CurrentCareFirstPolicy N/A

Autism Spectrum Disorders (Virginia Mandate)

Defines CareFirst's operating procedure for habilitative services related to autism spectrum disorders for members covered under Virginia-issued plans, summarizing mandate history, benefit applicability, provider and documentation expectations. Affects providers delivering diagnosis and treatment (including ABA) to eligible Virginia members.

Policy Summary

PayerCareFirst

PolicyAutism Spectrum Disorders (Virginia Mandate)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMar 1, 2026

Next Review DateDec 10, 2025

Key ActionVerify prior authorization requirements via the CareFirst Prior Authorization Look-up tool or by calling the Plan before providing services.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

no change2025 review

Jan 1, 2020Mandate effective

age 2+Original age range

requiredABA supervision

Coverage Criteria and Scope

Covered Services / Provider Requirements

Covered when ALL of the following are met:

eligible_contract_and_age: Member has a Virginia-issued policy/contract/plan to which the autism mandate applies (issued, reissued, or extended in the Commonwealth on or after the applicable effective dates); age applicability follows statutory revisions (originally ages 2–6 effective Jan 1, 2012; expanded to ages 2–10 effective Jan 1, 2016 for applicable contracts; any age effective Jan 1, 2020 for individual and small group markets).

Check the member contract for exact applicability and effective dates.

diagnosis_and_medical_necessity: Diagnosis of Autism Spectrum Disorder by a licensed physician or a licensed psychologist, who determines the care to be medically necessary.

service_types: Covered services include behavioral health treatment, pharmacy care, psychiatric care, psychological care, therapeutic care, and applied behavior analysis (ABA) when prescribed/ordered and determined medically necessary.

Policy Summary

PayerCareFirst

PolicyAutism Spectrum Disorders (Virginia Mandate)

Policy CodePolicy N/A

Change TypeNo material change

Effective DateMar 1, 2026

Next Review DateDec 10, 2025

Key ActionVerify prior authorization requirements via the CareFirst Prior Authorization Look-up tool or by calling the Plan before providing services.

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.

This policy defines CareFirst's operating procedure for habilitative services related to Autism Spectrum Disorder (ASD) for members covered under Virginia-issued plans. Coverage and applicability depend on the member's contract and the Virginia mandate revisions; specific contract provisions, restrictions, and exclusions take precedence and should be verified. The mandate history includes phased age applicability (originally ages 2–6, expanded to ages 2–10 for certain contracts, and extended to any age for individual and small group markets effective January 1, 2020), so providers must check the member's Virginia-issued policy to confirm whether the autism mandate applies to that contract.

Provider Responsibilities and Prior Authorization

Prior Authorization

Prior authorization verification

Some services, devices, drugs, and places of service may require prior authorization. Always check the member's contract for benefits. For Prior Authorization requirements please go to the Prior Authorization Look‑up tool (PAL Tool) at https://provider.carefirst.com/providers/medical/in-network-precertification-preauthorization.page or call 1-866-773-2884 (1-866-PRE-AUTH).

PAL Tool: https://provider.carefirst.com/providers/medical/in-network-precertification-preauthorization.page
Phone: 1-866-773-2884 (1-866-PRE-AUTH)

Denial Risk

Prior authorization may be required

Prior authorization may be required for certain services, devices, drugs, and places of service. Failure to obtain required prior authorization may result in claim denial or member liability. Verify authorization requirements before providing services to reduce denial risk.

Denial risk if authorization not obtained
Check member contract and PAL Tool for scope of items requiring authorization

Documentation Required

Required documentation on request

If requested by the Plan, a provider must make available supporting clinical documentation to substantiate medical necessity and the plan of care.

Brief medical history
Written evaluation establishing physical baseline data using objective tests/measurements when possible
Plan of treatment including: diagnosis; short‑ and long‑term goals; type of procedures to be performed; frequency of visits per week; estimated duration of therapy; date of last certification by referring physician
Treatment Plan reviews: Except for inpatient services, the Plan may request review of the Treatment Plan every 12 months or more frequently if the Plan and physician/psychologist agree

Note

Provider action: ABA reporting and supervision

ABA services: only a licensed Behavior Analyst may report ABA services for reimbursement. Services provided by a licensed assistant behavior analyst must be supervised and documented by a licensed behavior analyst and reported by the licensed applied behavior analyst.

ABA services reporting and supervision requirements

Key Definitions

Autism Spectrum Disorder

Definition (legal)As defined by the General Assembly of Virginia (Section 38.2-3418.17, Code of Virginia): 'Autism Spectrum Disorder' means any pervasive developmental disorder or autism spectrum disorder, as defined in the most recent edition or the most recent edition at the time of diagnosis of the Diagnostic and Statistical Manual of Mental Disorders of the American Psychiatric Association.'

Core clinical featuresCharacterized by deficits in the development of socialization and communication skills and by restrictive interests and/or unusual behaviors.

Scope of policyThis policy addresses habilitative services provided to members with autism and autism spectrum disorders; it does not generally address other habilitative services covered under Virginia situs plans.

OpenPayer

Autism Spectrum Disorders (Virginia Mandate)

Coverage Criteria and Scope

Provider Responsibilities and Prior Authorization

Clinical and Legislative Background

Key Definitions