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Applied Behavior Analysis - MEDICAID - SOUTH CAROLINA (New)
Effective date
Sep 23, 2026
Identified
Sep 16, 2026
Summary
Humana South Carolina Medicaid has released a new Applied Behavior Analysis (ABA) coverage policy effective 09/23/2026 establishing eligibility criteria, prior authorization requirements, provider credentialing standards, and comprehensive diagnostic evaluation requirements for ABA services in members aged 0-20 with autism spectrum disorder diagnoses. Billing teams must implement prior authorization workflows, validate provider credentials (BCBA, BCaBA, RBT), and ensure comprehensive diagnostic documentation before submitting claims.
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What to do
Action · 9 steps
01By 09/23/2026: Billing team must implement the following changes.
02Configure billing system to require prior authorization for ALL ABA therapy services for SC Medicaid members aged 0-20 with ASD diagnosis.
03Create validation rules to verify ABA provider credentials (BCBA-D, BCBA, BCaBA, or RBT) are current and enrolled with SC Medicaid before claim submission.
04Update claim submission requirements to mandate Comprehensive Diagnostic Evaluation (CDE) documentation, Behavior Identification Assessment (BIA), and Functional Behavior Assessment (FBA) as supporting documentation.
05Establish workflow to confirm prior authorization approval includes medical necessity pathway documentation before processing claims.
06Add member age verification (through last day of month of 21st birthday) into claim edits.
07Update provider enrollment to flag non-compliant technicians (those without RBT credential after 90-day grace period or delivering services outside clinic-based settings).
08Consequences: Claims will be denied without required prior authorization, complete CDE documentation, valid provider credentials, and age verification.
09Providers must be informed of documentation requirements immediately upon policy effective date.
Original notice
Applied Behavior Analysis - MEDICAID - SOUTH CAROLINA (New)
mcp.humana.com · Always check the source before changing claims.