CurrentBlue Cross Blue Shield - OklahomaPolicy CPCP011

Applied Behavior Analysis

Governs reimbursement and coding requirements for Applied Behavior Analysis services provided to Blue Cross and Blue Shield of Oklahoma members and affects providers billing ABA services to the Plan.

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyApplied Behavior Analysis

Policy CodePolicy CPCP011

Change TypeMoved to MCG Criteriaverbiage updates

Effective DateMarch 20, 2026

Next Review Date

Key ActionEnsure providers are BCBA-certified or state-licensed behavior analysts/psychologists and obtain prior authorization with documentation (typically 26-week authorization periods) before billing ABA services.

SourceLink

POLICY UPDATE CHANGES

New bullet added, verbiage updates to Guidelines; Removed from Additional Resources: Medical Policy PSY301.021.

Policy is moving to MCG Criteria, see Medical Policy ADM1001.036 effective January 1, 2026.

40 hrs/wkCMS MUE typical maximum direct services per week

26 hrsAuthorized parent education per authorization period

8 hrsMax billable time for evals/treatment plans

10-20%Recommended CASP percent of direct hours

2-8

Policy Summary

PayerBlue Cross Blue Shield - Oklahoma

PolicyApplied Behavior Analysis

Policy CodePolicy CPCP011

Change TypeMoved to MCG Criteriaverbiage updates

Effective DateMarch 20, 2026

Next Review Date

SourceLink

On This Page

Trek Health ingests and normalizes Transparency in Coverage data and payer policy updates to give provider organizations a clear view of how commercial reimbursement behaves across markets, payers, and services. Our platform transforms raw payer disclosures into structured intelligence that supports contract evaluation, payer negotiations, and service line strategy. By combining market benchmarks with ongoing policy visibility, Trek helps teams identify variability, risk, and opportunity in commercial reimbursement. The result is faster insight, stronger negotiating positions, and more informed financial decisions.

Coverage Criteria

Covered when ALL of the following documentation, provider qualification, coding, and billing rules are met. Services that do not meet these criteria are not eligible for reimbursement.

ALL of the following

Provider qualifications: Services must be delivered by a qualified healthcare professional who is Behavior Analyst Certification Board (BACB) certified as a Behavior Analyst (BCBA) and/or appropriately licensed in the provider’s state as a Licensed Behavior Analyst or Licensed Psychologist.
Providers must maintain credentialing documentation in the member record.
Service delivery and supervision
- Only one BCBA or qualified healthcare professional may be reimbursed for the same or similar services on the same date of service; this restriction does not apply to technicians or direct service providers rendering services under supervision.
- Direct supervision and billing: billable supervision must be face-to-face and involves only one technician; indirect supervision (patient not present) is considered a bundled practice expense and is not separately reimbursable, though documentation of indirect supervision is expected in the treatment plan.
  CASP guidance recommends 10–20% of direct hours be spent in combined direct and indirect case supervision; direct supervision may be authorized at a minimum of 1 hour/week when less than 10 hours of direct services are authorized.
- A provider who did not personally render the billed service (e.g., did not perform protocol modification, parent education, assessment, or report writing) should not bill for that service; billing through another provider’s NPI is not allowed unless permitted by applicable state law and formal supervisor-supervisee arrangements.
Place of service and setting
- Conventional POS: Services provided in Place of Service codes 10, 11, or 12 are the expected settings for reimbursement.
- Nonconventional settings: Services rendered in other settings may be considered only with supporting rationale and documentation in the member record describing the nonconventional POS and clinical justification.
Assessment, treatment planning, and reporting
- Assessments, reassessments, and report writing (including administration, scoring, interpretation, and report write-up) that exceed 8 hours (32 units of CPT 97151) may not be eligible for reimbursement and require documentation justification.
- CPT 0362T and 0373T: Assessments and direct treatments for severe maladaptive behavior must have defined, separate treatment protocols; be administered by the physician or other qualified healthcare professional on site; involve two or more technicians; be for patients exhibiting destructive behavior; and occur in an environment customized to the patient’s behavior (high-intensity safety setting).
  Such services may alternatively be delivered under different funding or procedural codes appropriate to day treatment or inpatient settings.
- CPT 97156 (Family Adaptive Behavior Treatment Guidance) is for face-to-face caregiver/guardian guidance (with or without the patient present) and should be used instead of 97155 when applicable; 97155 is reserved for supervisory activities related to patient care.
- CPT codes are face-to-face and with one patient unless the code description specifies otherwise; group interventions (97154, 97158) must include 2–8 members; qualified healthcare professional direction of a technician during 97154 is captured as 97155; qualified professional delivering group treatment with protocol modification is captured as 97158.
Coding, modifiers and timed services
- Use the single modifier (HM, HN, or HO) to indicate the level of education, training, and certification of the rendering provider when submitting CPT 97153.
- Reporting units for timed codes must follow the 8-minute rule and Medicare published unit thresholds for 15-minute timed procedures; report the actual treatment time only (exclude pre- and post-delivery activities).>= 8 minutes
  Medicare unit rules: 8–22 min = 1 unit; 23–37 = 2 units; 38–52 = 3 units; etc., through 113–127 = 8 units. Combine sub-8-minute services per CMS rules when appropriate.
- Documentation is required to substantiate units billed beyond industry standard coding guidelines; follow the CMS MUE table for guidance on maximum units per single date of service.
Documentation and recordkeeping
- Documentation must include: member signature (or caregiver) for each rendered service with service/code provided, rendering provider name/signature, provider certification and credentials, place of service, date of service, and beginning and end times; a written summary or note of the service rendered; and data points as required for audits.
- Session notes should reflect presence of both the contracting provider and member when required by direct personal supervision rules; direct personal supervision requires the contracted provider be in the immediate vicinity and session notes must reflect both parties were present for the entire encounter.
Billing restrictions and nonreimbursable services
- ABA services are not reimbursable when provided by individuals who are not BACB-certified or state-licensed as required, nor when provided for educational, vocational, respite, or custodial purposes.
- Reimbursement is not available for more than one BCBA/qualified professional providing the same/similar services on the same date of service; technicians’ services billed must be by appropriately trained technicians and not by caregivers.
- There is no CPT code for indirect (patient not present) supervision activities; these are bundled and not separately reimbursable except where codes explicitly allow patient-not-present billing (e.g., 97151 report writing, 97156).
Special billing notes
- When multiple timed therapies/modalities are provided in a single day, apply the 8-minute rule across services and bill the service with the greatest minutes when combining sub-8-minute services, per Medicare guidance.
- Co-treatment with another distinct service (e.g., Speech or Occupational Therapy) may be clinically indicated; co-treat sessions should be documented in the treatment plan and billed with the appropriate modifier.

Coding and Unit Limits

ABA-related CPT/temporary codes (CPT)CPT

0362T	Behavior identification support assessment each 15 min
0373T	Adaptive behavior treatment each 15 min
97151	Behavior identification assessment by physician/QHP
97152	Behavior identification support assessment by 1 technician
97153	Adaptive behavior treatment by technician
97154	Group adaptive behavior treatment by technician
97155	Adaptive behavior treatment by physician/QHP
97156	Family adaptive behavior treatment guidance by physician/QHP
97157	Multiple-family adaptive behavior treatment guidance
97158	Group adaptive behavior treatment by physician/QHP

CMS MUE / unit limits guidance

Primary guidance sourceUse the most current CMS Medically Unlikely Edits (MUE) table to determine typical maximum units and to inform billing limits (direct services typically up to 40 hours/week).

Timed‑service unit rulesFollow Medicare 15‑minute unit thresholds when billing 15‑minute timed services (units mapped to minute ranges: ≥8–22 min =1 unit; ≥23–37 =2 units; etc.).

8‑minute rule for multiple short servicesWhen two or more 15‑minute timed services on the same day are each ≤7 minutes but total ≥8 minutes, bill one unit for the service with the most minutes; same logic applies for three or more such services.

Treatment time definitionReport only time actually spent delivering the service; exclude pre/post delivery activities and patient waiting/resting time; record begin/end times in the medical record.

Authorization period limitationService units are also limited by the authorization period specified in the member's authorization (CMS MUE is a guide but subject to authorization limits).

Provider Qualifications, Authorization & Documentation

Prior Authorization

Prior authorization, provider credentials, authorization period, and required documentation

Providers must be certified/licensed to bill ABA services and maintain documentation to support authorizations and unusual billing. ABA services are not reimbursable unless provided by a Behavior Analyst certified by the Behavior Analyst Certification Board (BCBA) and/or a state-licensed Behavior Analyst or Licensed Psychologist; documentation must be maintained and made available upon request to justify non‑conventional place of service, units billed beyond coding guidelines, and services rendered. Parent education is typically authorized per authorization period (typically 26 weeks) for a total of 26 hours; direct supervision may be authorized at a minimum of 1 hour/week when less than 10 direct hours are authorized.

Provider credentialing: must be BCBA-certified and/or state-licensed Behavior Analyst or Licensed Psychologist.
Prior authorization/authorization period: parent education authorized per authorization period (typically 26 weeks) for a total of 26 hours; requests >1 hour/week require supporting clinical documentation.
Authorization/documentation expectations: supporting documentation must be on file for services rendered in non‑conventional POS (other than POS 10, 11, 12) and be made available upon request.
Billing limits justification: treatment plans/evaluations exceeding eight hours (32 units of 97151) may not be eligible for reimbursement per industry coding guidelines; follow CMS MUE guidance for maximum units.
Documentation elements required: caregiver signature for each service with service/code, provider name/signature, certification/credentials, place of service, date and start/end times; written note/summary and immediate data points as required for audit.

Definitions and Supervision

Direct supervision

DefinitionDirect supervision includes activities when the patient is present and involves direction of Registered Behavior Technicians, treatment planning/monitoring fidelity of implementation, and protocol modification.

Reimbursement noteDirect supervision may be authorized for coverage consistent with the member's benefits; when less than 10 direct hours are authorized, direct supervision may be authorized at a minimum of 1 hour per week.

Documentation expectationsDocument direct supervision occurrences in the treatment record with date/time, provider credentials/signature, and a written note describing the activity for audit purposes.

Indirect supervision

DefinitionIndirect supervision refers to case supervision activities when the patient is not present (e.g., developing goals, data analysis, coordinating care, report writing, transition planning, and staff training/directing protocol implementation).