WellSense Health Plan (listed by DHHS as Well Sense Health Plan) is one of New Hampshire’s three Medicaid Care Management plans. It is also the most explicit of the three about ABA: a New Hampshire-specific ABA prior authorization form, a behavioral health authorization matrix that marks ABA "Prior authorization required," and a provider manual that names "applied behavioral analysts" among the practitioners it credentials. The same company also sells NH Clarity marketplace plans; this guide covers the Medicaid product.
WellSense’s "Applied Behavioral Analysis Prior Authorization Form, New Hampshire" (updated November 14, 2025) runs in two steps. A "Request for initial evaluation" is pages 1–3 plus the "Comprehensive diagnostic evaluation completed by a neurologist, pediatrician, psychiatrist, psychologist, or other licensed physician experienced in autism." A "Request for continued services" is pages 1–6: prior ABA providers, school and community services, parent participation, coordination with the PCP, behavioral health, school and occupational therapy providers, medications, and a goals table (or an attached treatment plan with the same content), signed by the treating BCBA. "For initial request, you may request services for 3-month timeframe. For continued services, you may request services for 6-month timeframe." Units are requested for the whole period: "Please do NOT request units per week."[1][4][2]
The Medicaid code list on the form is 97151, 97153, 97154, 97155 and 97156; 97152, 97157 and 97158 appear only in the NH Clarity and Medicare section. The form asks for the agency NPI and tax ID, the BCBA’s NPI and "BCBA license #" (New Hampshire issues none, so expect to give the BACB certification number and confirm with the plan). Submit through the HealthTrio provider portal, which WellSense says can return real-time decisions, or fax 857-264-2670.[1][4][2]
Reauthorization: continued services are requested for up to six months by submitting pages 1–6 of the form, completed by the BCBA rendering or supervising the services. Those pages ask for every ABA provider the child has had, school and community services, other therapies and medications, and a treatment-goals table for the behaviors being changed (a treatment plan with the same content may be attached instead). The form does not ask for graphs.[1][4][2]
WellSense’s behavioral health matrix (effective October 1, 2026) says the plan uses InterQual criteria (the 2026 sets from June 1, 2026), ASAM or internal medical policies, and for ABA refers New Hampshire Medicaid members to its medical policy "for additional requirements." That policy sits on WellSense’s PolicyTech site, which did not load for automated retrieval. Behavioral health claims also moved in-house: for New Hampshire Medicaid, dates of service through November 30, 2025 went to Carelon and dates of service from December 1, 2025 go to WellSense (inpatient excepted), so older Carelon-era billing instructions no longer apply. On credentialing, the provider manual lists "applied behavioral analysts" among the practitioners WellSense credentials when they are "permitted to practice independently under New Hampshire law."[2][3][5]
WellSense’s NH manual (effective December 1, 2025): claims "must be submitted within one hundred 120 calendar days of service for NH Medicaid" (180 days for CCBHCs), and resubmissions within 240 days of the date of service. WellSense "seeks to process clean claims and reimburse providers within thirty (30) calendar days," and pays interest at the Medicare rate on clean claims unpaid after 30 days. Its CMS-1500 table marks box 24J, rendering provider ID/taxonomy code, as required. Timely-filing denials are disputed through the administrative claims appeal with a Request for Claim Review form. WellSense offers one level of internal administrative claims appeal, filed “within sixty (60) calendar days from the original denial date” through the provider portal or by mail to WellSense Health Plan Provider Appeals, P.O. Box 55049, Boston, MA 02205, with a written narrative, the claim and the remittance advice. After that, a participating provider may ask DHHS’s Administrative Appeals Unit for a State Fair Hearing within 30 calendar days of WellSense’s appeal denial.[3][1][11]
Corrected and secondary claims, and the claim form. Corrected claims for NH Medicaid must carry the original claim number and be received “within 120 calendar days of the original process paid date”; secondary (COB) claims within 120 days of the primary payer’s final payment determination, and the primary’s remittance with the claim within 90 calendar days of receiving it. WellSense’s required-data table for the CMS-1500 marks box 17, “Name of Referring Provider or Other Source,” and 24J, rendering provider ID and taxonomy code, as required on paper and electronic claims. The NH Medicaid code list on the ABA form is 97151, 97153, 97154, 97155 and 97156; no HCPCS H-code appears. EVV: the manual has no EVV rule for ABA, and DHHS’s EVV service list (updated May 2026) names no ABA code.[3][1][11]
Only with prior authorization. WellSense's New Hampshire provider manual says that, except for urgent/emergency and family planning services, “a WellSense member is not covered for services provided by an out-of-network provider unless the rendering provider has received prior authorization from us in advance of services being rendered.” For help arranging services with an out-of-network provider, call the Prior Authorization department at 877-957-1300. The manual names no ABA single-case-agreement rate.[3]
The questions that decide whether a family can start with WellSense Health Plan (New Hampshire), and what they have to bring. Each maps onto something intake should ask on the first call.
Under 21 for NH Medicaid ABA: the benefit is EPSDT, which covers members under 21 (He-W 546.02). WellSense’s NH documents set no different ABA age rule.[7][1]
A neurologist, pediatrician, psychiatrist, psychologist, or other licensed physician experienced in autism must complete the comprehensive diagnostic evaluation. LCSW: no. A licensed clinical social worker is not on this list, so an LCSW's diagnosis alone does not meet it.[1]
No separate physician order is asked for on the form; the gate is the comprehensive diagnostic evaluation from a listed physician or psychologist. At the state level, ABA must be "recommended by a licensed clinician" experienced in ASD (He-W 589.04(aj)).[1][7]
WellSense covers telemedicine generally, with modifiers listed in its telemedicine policy, but publishes no ABA-specific telehealth rule, so the state rule applies. RSA 167:4-d requires the NH Medicaid program to “provide coverage and reimbursement for health care services provided through telemedicine on the same basis as the Medicaid program provides coverage and reimbursement for health care services provided in person,” with “no restriction on eligible originating or distant sites” (the child’s home counts) and reimbursement for “all modes of telehealth, including video and audio, audio-only, or other electronic media … for all medically necessary services.” Its list of providers who may use all modes names “Professionals certified by the national behavior analyst certification board or persons performing services under the supervision of a person certified by the national behavior analyst certification board.” So the BCBA assessment (97151/97152), supervision with protocol modification (97155) and technician and family services are inside the statute, subject to medical necessity; the statute names no in-person minimum for supervision. It is “conditioned upon review and approval of a state plan amendment,” and no NH Medicaid ABA document read publishes an ABA telehealth code list, POS or modifier.[10][3]
Medicaid standard pre-service requests: "Written notification to the member and provider within 7 calendar days of the receipt of request." Urgent or expedited pre-service and concurrent requests: 72 hours. The clock runs from receipt, not from a complete file, so send the full packet the first time.[3][8]
When other coverage is primary, providers must "Pursue payment from all other liable parties prior to submitting claims to WellSense," then bill any secondary balance with the other carrier’s payment or denial details for each line. Medicaid claims must reach WellSense within 120 days of the primary payer’s determination (90 days for NH Clarity).[3][9]
The form requires a comprehensive diagnostic evaluation but states no maximum age for it.[1]
Blocked on: WellSense ABA medical policy on PolicyTech or the Prior Authorization Department, 877-957-1300.
The form names no instrument; it asks for a comprehensive diagnostic evaluation and, for continued services, a goals table with current level of functioning.[1]
Blocked on: WellSense ABA medical policy on PolicyTech or the Prior Authorization Department, 877-957-1300.
Coverage decides whether WellSense Health Plan (New Hampshire) 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.
WellSense publishes no New Hampshire ABA supervision ratio; the form only requires naming the BCBA "who will perform/supervise services." The state rule applies: a BCBA with BACB supervisory certification supervises BCaBAs, RBTs and rehabilitation assistants, with no numeric ratio (He-W 589.04(ah)).[1][7]
No daily or weekly cap is published. Units are authorized per period: up to 3 months on an initial request and 6 months on continued services, and the form says "Please do NOT request units per week. Instead request units per authorization period."[1]
Not addressed in the NH form, the matrix or the provider manual.[1][3]
Blocked on: WellSense ABA medical policy on PolicyTech (bostonmedicalcenter.policytech.com, public site 61882) or the Prior Authorization Department, 877-957-1300.
The PA form must be signed by the treating BCBA. WellSense publishes no rule on who signs individual session notes.[1][3]
Blocked on: WellSense ABA medical policy on PolicyTech or Provider Services, 877-957-1300.
Not addressed in the NH form or manual; the form does ask whether the child receives "special services at school or in the community." At the state level, school-based ABA is billed by school districts under He-W 589.[1][7]
Blocked on: WellSense ABA medical policy on PolicyTech or Provider Services, 877-957-1300.
The form captures both the agency NPI and the BCBA’s NPI and names the BCBA "who will perform/supervise services," but WellSense publishes no rule on whose NPI a technician’s claim goes out under.[1]
Ask the plan: WellSense Provider Services, 877-957-1300, or your provider agreement.
Only with prior authorization obtained in advance. Call WellSense's Prior Authorization department at 877-957-1300. No ABA single-case-agreement rate is published.
Yes, both for the initial evaluation and for continued services, on its New Hampshire ABA form or through the HealthTrio portal.
Up to 3 months for an initial request and 6 months for continued services, with units requested for the whole period rather than per week.
A neurologist, pediatrician, psychiatrist, psychologist, or other licensed physician experienced in autism, via a comprehensive diagnostic evaluation.
Yes, under New Hampshire law. RSA 167:4-d requires NH Medicaid to cover telehealth on the same basis as in-person care, from any site including the home, and names BACB-certified professionals and the staff they supervise. That includes the 97151 assessment and 97155 supervision when medically necessary. The plan publishes no ABA-specific telehealth rule, so ask it which POS and modifier to bill.
120 calendar days from the date of service; resubmissions within 240 days.
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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