Wellpoint West Virginia, Inc. is the Mountain Health Trust MCO formerly branded UniCare Health Plan of West Virginia (BMS’s prior-authorization page still links it as "Unicare"). Its August 2026 provider manual does not discuss ABA, but a May 2023 UniCare bulletin, still posted in Wellpoint’s West Virginia archive, told providers that WVCHIP ABA policy "was changed to mirror the Medicaid policy effective February 1, 2023," pointed to BMS Policy 519.23, and noted "there are no longer dollar limits associated with ABA services."
The 2023 bulletin is the plan’s only ABA-specific document we found: WVCHIP ABA mirrors Medicaid Policy 519.23 from February 1, 2023, with no dollar limits, and PA requirements are in the provider manual. The August 2026 manual says all PA requests "must be submitted electronically" through the Interactive Care Reviewer, "In accordance with W.Va. Code §9-5-32 and W.Va. Code §33-25A-8s." Wellpoint’s August 2026 list of adopted Clinical UM Guidelines has no ABA guideline (its autism entry, CG-BEH-15, covers activity therapy), and the list says MCG Care Guidelines apply to outpatient services without a Wellpoint policy, while "Medicaid state contracts, regulatory guidance, CMS requirements" supersede MCG. In practice that makes BMS Policy 519.23 the working criteria.[2][1][3][12][5]
For electronic routine requests, Wellpoint checks completeness within two business days, sends a request for information if needed (due back in three business days), and decides within two business days of receiving it. Urgent pre-service reviews are completed within the shorter of two business days or three calendar days. Peer-to-peer requests must come from the treating practitioner within two business days of the denial and happen within five business days. Wellpoint does not backdate authorizations beyond three business days, which matters because BMS rejects retro ABA authorizations outright.[2][1][3][12][5]
"Claims must be submitted within 180 days of the service date to be considered for payment"; when Wellpoint is secondary, the clock runs from the other payer’s remittance date. COB claims need the other payer’s remittance advice, explanation of payment or denial letter. Payment disputes start with a Claim Payment Reconsideration, decided within 45 business days, and a Claim Payment Appeal may follow within 60 calendar days of that outcome. The payer ID is WLPNT. Rates are contracted and unpublished; the BMS ABA fee schedule (97153 $9.90 per 15 minutes) is the public benchmark.[1][8]
More claim clocks from the August 2026 manual: "Provided the claim was originally received timely, a corrected claim must be received within 180 days of the date of service," but when a primary insurer’s payment is adjusted the period "starts with the date of the most recent OHI EOB"; resubmissions on the Claim Follow-Up form are due within 180 days of the EOB or letter, and requested information within 180 calendar days. TPL and COB claims are due "within 180 days of notice from the primary insurance." Wellpoint "will adjudicate a clean electronic claim within 30 calendar days of the date the claim is received," processes clean paper claims within 30 calendar days, and pays in-network providers 18% annual interest on clean claims it misses. No check-run schedule is published.[1][8]
The questions that decide whether a family can start with Wellpoint West Virginia (Mountain Health Trust), and what they have to bring. Each maps onto something intake should ask on the first call.
Wellpoint follows BMS Policy 519.23 for ABA. 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.[2][5]
Wellpoint 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).[2][5]
Wellpoint 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.[2][5]
Wellpoint 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).[2][5]
Wellpoint’s manual defers to BMS Policy 519.17 for telehealth, 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.[1][7][6]
Electronic routine requests: completeness check within 2 business days, information due back within 3 business days, decision within 2 business days of receipt. Urgent pre-service: the shorter of 2 business days or 3 calendar days. Peer-to-peer within 5 business days of the request.[1][12]
"If a member has other health insurance, Wellpoint defers all UM decisions to the primary insurer"; if the primary does not cover the service, submit its notice of noncoverage with the request. COB claims need the other payer’s RA, EOP or denial letter, and the 180-day limit runs from the other payer’s RA date.[1][14]
Coverage decides whether Wellpoint 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.
Wellpoint 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]
Wellpoint 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]
Wellpoint 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: Wellpoint WV reimbursement policies or Customer Care, 800-782-0095: ask whether 97153 and 97155 may be billed for the same minutes.
Wellpoint publishes no ABA setting rule. Under state policy, services may be delivered in the member’s natural environment, educational services cannot be authorized, and school-administered services are outside managed care.[1][5][9]
Ask the plan: Wellpoint WV UM, 866-655-7423: ask which POS codes it pays for ABA.
Wellpoint publishes no ABA-specific rendering rule. BMS lets the BCBA or BCaBA bill RBT-delivered codes.[1][5]
Ask the plan: Wellpoint WV Customer Care, 800-782-0095: confirm the rendering NPI on RBT lines.
Not addressed for ABA in the Wellpoint manual.[1]
Ask the plan: Wellpoint WV Customer Care, 800-782-0095, or the medical-records standards in your provider agreement.
Yes. ABA is a West Virginia Medicaid state-plan service under BMS Policy 519.23, and Wellpoint (then UniCare) told providers its WVCHIP ABA policy mirrors Medicaid’s, with no dollar limits, from February 1, 2023.
Yes. UniCare Health Plan of West Virginia rebranded as Wellpoint West Virginia; BMS’s prior-authorization page still lists it as Unicare.
180 days from the service date, or from the other payer’s remittance date when Wellpoint is secondary.
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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