Wisconsin Medicaid covers ABA through ForwardHealth’s Behavioral Treatment Benefit, which covers "services designed specifically for adaptive behavior assessment and treatment." It comes in two levels: comprehensive behavioral treatment, the high-intensity early-intervention model, and focused behavioral treatment, a time-limited, lower-intensity program aimed at specific behaviors or skills. The benefit is not limited to autism.
The single most important fact for intake: the benefit is "administered fee-for-service for all Medicaid-enrolled members" and is "carved out of MCOs," including BadgerCare Plus and Medicaid SSI HMOs, Children Come First, Wraparound Milwaukee, Care4Kids, Family Care, PACE and Family Care Partnership. Whatever HMO is on the child’s card, the PA request and the claims go to ForwardHealth, not the HMO.
ForwardHealth’s handbook is explicit: "The behavioral treatment benefit is carved out of MCOs, which include BadgerCare Plus and Medicaid SSI HMOs and special managed care plans," with "PA requests and claims processed by ForwardHealth instead of the member’s HMO." The managed care chapter lists "Behavioral treatment services (for example, autism services)" first among services that "are not covered by BadgerCare Plus HMOs or Medicaid SSI HMOs but are provided to members on a fee-for-service basis," and tells providers to "submit PA requests and claims directly to ForwardHealth." Care4Kids, the plan for children in out-of-home care, carves it out too. So this guide has no HMO companion pages: no Wisconsin Medicaid HMO authorizes or pays for ABA.[1][5][7]
The benefit covers behavior identification assessment and plan-of-care development, comprehensive treatment, focused treatment, treatment with protocol modification, family adaptive behavior treatment guidance (family treatment guidance and team meetings) and group treatment. It does not include diagnosis: "A comprehensive diagnosis precedes a referral for behavioral treatment services," and diagnostic and psychological testing is billed under the physician or outpatient mental health benefits. Comprehensive treatment is paid "under federal EPSDT authority," so "PA requests and claim submissions for comprehensive behavioral treatment for members 21 years of age or older will be denied." It is authorized at "no fewer than 20 hours per week at the outset," and for autism ForwardHealth names ABA and the Early Start Denver Model (ESDM) as evidence-based comprehensive models.[1][5][7]
An initial request covers "no more than six months of treatment." Amendments can extend it to 12 months under the same PA number, and subsequent requests cover up to 12 months. The packet is the PA/RF, the PA/BTA attachment, documentation for the approval criteria, and a prescription. The prescription can come from "any qualified medical provider" enrolled in Wisconsin Medicaid. It must state the hours per week and duration, and covered hours may vary "not exceeding a total of 45 treatment hours per week." The initial request must include the diagnostic report, the provider’s initial assessment, previous treatment history, age-normed testing (developmental, communication and adaptive measures for comprehensive treatment; standardized measures or an FBA for focused), the treatment team, the plan of care with discharge criteria, a care-collaboration plan, a grid-style weekly schedule of treatment and school hours, and the most recent IEP. All direct treatment (97153 and 97155) is requested "as a single lump sum using CPT code 97153." Family guidance, team meetings and group treatment are requested on separate lines.[6][7][8][10]
Children under 6 get a faster path. Requests must be submitted before the sixth birthday. ForwardHealth "will authorize up to 30 hours per week of direct treatment (CPT code 97153) through the member’s third birthday and up to 40 hours per week thereafter," for up to 12 months. The PA/BTA is not required, and a diagnostic evaluation can be replaced by "the provider’s attestation that the member has been diagnosed with an autism spectrum disorder by a qualified professional." A medical evaluation from the past 12 months and a prescription are still required. Requests can be backdated only if received within 14 calendar days of the requested start date. Amendment requests to continue treatment must arrive before the current PA expires. The start date can never precede the medical exam, diagnostic evaluation or prescription.[6][7][8][10]
ForwardHealth’s Behavioral Treatment max fee file (downloaded October 2026, dated 10/03/2026) pays per 15-minute unit: 97151 $25.90; 97152 $22.93; 97153 with TG (comprehensive) $11.91; 97153 with TF (focused) $41.44 for provider specialties 34/400 and 34/403 and $20.84 for 34/401 and 34/404; 97153 TF-52 (focused, rendered by a technician, specialty 34/402) $11.91; 97155 $22.93; 97156 $28.03; and the group codes 97154 and 97158 at $12.71 or $6.39 by specialty, with 97154 at $3.65 for a technician as assisting provider. Most rates have been effective since February 1, 2023 (the group codes since December 1, 2022). The two $41.44 specialty codes are also the only ones allowed to bill 97151, which the handbook reserves for licensed supervisors. 97157, 0362T and 0373T are not on the schedule. The interactive search flags 97153 TG with "Age < 21."[18][19][2][21][13][14][22]
Billing basics: claims go on the 837P or the 1500 form. Every line needs the TG or TF modifier, AM for team meetings, and TF-52 when a technician renders focused treatment. Since the modifier-52 guidance in 2026, providers who used 52 on focused claims not rendered by a technician must correct them. Claims must arrive within 365 days of the date of service. Claims picked for payment-integrity review need supporting documentation attached within seven days. EVV does not apply: Wisconsin’s EVV list covers personal care, supportive home care and home health codes, not the ABA codes.[18][19][2][21][13][14][22]
Every clinician who delivers behavioral treatment must be enrolled in one of five specialties. Behavioral treatment licensed supervisors and focused treatment licensed supervisors can bill and render. Behavioral treatment therapists, behavioral treatment technicians and focused treatment therapists render only. A behavioral treatment licensed supervisor needs either "a license as a behavior analyst issued by the Wisconsin Department of Safety and Professional Services (DSPS)" plus "at least 4,000 hours of documented experience as a supervisor," or a DSPS license as a psychiatrist, psychologist, clinical social worker, professional counselor or marriage and family therapist with the same 4,000 hours and a UC Davis ESDM certificate. A focused treatment licensed supervisor needs one of those DSPS licenses plus 2,000 hours of supervised experience in a focused model. Therapists qualify as a BCaBA, or with a master’s degree and 400 hours, or a bachelor’s degree and 2,000 hours (focused therapists can also qualify as an RBT with 2,000 hours). A technician needs RBT certification, or a high school diploma or GED plus 40 hours of training on the standard core curriculum. Therapist and technician applications must name an already-enrolled licensed supervisor.[12][20][4][25]
For out-of-state BCBAs: every specialty is eligible for border-status and telehealth-only border-status enrollment. But telehealth-only border status is open only to providers "licensed in Wisconsin under applicable Wisconsin statute and administrative code," and a supervisor’s eligibility rests on the Wisconsin DSPS license. Out-of-state providers without border status must get prior authorization before providing telehealth services. In practice a BCBA licensed elsewhere needs a Wisconsin behavior analyst license before they can supervise or bill Wisconsin Medicaid behavioral treatment, whether in person or by telehealth.[12][20][4][25]
The questions that decide whether a family can start with Wisconsin Medicaid (ForwardHealth), and what they have to bring. Each maps onto something intake should ask on the first call.
Comprehensive treatment is covered only under 21: it is paid "under federal EPSDT authority," and requests and claims for members 21 or older are denied. The max fee schedule flags 97153 TG with "Age < 21." Focused treatment carries no age limit in the handbook, which addresses members 18 and older (they must have input on goals and sign the plan if they make their own medical decisions). The simplified PA path is only for children who have not reached age 6.[1][19][6][7]
For comprehensive treatment, the diagnostic report "must be dated within one year of the PA request" (or within one year of the start of the current course for members continuously in treatment). For focused treatment, older reports are accepted with an updated clinical impression in the initial assessment. Under 6, a medical evaluation within the past 12 months is required, and an ASD attestation may stand in for the diagnostic report.[6][7]
The diagnostic evaluation is covered under the mental health benefit "when performed by a Medicaid-enrolled licensed physician or psychologist," and the report is submitted with the PA. Under 6, the provider may instead attest that the member "has been diagnosed with an autism spectrum disorder by a qualified professional." ForwardHealth may ask for an independent diagnostic evaluation when comorbid conditions are not clarified.[6][7]
The diagnostic report must use "a diagnostic tool that is validated in peer-reviewed clinical literature," administered according to protocol. For ASD, "the ADOS-2, ADI-R, and CARS-2 are examples." It must also include a developmental and history interview, direct observation, direct probing of skills, record review and a differential diagnosis. For treatment, comprehensive requests need age-normed testing (cognitive, communication, adaptive). Comprehensive ASD plans use a validated curriculum such as VB-MAPP, ABLLS or the ESDM Curriculum Checklist.[6]
Yes: a prescription is required. "Any qualified medical provider can write the prescription for behavioral treatment," and that provider must be enrolled with Wisconsin Medicaid. The prescription must give the date, member ID, service, hours per week and duration, and the prescriber’s NPI and signature. All authorized dates must fall within the prescription’s range. Claims for prescribed services must carry the prescriber’s Type 1 NPI.[6][10][13]
Allowed. The max fee schedule lists POS 02 and 10 for 97151 through 97158, which is how ForwardHealth marks a code as allowed under its permanent telehealth policy. Bill the same code with modifier GT or 95 (audio-video), 93 or FQ (audio-only) or GQ (asynchronous), plus POS 02 or 10, at the same rate as in person. Comprehensive and focused treatment must be "face-to-face," and ForwardHealth counts real-time audio-video as face-to-face but "does not consider a face-to-face requirement to be met by audio-only." Use modifier FR when the supervisor joins by video while the technician and member are together in person. Both member and provider must agree to telehealth, and consent should be documented at least annually. Out-of-state providers without border status need PA before any telehealth service.[4][18][1]
The handbook says "ForwardHealth will make a decision regarding a provider’s PA request within 20 working days from the receipt of all the necessary information." The federal rule for state Medicaid agencies is shorter: beginning January 1, 2026, standard decisions are due "in no case later than 7 calendar days after receiving the request," and expedited ones within 72 hours. The handbook had not been updated to match when we read it. If ForwardHealth returns a request for more information, the provider has 30 calendar days to respond (the original receipt date is kept), or the request goes inactive. Mark urgent requests with the Portal’s Urgent checkbox.[9][23][8]
ForwardHealth is payer of last resort and pays "only that portion of the allowed cost remaining after a member’s other health insurance sources have been exhausted." For behavioral treatment, bill the commercial plan first, using its codes, modifiers and units (no TG/TF unless it requires them), and then bill ForwardHealth for the balance with the same codes. ForwardHealth "will only coordinate benefits when members use a provider in their commercial insurer’s network," and will not pay claims denied for billing errors. When ABA is excluded by the commercial plan or its annual maximum is reached, bill ForwardHealth with the matching claim adjustment reason code and keep the carrier’s Administrative Denial Letter on file. An approved ForwardHealth PA is required for those dates. ForwardHealth is not payer of last resort to programs such as Birth to 3, the CLTS waiver, IDEA or Indian Health Service.[15][16][11][24]
Coverage decides whether Wisconsin Medicaid (ForwardHealth) 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.
Treatment supervisors (licensed supervisors or treatment therapists) must observe, demonstrate and provide simultaneous direction "for a minimum of one hour and a maximum of two hours for every 10 hours of direct treatment provided, averaged over a calendar month." More than two hours needs documented exceptional circumstances. The licensed supervisor must directly observe the member "for at least one hour every 60 to 75 days." If more than 75 days pass, ForwardHealth "may recoup all payments made for services delivered after day 75." Each treatment therapist gets weekly face-to-face or indirect contact plus monthly face-to-face supervision from a licensed supervisor, and each technician gets face-to-face supervision at least monthly. Protocol modification (97155) may generally be requested at up to one hour per five hours of direct treatment.[6][1]
"ForwardHealth does not permit concurrent billing of adaptive behavior treatment by protocol (CPT procedure code 97153) and adaptive behavior treatment with protocol modification (CPT procedure code 97155)." When two or more providers are present, "each minute of service provided to the member is claimed only once." The code table adds "do not bill separately for 97153 during simultaneous direction of technician." Co-treatment with a therapist, outpatient mental health or PDN provider can be paid for the same time only if approved on the PA.[1][2]
Handbook limits: 97151, 96 units (24 hours) per calendar year without PA; 97152, two hours per day of service; 97154 and 97158, 8 units (2 hours) per member per day; 97156 family treatment guidance, 8 units per day; 97156-AM team meetings, 4 units (1 hour) per week. Treatment units per week are set by the PA, and covered hours may vary up to 45 treatment hours per week. ForwardHealth follows the CMS NCCI standards.[2][1][6]
Every session note must carry the "Renderer’s signature and signature date," along with the date of service, time in and out, mode of delivery (in person or telehealth), staff present, goals addressed, techniques and data. "Documentation should be completed no later than 48 hours after the DOS as evidenced by the renderer’s signature and signature date on the record." The plan of care "must be signed and dated by the supervising provider prior to provision of care." Time spent documenting after the service is not reimbursable.[1][6]
Treatment "may occur in the member’s home, the provider’s office, or in the community." Allowed POS codes are 02, 03 (school), 04–08, 10, 11, 12, 13, 14, 16, 19, 27, 49, 50, 71 and 72. For parks, libraries or stores, bill POS 12. ForwardHealth "will not authorize a plan of care or reimburse behavioral treatment providers for providing educational instruction" to members 6 and older. Treatment during school hours must explain why a behavioral provider is needed and plan to hand the work over to school supports.[2][1][6]
"Only licensed supervisors can submit and be reimbursed for claims." The licensed supervisor overseeing the member’s plan of care is the billing provider, and the licensed supervisor, treatment therapist or technician who rendered the service is the rendering provider. "Each detail line on the claim requires a rendering provider number." Therapists and technicians are enrolled as rendering-only providers. Family treatment guidance (97156) must show the licensed supervisor as rendering provider.[13][12][1]
Yes, through ForwardHealth’s Behavioral Treatment Benefit: comprehensive treatment (high-intensity early intervention, under 21) and focused treatment (time-limited, for specific behaviors or skills). It is not limited to autism.
Yes to both. "Any qualified medical provider can write the prescription for behavioral treatment," and that provider must be enrolled with Wisconsin Medicaid. The prescription must give the date, member ID, service, hours per week and duration, and the prescriber’s NPI and signature, and every authorized date must fall within the prescription’s range. Claims for prescribed services must carry the prescriber’s Type 1 NPI.
No. Behavioral treatment is carved out of BadgerCare Plus and Medicaid SSI HMOs and the special managed care plans. PA requests and claims go to ForwardHealth fee-for-service, whatever HMO is on the card.
Not at first. ForwardHealth covers up to 96 units (24 hours) of 97151 per calendar year without PA. More than that needs a PA amendment. All treatment needs PA.
Per 15-minute unit on the October 2026 max fee schedule: 97151 $25.90, 97152 $22.93, 97153 $11.91 for comprehensive treatment (focused treatment pays $41.44 or $20.84 by provider level, $11.91 for a technician), 97155 $22.93, 97156 $28.03.
Not without a Wisconsin license. A licensed supervisor needs a Wisconsin DSPS behavior analyst license, and ForwardHealth’s telehealth-only border-status enrollment is open only to providers licensed in Wisconsin. Out-of-state providers without border status also need PA before telehealth.
365 days from the date of service for claims, corrected claims and adjustments. Claims must be billed by the licensed supervisor on the plan of care, with the rendering provider on every line.
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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