Harvard Pilgrim Health Care

CommercialMA/ME/NH

ABA billing requirements · Source: Harvard Pilgrim / Point32Health — ABA Services Policy

High confidence

Verified 2026-03-01

1 active policy alert

Harvard Pilgrim expands ABA coverage to include Down Syndrome diagnosesEffective 2026-01-01

Harvard Pilgrim Health Care has updated its ABA policy effective January 1, 2026 to include coverage for individuals with Down Syndrome in addition to Autism Spectrum Disorder. This applies to MA, ME, NH, and RI products. Previously, ABA was only covered for ASD diagnoses.

Authorization Requirements

Requires prior auth Yes

Initial auth durationN/A

Renewal auth durationN/A

Submission deadlineN/A

Unit tracking cadenceTotal

Requires FBA Yes

Diagnostic eval validityN/A

Re-eval cadenceN/A

BH carve-out managerBeacon

Documentation Requirements

Parent signatures required Yes

Start/stop times required Yes

Treatment plan componentsAdaptive behavior treatment by protocol, Behavior identification assessment, Family adaptive behavior treatment guidance, Habilitative services

Progress summary cadenceEvery 6 months

Policy Notes

Policy updated to include coverage for Down Syndrome, effective Jan. 1, 2026. Applies to MA, ME, NH, and RI products.

CPT & Modifier Rules

CPT rules require a free account

View H-codes, modifiers, unit limits, and billing restrictions for Harvard Pilgrim Health Care.

Official policy source:Harvard Pilgrim / Point32Health — ABA Services Policy

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Data last verified: 2026-03-01 · Confidence: High · See our methodology

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