---
title: "Wellpoint Washington ABA coverage: the intake guide."
url: "https://carelu.com/payers/wellpoint-washington"
markdown_url: "https://carelu.com/payers/wellpoint-washington.md"
state: WA (Washington)
payer: Wellpoint Washington
kind: Medicaid managed care plan (MCO)
parent_program: Washington Apple Health (HCA)
description: "How Wellpoint Washington, formerly Amerigroup, covers ABA for Apple Health members: the COE referral, treatment plan and Level of Support form for prior authorization, decision timeframes, claims rules and what intake should collect."
last_reviewed: October 2026
---

# Wellpoint Washington ABA coverage: the intake guide.

_Payer Guide · Wellpoint · Washington · Last updated October 2026 · 10 primary sources_

> Elevance’s Apple Health plan (formerly Amerigroup): ABA requests need the COE script, an updated plan and the Level of Support form; 3-day electronic decisions.

Wellpoint Washington, previously Amerigroup Washington, is one of the five Apple Health managed care plans HCA lists. Its July 1, 2026 Apple Health provider manual lists applied behavior analysis among the behavioral health services covered in integrated managed care and Behavioral Health Services Only, runs an ABA line for members (833-324-2088), and sets out what to send with an ABA authorization request.

This plan administers the **Washington Apple Health (HCA)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Washington Apple Health (Medicaid) guide](https://carelu.com/payers/washington-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment:** Not published / unverified. Verify via: Wellpoint Prior Authorization Lookup Tool (PLUTO) at provider.wellpoint.com/washington-provider, or PA line 833-731-2274: check 97151. [1][2]
- **Prior auth for treatment**: Yes. Wellpoint’s manual lists what to include "When requesting authorization for Applied Behavioral Analysis service": a recent referral or script from an ABA Center of Excellence, an updated treatment plan, and the ABA Level of Support document. Request by Availity, phone 833-731-2274 or BH outpatient fax 1-844-442-8012 [1][2]
- **Autism diagnosis required?**: Yes. Wellpoint requires "Center of Excellence Treatment Provider Recommendation" with ABA requests, and the state rule requires a COE-confirmed ASD or other developmental/intellectual disability for which ABA is effective (WAC 182-531A-0400) [2][1][4]

## At a glance

- **Covers ABA?:** Yes, in Integrated Managed Care and BHSO (July 2026 manual)
- **Prior auth:** Send a recent COE referral/script, an updated treatment plan and the ABA Level of Support document
- **Decision clock:** Standard: 3 calendar days via Availity, 5 by phone or fax; urgent: 1 and 2 days
- **Submit via:** Availity; PA phone 833-731-2274; BH outpatient fax 1-844-442-8012
- **Claims:** Availity payer ID WLPNT; clean claims adjudicated within 30 calendar days
- **Member ABA line:** 833-324-2088

## Prior authorization and what to include

Wellpoint’s July 2026 manual: "When requesting authorization for Applied Behavioral Analysis service, please include the following: Recent referral/script from Applied Behavior Analysis Center of Excellence (COE) provider for ABA services; An Updated Treatment Plan; ABA Level of Support Document." At HCA’s February 2025 session Wellpoint added that requests "require treatment recommendations for a qualified Center of Excellence Provider," the HCA Level of Support form, a treatment plan with dosage, frequency and duration, progress notes, current medications and prior treatment records, and pointed to its prior-authorization lookup tool (PLUTO). Decisions: urgent requests within one calendar day through Availity and two days by phone or fax; standard requests within three calendar days through Availity and five days by phone or fax. Nonparticipating providers need prior authorization for all services. [1][2]

## Network, claims and appeals

Wellpoint lists behavior analysts, "including ABA, LABA, and CBT," among the provider types submitted as specialty care providers, and takes rosters through Availity’s Provider Data Management tool using the standard Washington all-MCO roster template. Claims go through Availity (payer ID WLPNT) or by mail to Wellpoint Washington Claims, PO Box 61010, Virginia Beach, VA 23466-1010. Wellpoint says it will "adjudicate clean claims to a paid or denied status within 30 calendar days of receipt" and pays interest when it does not pay within 61 days. Timely filing for most providers is set in the provider contract. Members may appeal within 60 calendar days of the notice; expedited appeals are decided within 72 hours. After the plan’s appeal, a member has 120 calendar days to request a state hearing (WAC 182-526-0200). [1][2][7]

## Intake gates

The questions that decide whether a family can start with Wellpoint Washington, and what they have to bring.

- **Age limit**: Wellpoint’s manual sets no ABA age limit, so the state rule applies: No upper age limit. Chapter 182-531A WAC sets no age bound for ABA, and EPSDT (age 20 and younger) lets published limits be exceeded on medical necessity review. For a client first diagnosed at 21 or older, the COE who evaluates and orders ABA must be a psychiatric mental health nurse practitioner or a general practitioner designated by HCA as a COE, or a neurologist, psychiatrist or psychologist; ARNPs, physicians, PAs and naturopaths need additional COE training to prescribe ABA for adults. [1][4]
- **Who may diagnose**: A qualified Center of Excellence provider (Wellpoint, HCA session February 2025). A Center of Excellence: an individual provider, not a facility. Licensed under Title 18 RCW and experienced in diagnosing and treating ASD, a developmental pediatrician, neurologist, pediatric neurologist, pediatric psychiatrist, psychiatrist or psychologist qualifies whether or not they are on HCA’s COE list. ARNPs (including psychiatric mental health nurse practitioners), physicians, physician assistants and naturopaths qualify only after HCA’s COE training and designation, on a signed COE Attestation form HCA 13-0009 (WAC 182-531A-0800). HCA may, at its discretion, accept a non-COE evaluation, for example a recent evaluation paid by the child’s primary insurance. A COE serving an MCO member must also be contracted with that MCO. [2][4]
- **Diagnostic tools required**: Wellpoint names no instrument, so the state COE rule applies: The COE documents "Results of formal diagnostic procedures performed by a provider, including name of measure, dates, and results, as available," or the clinical findings and observations used to confirm the diagnosis (WAC 182-531A-0500). The rule’s examples of ASD diagnostic tools are the ADI and the ADOS. If the COE has them, the evaluation must also include the ASD screening tool and date, a formal cognitive or developmental assessment with verbal, nonverbal and full-scale scores (examples: Mullen, Bayley, Wechsler) and a formal adaptive behavior assessment with domain scores (Vineland, ABAS), plus vision and hearing results. [1][4]
- **Referral required?**: Yes: a "Recent referral/script from Applied Behavior Analysis Center of Excellence (COE) provider for ABA services" goes with the request. Yes: a COE prescription. "Any person may refer a client" to a COE for an evaluation, including the PCP, a school or early intervention professional, the family or the MCO, though many COEs require a PCP referral and an MCO may require prior authorization for the COE evaluation. If the COE concludes ABA is appropriate it writes "a prescription for ABA services" and sends the evaluation and prescription to the chosen ABA provider or the family (WAC 182-531A-0500). The COE evaluation and order go in with the first PA request. [1][4]
- **Telehealth**: Wellpoint’s manual publishes no ABA telehealth rule, so the state rule applies: HCA’s ABA billing guide (January 1, 2026) lists the ABA codes allowed by telemedicine. Allowed: 97155, 97156 and 97157, plus team conferences 99366 and 99368. Allowed with limits: 97151, but only for indirect work (caregiver interviews and rating scales, treatment plan development, record review, scoring); direct observation and direct assessment of the child may not be done remotely. In the day treatment program (H2020), direct ABA must be in person in the clinic, and CBT supervision may be by audio-visual telemedicine only while an LBAT stays on site. Not allowed by telemedicine: 0362T, 0373T, 97153, 97154 and 97158. For telemedicine the originating site is where the client is (where the caregiver is, for caregiver training). Bill POS 02, or POS 10 when the client is at home, and add modifier 95 when the distant site is a nonfacility; to bill for a client located in Washington the practitioner must be licensed in Washington or hold a compact license Washington recognizes, and no behavior analyst compact is on HCA’s list. [1][5][6]
- **Prior-auth decision time**: Per Wellpoint’s July 2026 manual: urgent requests within one calendar day through Availity and two calendar days by phone or fax; standard requests within three calendar days through Availity and five calendar days by phone or fax. If documentation is incomplete, Wellpoint asks for more. Peer-to-peer before a final outpatient denial: two business days (one business day for behavioral health). [1]
- **Other insurance (who pays first)**: Wellpoint follows Washington COB rules: it resolves which plan is primary within 30 days; as secondary it notifies the provider within 30 days if payment details are missing; and "If the primary plan has not adjudicated the claim within 60 days," the provider may submit to Wellpoint, which "must pay as the primary within 30 days." Pay-and-chase applies to preventive pediatric care including EPSDT; the manual does not say whether ABA counts. [1][9]
- **Diagnosis recency** _(ask the plan)_: Wellpoint asks for a "Recent referral/script" from the COE but does not define recent. [1]
  - Ask the plan: Wellpoint UM, 833-731-2274: ask how recent the COE referral must be.

## Delivery and billing rules

Coverage decides whether Wellpoint Washington 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**: Wellpoint’s manual publishes no ABA supervision rule of its own, so the state rule applies: The lead behavior analysis therapist (LBAT) must "Supervise a minimum of five percent of the total direct care per week provided by the CBT (e.g., one hour of supervision per twenty hours of care)," and a CBT must be "supervised directly by an LBAT for at least five percent of total direct care per week" (WAC 182-531A-0700) and review the client’s progress with the LBAT at least every two weeks. When a LABA fills the LBAT role, the LABA and the supervising LBA or licensed psychologist share those duties. DOH’s licensing rule layers on top: at least two face-to-face contacts a month with each CBT and direct supervision and observation of at least five percent of the CBT’s monthly hours, seeing the CBT with each client at least once every three months (WAC 246-805-330). [1][5][4]
- **Place of service**: Wellpoint’s manual publishes no ABA setting rule of its own, so the state rule applies: Home, center, community (a school, daycare, inpatient unit or playground, for example) or an HCA-approved day treatment program, or a mix. Services in community settings such as a school or restaurant "must be included in the ABA therapy treatment plan" (WAC 182-531A-0600). Not covered unless prior authorized: "School-based health care services or early intervention program-based services" (WAC 182-531A-1000). Inpatient ABA is limited to short-term, focused treatment of severe harmful behavior that is preventing discharge, ordered by a COE. The day treatment program (H2020) is typically authorized once in a lifetime for 48 service days. [1][4][5]
- **Bill as provider**: The rendering clinician. Wellpoint adds no ABA-specific rule; HCA requires each LBA, LABA and CBT to be enrolled, on the roster sent to the MCO, and in the servicing provider box for dates of service from July 1, 2025, with taxonomy 103K00000X; Wellpoint’s clean-claim definition includes "Appropriate taxonomy code is present." [2][5][1]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not addressed in Wellpoint’s manual, and the state guide does not settle 97153/97155 overlap. [1][11]
  - Ask the plan: Wellpoint Provider Services, 833-731-2274, or your Provider Relations representative.
- **Daily limits / MUEs** _(ask the plan)_: Wellpoint’s manual publishes no ABA unit limits; units are set per authorization. [1]
  - Ask the plan: Wellpoint UM, 833-731-2274: ask whether HCA’s fee-schedule limits apply.
- **Session-note signature** _(ask the plan)_: Wellpoint’s manual publishes no ABA session-note rule. [1]
  - Ask the plan: Wellpoint Provider Services, 833-731-2274, or your provider agreement’s documentation standards.

## What intake should collect for Wellpoint Washington

- **Member ID:** Confirm Wellpoint Apple Health (IMC or BHSO) on the date of service.
- **COE referral or script:** Recent, from an ABA Center of Excellence.
- **Treatment plan and Level of Support form:** Updated plan with dosage, frequency and duration, plus HCA’s ABA Level of Support form.
- **Other insurance:** Wellpoint resolves primacy with the other plan within 30 days; if the primary has not adjudicated within 60 days, Wellpoint pays as primary.

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

## Common questions

### Is Wellpoint Washington the same as Amerigroup?

Yes. HCA lists the plan as "Wellpoint Washington (previously Amerigroup)." It is one of the five Apple Health managed care plans.

### What does Wellpoint need for an ABA authorization?

A recent referral or script from an ABA Center of Excellence, an updated treatment plan, and HCA’s ABA Level of Support form, submitted through Availity, by phone at 833-731-2274 or by fax to 1-844-442-8012.

### How fast does Wellpoint decide?

Standard requests within three calendar days through Availity (five by phone or fax); urgent requests within one calendar day through Availity (two by phone or fax).

## Primary sources

1. [Wellpoint Washington — Apple Health Provider Manual (WA-WP-CD-PM-014310-26, July 1, 2026)](https://www.provider.wellpoint.com/docs/gpp/WA_WLP_CAID_ProviderManual.pdf)
2. [HCA — ABA Provider Technical Assistance webinar slides, with DOH and all five Apple Health MCOs (February 27, 2025)](https://www.hca.wa.gov/assets/billers-and-providers/aba-provider-technical-assistance-february-27-2025.pdf)
3. [HCA — Apple Health managed care (plan list and phone numbers)](https://www.hca.wa.gov/free-or-low-cost-health-care/i-need-medical-dental-or-vision-care/apple-health-managed-care)
4. [Chapter 182-531A WAC — Applied behavior analysis (Apple Health ABA rules: COE evaluation, stages, provider requirements, PA)](https://app.leg.wa.gov/wac/default.aspx?cite=182-531A&full=true)
5. [HCA — Washington Apple Health Applied Behavior Analysis (ABA) Program Billing Guide (January 1, 2026)](https://www.hca.wa.gov/assets/billers-and-providers/aba-services-bg-20260101.pdf)
6. [HCA — Washington Apple Health Telemedicine Policy and Billing Guide (January 1, 2026)](https://www.hca.wa.gov/assets/billers-and-providers/telemedicine-policy-and-billing-bg-20260101.pdf)
7. [WAC 182-526-0200 — Enrollee appeals of a managed care organization action (hearing deadlines)](https://app.leg.wa.gov/WAC/default.aspx?cite=182-526-0200)
8. [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)
9. [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)
10. [Wellpoint Washington — Provider News (all provider news articles, filterable by Medicaid)](https://providernews.wellpoint.com/wa)
11. [HCA — ABA Treatment Fee Schedule (effective July 1, 2026; last updated July 29, 2026)](https://www.hca.wa.gov/assets/billers-and-providers/aba-20260701.xlsx)

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.