MedicaidPrior AuthHigh impact
Applied Behavior Analysis - MEDICAID - OKLAHOMA (New)
Humana·OK · Pediatrics, Psychiatry, Neurology·Medicaid
Effective date
Sep 16, 2026
We identified it
Sep 15, 2026
Summary
Humana has released a new Applied Behavior Analysis (ABA) coverage policy for Oklahoma Medicaid effective 09/16/2026. The policy establishes coverage limits for ABA initial assessments (24 units/6 hours) and reassessments (16 units/4 hours every 6 months), with defined exception criteria for complex cases including regression, comorbid conditions, major treatment changes, severe behaviors, language barriers, and multi-system coordination. Billing teams must implement prior authorization requirements and ensure documentation supports medical necessity for any units exceeding standard limits.
Action Required
By 09/16/2026: (1) Billing team must implement prior authorization workflow for all ABA services (CPT 97151, 97153, 97155, 97156) submitted to Humana Oklahoma Medicaid. (2) Update billing system to enforce coverage limits: 24 units for initial assessment and 16 units for reassessment every 6 months. (3) Configure system to flag requests exceeding limits and require documentation of exception criteria (regression, comorbid conditions, treatment changes, severe behaviors, language barriers, or multi-system coordination). (4) Providers must document specific clinical justification in encounter notes when requesting units beyond standard limits, including incident reports or progress notes for safety-related exceptions. (5) Train billing and clinical staff on exception criteria requirements. (6) Update prior auth request templates to capture required documentation elements. Claims submitted without prior authorization or supporting documentation for exceptions will be denied.