17-160). School IEP and family-service-plan obligations are untouched (58-17-161). The reach is narrower than in most states. The mandate covers individual and group policies from health carriers and self-funded non-federal governmental plans, but it does not apply to the State of South Dakota employee plan (58-17-156), to self-funded ERISA plans, or to "nongrandfathered plans in the individual and small group markets that are required to include essential health benefits" under the ACA (58-17-155). In practice it binds fully insured large-group and grandfathered plans and local-government self-funded plans. For an ACA individual or small-group plan, check the plan’s own benefit documents.[5]
South Dakota licenses behavior analysts. Under SDCL 36-38 (SL 2016, ch 199) the license is issued by the Board of Social Work Examiners (36-38-1(3)), advised by a three-member Applied Behavior Analyst Advisory Committee. An applicant needs a master’s or doctoral degree and current BCBA certification (36-38-7). No one may "engage in the practice of, or attempt to practice applied behavior analysis" without the license or an exemption (36-38-6), and practicing without one is a Class 2 misdemeanor (36-38-19). BCaBAs and technicians are exempt if they work "under the extended authority and direction of a behavior analyst" and are supervised under BACB requirements, but each must pass a fingerprint background check, which the supervising analyst pays for (36-38-5(6), 36-38-25). Credentialing is on a state clock. A carrier must send an application within 10 business days of a request (58-17-151). It must flag an incomplete application within 30 days and decide a complete one within 90 days, longer only for a "special review." It must then pay clean claims for covered services delivered during the credentialing period, and its timely-filing clock starts only when you are notified that you are credentialed (58-17-150). Do not submit claims during that period (58-17-150(3)). The rule does not apply to Medicaid (58-17-152). Commercial ABA rates are negotiated and unpublished. The public benchmark is the South Dakota Medicaid ABA fee schedule (97153 $21.73 and 97155 $39.00 per 15-minute unit, effective July 1, 2026).[6][14][8][16]
Can a BCBA licensed in another state treat a South Dakota child? Generally not without a South Dakota license. SDCL 36-38-6 requires the state license to practice ABA here. The only exemption for out-of-state analysts is narrow: a provider "who is not a resident of this state, and who has established an office in this state," authorized in their home state, may practice for no more than an aggregate of 20 days a year, and must report to the board once past 20 consecutive days (36-38-5(2)). Telehealth does not get around this. SDCL 34-52-2 says any health care professional "treating a patient in the state through telehealth" must be "fully licensed to practice in the state" or employed by one of the listed facility types (a licensed health care facility, accredited prevention or treatment facility, community support provider, nonprofit mental health center, or licensed child welfare agency). The carriers say the same thing: Aetna tells providers to "ensure that they have the proper licensure based on state requirements," and Aetna’s ABA guide requires billing by "licensed behavior analysts (in states with behavior analyst licensure laws)." For a remote BCBA, plan on a South Dakota license before the first session.[6][7][18][19]
South Dakota’s prompt-pay law covers insured plans. A clean claim must be paid, denied or settled "within thirty calendar days after receipt by the carrier if submitted electronically and within forty-five calendar days" on paper. If the carrier needs more information, it must ask within 30 days, and the provider then has 30 days to supply it (SDCL 58-12-20). A paid claim can be recouped only within 18 months of payment, with written notice of the reason. That limit does not apply to self-funded ERISA plans or to fraud (58-17H-30.1). An appeal of a denied authorization (first-level grievance) may be filed within 180 days of the denial notice (58-17I-7). Wellmark’s own timely-filing limit is in your provider agreement and the Wellmark Provider Guide.[10][11][12][4]
The questions that decide whether a family can start with Wellmark Blue Cross and Blue Shield of South Dakota, and what they have to bring. Each maps onto something intake should ask on the first call.
Wellmark publishes no ABA age limit. For plans subject to the South Dakota mandate, the coverage duty in SDCL 58-17-157 names no age limit, but the minimum annual benefits in 58-17-158 run only through age 18: $36,000 through age 6, $25,000 from 7 to 13, and $12,500 from 14 to 18. Self-funded ERISA plans, the State employee plan and ACA individual or small-group plans are outside the statute, so the plan type decides whether those floors apply.[5][1]
Ask the plan: Live benefits verification: establish the plan type first, then the plan’s own ABA age and dollar terms.
For plans under the mandate, treatment is care ordered for a person diagnosed with ASD "by a licensed physician or psychologist" (SDCL 58-17-154(4)). Wellmark publishes no rule of its own.[5][1]
Ask the plan: Wellmark Provider Services: confirm which diagnosing credentials Wellmark accepts.
Wellmark publishes no ABA referral rule. For a plan subject to the South Dakota mandate, treatment is care "prescribed or ordered" for a child diagnosed with autism "by a licensed physician or psychologist" (SDCL 58-17-154(4)), so keep that order on file. Self-funded ERISA and ACA individual or small-group plans sit outside the statute.[5][1]
Ask the plan: Benefits verification: ask whether the plan (HMO or PPO) needs a PCP referral or physician order on file for ABA.
Wellmark publishes no ABA telehealth rule. For an insured South Dakota plan, SDCL 58-17-168 says no health insurer "may exclude a service for coverage solely because the service is provided through telehealth," and 58-17-169 bars discrimination between in-person and telehealth coverage for services "appropriate to be provided through telehealth" (policies issued or renewed from January 1, 2020). South Dakota’s insurance definition of telehealth is "HIPAA-compliant interactive audio-video" and excludes audio-only (58-17-167(4)). The insurer may still set criteria for a service it does not already pay others to deliver by telehealth, as long as they are not "unduly burdensome or unreasonable." Separately, the clinician must hold a South Dakota license (SDCL 34-52-2).[9][7][1]
Ask the plan: Wellmark Provider Services: ask which ABA codes, POS and modifier Wellmark pays by telehealth on this plan.
Depends on how the plan is funded. Insured South Dakota plans fall under SDCL 58-17H. A prospective (pre-service) decision is due "within a reasonable period of time appropriate to the covered person’s medical condition, but in no event later than fifteen days after the date the health carrier receives the request," with one 15-day extension for matters beyond the carrier’s control. If the extension is for missing information, the family gets "at least forty-five days" to supply it, and the clock stops in the meantime (58-17H-28, -31). An urgent request is decided within 24 hours of receipt (58-17H-43). A request to extend an ongoing course, made at least 24 hours before it ends, is also decided within 24 hours (58-17H-46). Cutting or ending an authorized course early counts as an adverse determination, and the service continues until the internal review is decided (58-17H-29). An appeal (first-level grievance) may be filed within 180 days of the denial notice (58-17I-7) and is decided within 30 days for a pre-service request (58-17I-9). Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1 instead: pre-service decisions "not later than 15 days after receipt of the claim," with one 15-day extension. Wellmark publishes no ABA-specific turnaround.[11][12][15]
Ask the plan: At benefits verification ask whether the plan is insured (South Dakota-regulated) or self-funded (ERISA), and what reauthorization lead time Wellmark expects.
For a child on two group plans, South Dakota uses the birthday rule. When the parents are married or living together, "the plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (SDCL 58-18A-70); a court decree controls for separated parents. That binds plans regulated by the state; a self-funded plan sets its own order. If the child also has South Dakota Medicaid, the commercial plan pays first, because Medicaid is generally the payer of last resort (42 CFR 433.139). South Dakota Medicaid also processes the claim "even if the commercial payer denies the claim (i.e., out of network)." A claim filed with the primary insurer’s EOB is timely if it reaches Medicaid within 6 months of the primary’s payment or denial. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)), and CHAMPVA is the last payer (38 CFR 17.270).[13][20][17][21][22]
Ask the plan: Ask Wellmark at benefits verification for the coordination-of-benefits order, and record every other coverage the child has.
Not published by Wellmark or the mandate.[1][5]
Blocked on: Wellmark Provider Services: ask how recent the diagnostic evaluation must be for an initial ABA request.
Not published by Wellmark.[1]
Blocked on: Wellmark Provider Services: ask which instruments and functional measures Wellmark expects with the initial request.
Coverage decides whether Wellmark Blue Cross and Blue Shield of South Dakota 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.
Wellmark publishes no ABA supervision rule. For plans under the mandate, anyone who "performs or supervises applied behavior analysis" must be a South Dakota-licensed physician or psychologist with documented ABA training, or a licensed behavior analyst (SDCL 58-17-159). State licensure law lets BCaBAs and technicians work under a behavior analyst if they are supervised under BACB requirements (36-38-5(6)).[5][6][1]
Blocked on: Wellmark Provider Guide, Behavioral Health section, or Wellmark Provider Services: ask for Wellmark’s ABA supervision and technician-credential requirements.
Wellmark publishes no ABA unit limit. The mandate allows "limits on the number of individual visits" under the plan’s general care-management provisions, subject to the annual benefit floors in SDCL 58-17-158.[5][1]
Ask the plan: Benefits verification on the member ID: ask for any ABA visit, hour or dollar limit and the amount already used this year.
Wellmark publishes no ABA setting rule. The mandate does not change any obligation to serve a child under an IEP, IFSP or individualized service plan (SDCL 58-17-161).[5][1]
Blocked on: Wellmark Provider Services: ask which places of service (home, clinic, school, community) Wellmark pays for ABA.
Not published by Wellmark.[1]
Blocked on: Wellmark Provider Services or your Wellmark provider agreement: ask whether 97153 and 97155 may be billed for the same minutes.
Not published by Wellmark.[1]
Blocked on: Wellmark Provider Guide (documentation standards) or your provider agreement.
Not published by Wellmark. Under state law the analyst must hold a South Dakota behavior-analyst license (SDCL 36-38-6), and technicians cannot hold one, so expect the licensed analyst to be the rendering or supervising provider on the claim.[6][1]
Blocked on: Wellmark Provider Services: ask whether technician services are billed under the supervising analyst’s NPI and which modifiers Wellmark requires.
On plans subject to South Dakota’s mandate (insured large-group, grandfathered and local-government self-funded plans), yes: ABA for autism must be covered with annual benefits of at least $36,000 through age 6, $25,000 for ages 7–13 and $12,500 for ages 14–18. Self-funded ERISA, ACA individual and small-group plans and the State employee plan follow their own documents.
Not as a rule. None of 97151–97158, 0362T or 0373T is on Wellmark’s medical Authorization Table, which answers each with "no medical policy/criteria or preservice requirement at this time" (October 2026). Wellmark notes that some group plans add behavioral health precertification, so check the member’s benefits in the Provider Portal or call the number on the card. The South Dakota mandate allows carriers to require pre-authorization for ABA.
Wellmark’s authorization page says providers outside Iowa and South Dakota "should log in to their home plan website and navigate to the out-of-state pre-service review information page," and non-Wellmark providers should call the number on the member’s ID card. So a South Dakota provider treating a child with another state’s Blue card follows that home plan’s pre-service rules, and a Wellmark member treated out of state is handled through the provider’s local Blue plan. Wellmark’s BlueCard Program section of its Provider Guide (May 2026) is behind the provider login.
Not a public one: its A–Z medical-policy index (September 2026) lists no ABA or autism policy. Ask Wellmark which criteria it uses for ABA review.
Yes. South Dakota licenses behavior analysts (SDCL 36-38, Board of Social Work Examiners), practicing without a license is a misdemeanor, and the mandate requires ABA to be performed or supervised by a licensed physician, psychologist or behavior analyst.
For insured plans, South Dakota law requires payment, denial or settlement within 30 calendar days of an electronic clean claim and 45 days of a paper one (SDCL 58-12-20).
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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