Anthem/Elevance Medicare Advantage

Commercial

ABA billing requirements · Source: Anthem/Elevance Medicare Advantage — Clinical Guideline: Applied Behavior Analysis

High confidence

Verified 2026-03-16

Authorization Requirements

Requires prior auth Yes

Initial auth duration12 months

Renewal auth duration12 months

Submission deadline14 days

Unit tracking cadenceTotal

Requires FBA Yes

Diagnostic eval validity36 months

Re-eval cadenceEvery 12 months

BH carve-out managerCarelon

Documentation Requirements

Parent signatures required No

Start/stop times required Yes

Treatment plan componentsASD diagnosis (ICD-10 F84.0), Medical necessity documentation, Functional Behavior Assessment, Baseline data, Measurable goals, Intervention strategies, BCBA supervision documentation

Progress summary cadenceEvery 12 months

Policy Notes

Anthem/Elevance Medicare Advantage plans cover ABA for adults with ASD following 2025 MPFS. Prior auth required — submitted through Availity or Carelon (Anthem BH subsidiary). BCBA must be enrolled as Medicare provider AND in Anthem MA network. Annual auth cycle.

CPT & Modifier Rules

CPT rules require a free account

View H-codes, modifiers, unit limits, and billing restrictions for Anthem/Elevance Medicare Advantage.

Official policy source:Anthem/Elevance Medicare Advantage — Clinical Guideline: Applied Behavior Analysis

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Data last verified: 2026-03-16 · Confidence: High · See our methodology

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