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Applied Behavior Analysis - MEDICAID - SOUTH CAROLINA (New)
Effective date
Sep 23, 2026
Identified
Oct 6, 2026
Summary
Humana has established a new Applied Behavior Analysis (ABA) coverage policy for South Carolina Medicaid members aged 0–20 years with autism spectrum disorder or related IDEA/BHDD designations. The policy became effective September 23, 2026, and requires prior authorization, comprehensive diagnostic evaluation, eligible provider credentials (BCBA, BCaBA, RBT), and documentation of medical necessity before ABA services are covered. Billing teams must verify member eligibility, obtain prior authorization, and ensure providers meet South Carolina Medicaid credentialing requirements.
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What to do
Action · 7 steps
01ALREADY EFFECTIVE (September 23, 2026): Billing and clinical teams should verify current applicability and implementation status immediately.
02Billing team: Update billing software and intake workflows to require prior authorization for all ABA treatment requests submitted to Humana South Carolina Medicaid (Policy HUM-SC-2663-000).
03Prior Authorization team: Establish internal processes to collect and review required documentation before claim submission, including Comprehensive Diagnostic Evaluation (CDE), Behavior Identification Assessment (BIA), Functional Behavior Assessment (FBA) when required, Individualized Plan of Care (IPOC), and medical necessity pathway documentation (per DSM-5 ASD diagnosis, IDEA designation, or BHDD eligibility).
04Credentialing/Provider Relations: Verify that all ABA providers in the network are South Carolina Medicaid-enrolled and hold valid BACB credentials (BCBA-D, BCBA, BCaBA, or RBT); ensure BCaBAs are supervised by BCBA-D or BCBA, and uncredentialed Behavior Technicians are limited to clinic-based settings with direct on-site BCBA/BCaBA supervision during the 90-day credentialing window.
05Encounter forms and clinical documentation: Confirm member age is 0–20 years (through last day of month of 21st birthday) and that one autism eligibility criterion is met before scheduling services.
06Claims processing: Reject or hold claims lacking prior authorization or required documentation per South Carolina Medicaid ASD policy.
07CONSEQUENCES: Claims submitted without prior authorization or from non-credentialed/non-enrolled providers will be denied.
Original notice
Applied Behavior Analysis - MEDICAID - SOUTH CAROLINA (New)
mcp.humana.com · Always check the source before changing claims.