---
title: "West Virginia Medicaid ABA coverage: the intake guide."
url: "https://carelu.com/payers/west-virginia-medicaid"
markdown_url: "https://carelu.com/payers/west-virginia-medicaid.md"
state: WV (West Virginia)
payer: West Virginia Medicaid (BMS)
kind: State Medicaid program
description: "How West Virginia Medicaid covers ABA under BMS Policy 519.23: ages 18 months through 20, ASD diagnosed before age 8, prior authorization on every code, a 40-hour weekly cap, published rates, four Mountain Health Trust MCOs, and no state behavior-analyst license."
last_reviewed: October 2026
---

# West Virginia Medicaid ABA coverage: the intake guide.

_Payer Guide · West Virginia Medicaid · Last updated October 2026 · 20 primary sources_

> BMS Policy 519.23: ages 18 months–20, ASD diagnosed before age 8, PA on every code, 40 hr/week cap; four MCOs carry it.

West Virginia Medicaid covers applied behavior analysis under its own provider-manual chapter, Policy 519.23 in Chapter 519 (Practitioner Services), administered by the Bureau for Medical Services (BMS). The rules are tighter than in most states: the child must be between 18 months and 20 years old, the autism diagnosis must have been made before the eighth birthday, the diagnostic assessment behind the request must be less than 24 months old, and every ABA code needs prior authorization before the first unit.

Most children never touch fee-for-service. BMS says Mountain Health Trust, its managed care program, covers about 87% of members through four MCOs (Aetna Better Health of West Virginia, The Health Plan, Highmark Health Options and Wellpoint), and children in foster, kinship and adoptive care are in Mountain Health Promise, run by Aetna Better Health. Policy 519.23 is the floor each plan works from, but the plan on the card decides who reviews the authorization and pays the claim.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Yes. Policy 519.23 marks both assessment codes, H0031 (the annual functional assessment) and 97151 (behavior identification assessment), "Prior Authorization: Required," and says PA "for all ABA services requests must be made prior to any service being rendered" [1]
- **Prior auth for treatment**: Yes for every ABA code (97152–97156, 97158). No backdating: "retrospective review requests" will be denied, and a provider who skips PA cannot bill the family. MCO members follow their plan’s PA process [1][9]
- **Autism diagnosis required?**: Yes: a primary ASD diagnosis made before the child’s eighth birthday, documented with DSM criteria, severity level and specifiers, from a diagnostic assessment completed within the previous 24 months [1]

## At a glance

- **Covers ABA?:** Yes: ages 18 months through 20, primary ASD diagnosis before age 8 (Policy 519.23)
- **Structure:** Carved in to Mountain Health Trust (4 MCOs) and Mountain Health Promise (Aetna); FFS for the rest
- **Prior auth:** Required on every ABA code, before services; no retro authorizations
- **Hour cap:** 40 hours/week and/or 8 hours per 24 hours across 97151–97156, 97158
- **FFS rates (per 15 min):** 97151/97155 $29.14 · 97156 $17.43 · 97158 $11.79 · 97152/97153 $9.90 · 97154 $4.50 · H0031 $120/assessment
- **Who may deliver:** BCBA/BCBA-D; BCaBA and RBT under supervision, all with current BACB certification
- **Licensure:** None: WV does not license behavior analysts; BACB certification governs
- **Timely filing:** 12 months from date of service (FFS); MCOs set their own

## Who qualifies: the age, diagnosis-age and recency gates

Policy 519.23.1 limits ABA to "Medicaid members ages 18 months through age 20 with a primary diagnosis of Autism Spectrum Disorder (ASD) prior to their eighth birthday," referred for treatment identified during an EPSDT encounter. The diagnosis-before-eight rule is unusual and decisive: the first PA request must include "documentation indicating that the primary diagnosis was rendered prior to the child’s eighth year of age." A child first diagnosed at nine does not meet the written policy, even though EPSDT generally covers medically necessary care to 21, so a family in that position should ask BMS or the MCO in writing. [1]

The second gate is recency. The diagnostic assessment must have been "conducted within the previous 24 months by a qualified diagnostic provider," and must document the current ICD/DSM ASD diagnosis, the severity level for communication and restricted repetitive behaviors, and the diagnostic specifiers (with or without intellectual impairment, associated conditions). The request also needs service intensity matched to the assessed level of functioning, baseline data on adaptive and maladaptive behaviors, and a description of natural supports, including what the IEP already provides. "Services that are educational in nature cannot be authorized." [1]

## Prior authorization and the codes BMS pays

Every ABA code needs prior authorization "prior to any service being rendered." The request must include the qualifying diagnostic assessment, a comprehensive diagnostic assessment from the past 24 months, "The annual physician’s order for ABA Services," a Consent to Release Information and Bill Medicaid form or Statement of Assurances (the reviewer may also ask for the IEP, or for a homeschooled child the parent and Department of Education agreement letter), and an annual functional assessment of adaptive skills. Four things are not allowed: balance billing the family when PA was skipped or denied, backdated authorizations, requests submitted by parents, and ABA delivered by family members or any non-credentialed person. For fee-for-service members, BMS routes prior authorization to its utilization management vendor, which its prior-authorization page identifies as Acentra; MCO members go to their plan. [1][12][5][6]

The codes, with their staff credentials: H0031 functional assessment (BCBA or BCaBA, one per year), 97151 behavior identification assessment (BCBA or BCaBA), 97152 supporting assessment and 97153 treatment by protocol (RBT under supervision; "The BCBA or BCaBA may bill for this service"), 97154 group treatment by an RBT, 97155 protocol modification and 97156 family guidance (BCBA or BCaBA; the member must be present for 97155), and 97158 group skills training by a BCBA or BCaBA. 97157, 0362T and 0373T are not covered codes in the policy. [1][12][5][6]

Rates come from BMS’s ABA fee schedule. BMS’s ABA fee schedule ("Contracts & Codes for: ABA - Medicaid") pays per 15-minute unit: 97151 $29.14, 97152 $9.90, 97153 $9.90, 97154 $4.50, 97155 $29.14, 97156 $17.43, 97158 $11.79, and H0031 (the annual functional assessment) $120.00 per event. Legacy lines remain for H0032 and H2012 ($29.14), H2014 ($11.79; U4 $5.50, U5 $2.50) and H2019 ($29.14). 97157, 0362T and 0373T are not on the schedule. These are the only published ABA rates in the state and well below commercial levels; the MCOs pay contracted rates. [1][12][5][6]

## Delivery rules: hours, staffing, documentation

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. 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]

Documentation is audited hard. Policy 519.23.5.1 says "Copied or boilerplate language in documentation will not be reviewed and will cause disallowment," illegible records "will result in dis-allowment," records must be produced "within one business day of the request," and documentation "must demonstrate only one staff person’s time is billed for any specific activity provided to the member." Discharge reports are filed at case closure, and the policy lists four discharge criteria, from goals met to no measurable progress with no reasonable expectation of it. Policy 519.23 does not mention electronic visit verification. [1]

## Managed care: four MCOs and Mountain Health Promise

Enrollment in an MCO "is mandatory" for children and most other members (Chapter 527). The MCO "is responsible for providing most services covered under this policy manual"; the managed-care exclusions are residential services, certain waiver services, school-administered services under Chapter 538, most pharmacy and early intervention, and ABA is not among them. "The BMS Medicaid Provider Manual is the source of authority for defining minimum state plan covered services," but "Providers must obtain all necessary service authorizations as specified by the MCO," and each MCO credentials its own network. Every MCO network provider must also be enrolled with West Virginia Medicaid. BMS lists the four Mountain Health Trust plans as Aetna Better Health of West Virginia, The Health Plan of West Virginia, Highmark Health Options of West Virginia and Wellpoint of West Virginia; Aetna Better Health is also "the single managed care organization" for Mountain Health Promise. WVCHIP members are inside Mountain Health Trust, and WVCHIP has covered ABA for children with a primary ASD diagnosis since February 1, 2023. [9][10][11][14]

## Claims operations: filing limits, appeals, other insurance

Fee-for-service claims must reach Medicaid "within 12 months from date of service"; denied claims can be corrected or paid claims replaced up to 24 months from the date of service. TPL claims carry the same 12-month limit, and claims for members with backdated Medicaid cards have 12 months from the card’s issuance. A medical-necessity denial can be taken to the utilization management contractor for reconsideration, which "must receive the written request and supporting documentation within 60 days of the notification of denial"; anything delivered after a denial is "at risk." MCOs set their own filing limits (Aetna Better Health 365 days; The Health Plan and Wellpoint 180 days; Highmark Health Options 12 months), and the MHP contract requires MCOs to pay clean claims within 30 calendar days with 18% annual interest after that. [7][21][22][23][24][25]

Medicaid is "always the payer of last resort." Bill the commercial plan first and meet its rules, "including use of in-network providers"; if it denies, send the paper claim with the EOB showing the denial reason. [7][21][22][23][24][25]

Payment schedule: under Chapter 100, section 100.12, "BMS processes provider payments once per week," approved claims are posted to accounts payable after the MMIS adjudication cycles and held until funds are available, and "The provider payment cycle begins each Friday." The chapter publishes no submission cut-off time for a given week’s cycle; the MCOs pay on their own schedules. [7][21][22][23][24][25]

## Intake gates

The questions that decide whether a family can start with West Virginia Medicaid (BMS), and what they have to bring.

- **Age limit**: 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. [1]
- **Diagnosis recency**: 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). [1]
- **Who may diagnose**: 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. [1]
- **Diagnostic tools required**: No named diagnostic instrument. The diagnostic assessment must document DSM criteria, severity level and specifiers; the request needs baseline data on adaptive and maladaptive behaviors and, annually, "a functional assessment of adaptive skills." The glossary defines objective evidence as "Results of standardized member assessment instruments." [1]
- **Referral required?**: 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). The order is renewed every year with the PA ("The annual physician’s order for ABA Services to be submitted with all other requirements"), alongside a diagnostic assessment completed within the previous 24 months and an annual functional assessment of adaptive skills. Policy 519.23 names a physician as the signer, publishes no order form of its own, and says nothing about a referring provider on the claim; back-dated authorizations are not allowed. [1]
- **Telehealth**: 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. [4][3][1]
- **Prior-auth decision time**: W. Va. Code § 9-5-32 requires electronic PA submission and a response "within five business days from the day on the electronic receipt" once complete, or "within two business days" for urgent care. An incomplete request is returned within two business days; the practitioner has three business days to complete it, and BMS decides within two business days after that. Peer-to-peer appeals take no longer than five business days and PA appeals no longer than ten. A BMS-approved PA "is carried over to all other managed care organizations and health insurers for three months" for in-state services. The federal fee-for-service ceiling is 7 calendar days for a standard decision and 72 hours for an expedited one (42 CFR 440.230). [13][17]
- **Other insurance (who pays first)**: Medicaid pays last. "Prior to submitting a claim to Medicaid, the provider must secure information regarding possible third-party coverage," bill that payer, and meet "All requirements of the third-party insurance plan … including use of in-network providers." After a denial, submit a paper claim with the EOB showing the reason. Members owe no third-party coinsurance or deductibles. TPL claims have the same 12-month filing limit. [7][18]

## Delivery and billing rules

Coverage decides whether West Virginia Medicaid (BMS) 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**: 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]
- **Concurrent billing (97153 + 97155)**: Not allowed for the same activity. Policy 519.23.5.1 requires documentation to "demonstrate only one staff person’s time is billed for any specific activity provided to the member." 97155 may include coaching a technician "at the same time," but the policy gives no exception that lets 97153 and 97155 both be billed for that time. [1]
- **Daily limits / MUEs**: 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]
- **Place of service**: Therapeutic activities "may be provided to a member in his/her natural environment through a structured program." Services must not "supplant or duplicate those provided by educational authorities," "Services that are educational in nature cannot be authorized," and school-administered services (Chapter 538) are carved out of managed care. Telehealth uses POS 02, or POS 10 in the member’s home. [1][9][3]
- **Bill as provider**: For 97152, 97153 and 97154, direct contact is made by the RBT, and "The BCBA or BCaBA may bill for this service." The BCBA, BCaBA and RBT must all have "met participation enrollment requirements," and every rendering practitioner who directly bills must be enrolled with West Virginia Medicaid (Chapter 300). [1][8]

## What intake should collect for West Virginia Medicaid (BMS)

- **Which Medicaid plan:** Aetna Better Health (MHT or Mountain Health Promise), The Health Plan, Highmark Health Options, Wellpoint, or fee-for-service.
- **Age at diagnosis:** The ASD diagnosis must have been made before the eighth birthday; get the original report.
- **Diagnostic assessment under 24 months old:** From a qualified diagnostic provider, with DSM criteria, severity levels and specifiers.
- **Annual physician’s order + EPSDT referral:** Every PA request carries the annual physician’s order for ABA.
- **IEP or homeschool letter:** The reviewer may ask for it to rule out duplication; educational services are not authorized.
- **Other insurance:** Commercial coverage is billed first, in network, with its PA; Medicaid pays last.

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

## Common questions

### When does West Virginia Medicaid pay claims?

Once a week: BMS’s provider payment cycle begins each Friday, after approved claims are posted from the MMIS adjudication cycles. No weekly submission cut-off time is published, and the four MCOs pay on their own schedules.

### Does West Virginia Medicaid cover ABA therapy?

Yes, under BMS Policy 519.23, for members ages 18 months through 20 whose primary ASD diagnosis was made before their eighth birthday. Most children get it through one of the four Mountain Health Trust MCOs or Mountain Health Promise.

### What if my child was diagnosed with autism after age 8?

Policy 519.23 requires the primary ASD diagnosis "prior to their eighth birthday" and documentation of it on the first request. A later diagnosis does not meet the written policy; ask BMS or the MCO in writing whether EPSDT medical necessity can override it.

### What does West Virginia Medicaid pay for ABA?

Per 15-minute unit on the BMS ABA fee schedule: 97151 and 97155 $29.14, 97156 $17.43, 97158 $11.79, 97152 and 97153 $9.90, 97154 $4.50, plus $120 per H0031 assessment. MCOs pay contracted rates, which are not published.

### Does a BCBA need a West Virginia license?

No. West Virginia does not license behavior analysts. Medicaid requires current BACB certification (BCBA, BCaBA or RBT) plus enrollment with West Virginia Medicaid and credentialing with each MCO.

### Can West Virginia Medicaid ABA be delivered by telehealth?

BMS’s telehealth code list includes 97151–97156 and 97158 as "provisional" telehealth codes, billed with POS 02 or 10 and with written member consent. Policy 519.17 does not list behavior analysts as distant-site practitioners, so confirm with BMS or the MCO first.

### What is the timely filing limit for West Virginia Medicaid?

12 months from the date of service for fee-for-service claims, with corrections allowed up to 24 months. MCOs differ: Aetna Better Health 365 days, Highmark Health Options 12 months, The Health Plan and Wellpoint 180 days.

## Primary sources

1. [BMS Provider Manual Chapter 519, Policy 519.23 — Applied Behavior Analysis (effective April 1, 2020; current posting)](https://bms.wv.gov/media/40119/download?inline)
2. [BMS Provider Manual — Chapter 519 Practitioner Services (policy index)](https://bms.wv.gov/providers/policy-manuals/chapter-519-practitioner-services)
3. [BMS Provider Manual Policy 519.17 — Telehealth Services (effective 1/1/2022)](https://bms.wv.gov/media/40772/download?inline)
4. [BMS Policy 519.17 Appendix A — Medicaid Telehealth Standard Codes (effective 1/1/2025)](https://bms.wv.gov/media/22096/download?inline)
5. [BMS — Applied Behavior Analysis Fee Schedule ("Contracts & Codes for: ABA - Medicaid")](https://bms.wv.gov/media/39954/download?inline)
6. [BMS — West Virginia Medicaid Fee Schedules](https://bms.wv.gov/providers/west-virginia-medicaid-fee-schedules)
7. [BMS Provider Manual Chapter 100 — General Information (100.15 timely filing, 100.16 TPL, 100.17 appeals)](https://bms.wv.gov/media/39982/download?inline)
8. [BMS Provider Manual Chapter 300 — Provider Participation Requirements](https://bms.wv.gov/media/41119/download?inline)
9. [BMS Provider Manual Chapter 527 — Mountain Health Trust (Managed Care)](https://bms.wv.gov/media/40937/download?inline)
10. [BMS — Mountain Health Trust (Managed Care): the four MCOs](https://bms.wv.gov/members/mountain-health-trust-managed-care)
11. [BMS — Mountain Health Promise (foster, kinship and adoptive care; Aetna Better Health of WV)](https://bms.wv.gov/members/mountain-health-promise)
12. [BMS — Prior Authorizations (UM vendor, Gold Card program, MCO links)](https://bms.wv.gov/members/prior-authorizations)
13. [W. Va. Code § 9-5-32 — Prior authorization (Bureau for Medical Services)](https://code.wvlegislature.gov/9-5-32/)
14. [WVCHIP — Autism Disorders: ABA therapy coverage (effective February 1, 2023)](https://chip.wv.gov/page/autism-disorders)
15. [BACB — U.S. Licensure of Behavior Analysts (West Virginia not listed)](https://www.bacb.com/u-s-licensure-of-behavior-analysts/)
16. [W. Va. Code Chapter 30 — Professions and Occupations (article list: no behavior-analyst article)](https://code.wvlegislature.gov/30/)
17. [42 CFR 440.230(e) — State Medicaid agency prior-authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-440/subpart-B/section-440.230)
18. [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)
19. [WV BMS — News (Medicaid and provider announcements)](https://bms.wv.gov/news)
20. [WV BMS — Provider News Archive (provider memos)](https://bms.wv.gov/provider-news-archive)
21. [BMS — SFY 2026 Model Purchase of Service Provider Agreement for Mountain Health Promise (Aetna Better Health of WV)](https://bms.wv.gov/media/40865/download?inline)
22. [Aetna Better Health of West Virginia — Provider Manual 2026–2027 (MHT, MHP, WVCHIP)](https://fr.aetnabetterhealth.com/content/dam/aetna/medicaid/west-virginia/provider/pdf/abhwv_provider_manual.pdf)
23. [The Health Plan — Provider Manual Chapter 3, Claims (as of July 1, 2026)](https://www.healthplan.org/application/files/2117/8291/6899/Chapter_3_-_Claims_-_2026_Provider_Manual.pdf)
24. [Wellpoint West Virginia — Mountain Health Trust Provider Manual (WV-WP-CD-PM-011722_26, August 1, 2026)](https://www.wellpoint.com/content/dam/digital/wellpoint/documents/provider/west-virginia/other/wv_wlp_caid_providermanual.pdf)
25. [Highmark Health Options West Virginia — 2025 Medicaid Provider Manual (updated 11/4/25)](https://providers.highmark.com/content/dam/highmark/en/providerresourcecenter/highmark-health-options/hho-wv/documents/pdfs/resources/provider-manual-and-newsletters/provider-manual/2025-HHOWV-ProviderManual.pdf)

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.