CPT 97152 is referenced in 20 tracked payer policy changes from Sentara Health Plans, NC Medicaid - NCDHHS, and 10 other payers. For billers and coders, staying current on payer-specific coverage criteria, reimbursement rules, and prior-authorization requirements for CPT 97152 is critical to clean claim submission. Each entry below links to the full policy analysis with effective dates and action steps.
Starting January 1, 2027, Sentara Health Plans will require prior authorization for a long list of codes on Virginia commercial plans, including self-funded (ASO) plans, and for code 88380 on commercial, Medicaid and Medicare products, plus code 22860 on Medicare products. Sentara will also stop covering a separate list of codes on Virginia commercial and self-funded plans.
NC Medicaid published an updated Clinical Coverage Policy 8F for Research-Based Behavioral Health Treatment (RB-BHT) services, effective Aug. 1, 2026, and it applies to NC Medicaid Direct and NC Medicaid Managed Care. Paraprofessionals must hold a qualifying RBT certification from the BACB or ABAT certification from QABA for their RB-BHT services to be reimbursed, and telehealth is removed for paraprofessional RB-BHT services under CPT 97152 through 97154. Existing paraprofessionals without a qualifying certification have a 120-day grace period that starts Aug. 1, 2026.
Ambetter from Arkansas Health & Wellness is implementing new prior authorization requirements for three ABA therapy service codes (97152, 97157, 97158) effective August 1, 2026. Billing teams must obtain prior authorization before rendering these services or claims will be denied for non-participating providers and facilities.
NC Medicaid updated Clinical Coverage Policy 8F for research-based behavioral health treatment (RB-BHT) services, effective August 1, 2026. Paraprofessionals must hold at least one qualifying certification, either the Registered Behavior Technician certification from the BACB or the ABAT certification from QABA, for their services provided to Medicaid beneficiaries to be reimbursed. Telehealth is removed for paraprofessional RB-BHT services under CPT codes 97152-97154, and telehealth may be used for up to 50% of total 97155 billing per beneficiary per 180-calendar day period.
Effective April 1, 2026, Indiana Medicaid covers ABA therapy exclusively through EPSDT, and for dates of service on or after October 1, 2026 it no longer authorizes or reimburses ABA therapy for members 21 and older after a transition window from April 1, 2026 through September 30, 2026. Maximum rates for nongroup ABA therapy services drop 6% for dates of service on or after April 1, 2026, and group codes 97154, 97157 and 97158 now have rate tiers by group size of two, three, and four to eight participants. The changes also add a 4,000-hour lifetime allocation for comprehensive ABA therapy, a new modifier UA requirement, required caregiver coaching in PA requests, RBT supervision requirements, and telehealth restrictions for certain codes.
Effective February 1, 2026, provisional licensed behavior analysts and assistant behavior analysts in Missouri Medicaid (MO HealthNet) can only bill three specific procedure codes (97152, 97153, 97154) until they complete BACB-equivalent educational requirements. Claims for other ABA codes (97151, 0362T, 97155-97158, 0373T) submitted by non-compliant provisional licensees will be recouped.
Point32Health will continue telehealth coverage for Medicare Advantage members as supplemental benefits effective October 1, 2025, regardless of CMS decisions. Specific codes across multiple specialties including cardiac rehab, mental health, physical therapy, and pulmonary rehab will remain eligible for telehealth reimbursement.
Blue Cross Blue Shield of Arizona's Applied Behavior Analysis guideline for Autism Spectrum Disorder is effective October 1, 2026. Initiating ABA requires a confirmed ASD diagnosis with the severity level documented, clinically significant behavioral or skill deficits documented in a formal treatment plan, and a formal treatment plan completed by a BCBA or BCBA-D that includes the required elements. Comprehensive ABA is generally more than 25 hours per week of direct treatment, up to 40 hours per week, and focused ABA is generally fewer than 25 hours per week. Coverage depends on the member's benefit plan, and ABA is a benefit plan exclusion when the plan does not cover the autism diagnosis.
Blue Shield of California's outpatient applied behavior analysis (ABA) policy for autism spectrum disorder or pervasive developmental disorder (BSC3.01) took effect August 1, 2026, with an annual review that updated the policy statement, guidelines and literature and changed the policy title. Initial ABA assessment may be medically necessary when a member is new to the requesting provider, has the diagnosis made by a licensed qualified health care provider, and the hours or units requested for each CPT code are provided. ABA services may be medically necessary when a comprehensive baseline assessment, objective data analysis, caregiver training and a transition and discharge plan are in place, and ABA is considered not medically necessary once the desired outcomes are achieved, the diagnosis no longer materially impacts functioning, or the member is no longer benefiting from services.
Effective August 1, 2026, Blue Shield of California updated the policy statement, guidelines and literature for applied behavior analysis (ABA) for autism spectrum disorder or pervasive developmental disorder. The policy covers outpatient ABA only, and outpatient ABA must be prior authorized by Blue Shield, with home-based or other non-institutional services obtained from participating providers. Outpatient ABA is generally not a covered benefit for respite, day care, educational services, or to reimburse a parent for participation in the treatment, and Blue Shield covers ABA when it is state mandated or specifically included in a member's benefit plan.
Nebraska Medicaid has updated Applied Behavior Analysis (ABA) service definitions and billing requirements effective July 1, 2026. Key changes include: ABA services in schools cannot be billed directly by independent providers (only through school-based services reimbursement), and individuals receiving waiver services from the Division of Developmental Disabilities may now receive ABA assessments regardless of age.
Nevada Medicaid has removed the 40-hour per week service limit for Applied Behavior Analysis (ABA) providers effective December 21, 2025. Error code 5735 (Limit of Forty Hours per Week PA Override) no longer applies to procedure codes 0362T, 97151, and 97152.
Blue Shield of California medical policy BSC3.01 covers outpatient behavioral health treatment, including applied behavior analysis (ABA), for autism spectrum disorder or pervasive developmental disorder when it is medically necessary. Blue Shield covers BHT/ABA when it is state mandated or when it is specifically included in a member's benefit plan. Respite, day care, educational services, and reimbursing a parent for participating in treatment are generally not covered benefits.
Nebraska Medicaid is adjusting reimbursement rates for Applied Behavior Analysis (ABA) services effective August 1, 2025. Seven ABA procedure codes will have new payment rates, with rates ranging from $7.49 to $38.16. Both fee-for-service Medicaid and managed care rates will be updated.
New Mexico Medicaid covers medically necessary, empirically supported Applied Behavior Analysis (ABA) services for eligible recipients 12 months and older who have a well-documented diagnosis of autism spectrum disorder (ASD), and for eligible recipients with well-documented risk for the development of ASD. ABA services are delivered in three stages: Stage 1 evaluations by approved Autism Evaluation Practitioners, Stage 2 assessment and treatment planning by Behavior Analysts and qualifying psychologists, and Stage 3 treatment that includes Stage 2 practitioners as well as Registered Behavior Technicians, Board Certified Autism Technicians and non-certified behavior technicians. For EPSDT-aged recipients from 12 months to 21 years, ABA services are part of the Early Periodic Screening, Diagnosis and Treatment (EPSDT) program.
Supplement 24-13, issued September 17, 2024, gives New Mexico Medicaid guidance for applied behavior analysis (ABA) services for recipients 12 months and older with autism spectrum disorder or with risk for it, and it replaces Supplement 23-02. Stage 1 evaluations are billed as T1026 TG, T1026 HK and T1026 TG/HI, Stage 2 assessments as 97151, 97152 and 0362T, and Stage 3 treatment as 97153 through 97158, T1026 UD and 0373T for specialty care. Stage 3 services require both a Service Authorization and a Prior Authorization, and the supplement sets CMS Medicaid NCCI MUE unit limits for each code.
Applied Behavior Analysis is a covered service for treatment of Autism Spectrum Disorder for BCBSMS members when rendered by a BCBA or BCBA-D, or by a BCaBA or RBT supervised by a BCBA or BCBA-D. Claims can only be filed by the BCBA or BCBA-D provider, and the time of the BCaBA or RBT is considered practice expense and is not reported separately. The policy defines the reporting limits for ABA identification, follow-up assessment, adaptive behavior treatment and protocol modification codes, including 97151 through 97158, 97155, and 0360T through 0374T.
The 10/15/2025 policy update states that ABA treatment (codes 97153, 97154, 97156, 97157 and 97158) is considered medically necessary according to the member's individualized specific treatment plan, and removed the maximum of 25 hours a week. Effective 08/01/2024, submission of the individualized ABA treatment plan for approval is no longer required for Fully-Insured and Self-Funded Group Members and State Health Plan Participants, and prior authorization requirements were removed for those members. The 09/10/2025 update removed the network provider requirements for the ASD diagnosis and for the referral for ABA assessment.
The IHCP reviewed the Outpatient Fee Schedule, found discrepancies, and will reflect the changes in the next regular update to that schedule. Codes listed twice on previous versions will appear only once, codes missing from the schedule are covered in the outpatient setting and can be billed for dates of service on or after the date listed for each code, and other listed codes are noncovered and will be added to the schedule. Codes that have been nationally end dated will be removed from the schedule, and Current Dental Terminology (CDT) codes cannot be billed on institutional claims (UB-04 claim form or electronic equivalent).
BCBSAZ covers telehealth only as the member's benefit plan provides. Under the BlueCare Anywhere benefit, telehealth is covered when the Telehealth Services Administrator provides the service and determines the condition is appropriate, for a medical, therapy or psychiatry consultation. Under the in-network telehealth benefit, a service is covered when it would be covered in person and can be provided effectively by telehealth, through audio-visual services or limited audio-only services, and out-of-network non-emergency telehealth is not covered. The most recent review, dated 07/29/26, made no revisions.
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