Service Authorization Update for Applied Behavior Analysis (ABA) Effective October 15, 2025
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The purpose of this bulletin is to inform providers of changes to the service authorization process for Applied Behavior Analysis (ABA). Currently, providers submit service authorization requests for ABA treatment under the Current Procedural Terminology (CPT) code 97155. Providers submit claims based on the appropriate ABA CPT code for the service provided. Effective for dates of service October 15, 2025, and later, providers will be required to submit service authorizations that include the units requested for each ABA CPT code used for treatment. This change applies to both fee-for-service (FFS) and Cardinal Care Managed Care (CCMC) service authorizations.
The change will affect the following ABA CPT codes used for ABA treatment:
CPT Code | Unit | Description |
|---|---|---|
97153 | per 15 min | Adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with one patient, each 15 minutes. |
97154 | per 15 min | Group adaptive behavior treatment by protocol, administered by technician under the direction of a physician or other qualified healthcare professional, face-to-face with two or more patients, each 15 minutes. |
97155
| per 15 min | Adaptive behavior treatment with protocol modification, administered by physician or other qualified healthcare professional, which may include simultaneous direction of technician, face-to-face with one patient, each 15 minutes. |
97156
| per 15 min | Family adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (with or without the patient present), face-to-face with guardian(s)/caregiver(s), each 15 minutes. |
97157
| per 15 min | Multiple-family group adaptive behavior treatment guidance, administered by physician or other qualified healthcare professional (without the patient present), face-to-face with multiple sets of guardians/caregivers, each 15 minutes. |
97158
| per 15 min | Group adaptive behavior treatment with protocol modification, administered by physician or other qualified healthcare professional, face-to-face with multiple patients, each 15 minutes. This code is used when the youth also has an assigned one-to-one technician present during the group treatment. |
0373T | per 15 min | Adaptive behavior treatment with protocol modification, each 15 minutes of technicians’ time face-to-face with a patient, requiring the following components: |
The ABA assessment codes (97151, 97152, and 0362T) do not require service authorization and are not affected by this change.
Process for existing FFS authorizations that span past 10/15/2025:
Existing service authorizations will continue through the authorization end date. Acentra Health will reach out to individual providers regarding current service authorizations that span past October 15, 2025. If additional units are required prior to the end of the current service authorization, contact Acentra Health through the Atrezzo portal at https://atrezzo.acentra.com/
Process for existing CCMC authorizations that span past 10/15/2025:
Existing service authorizations will continue through the authorization end date. Providers are not required to update existing service authorizations that span past October 15, 2025. Providers should contact the CCMC Managed Care Organization (MCO) If changes are needed to existing service authorizations that span past October 15, 2025.
New service authorization form for dates of service beginning 10/15/2025 (FFS and CCMC):
ABA providers are required to use the new service authorization form for service authorizations with start dates of October 15, 2025 and later. Copies of the form are located here .
Claims:
There are no changes to the existing process for claims. Providers are required to submit claims that accurately reflect the time and treatment service provided including all required modifiers. Refer to the Mental Health Services Manual located here for additional details.
To avoid disruption to claims payment through FFS and the MCOs providers must periodically check the DMAS provider portal, also known as the Provider Services Solution (PRSS), to ensure that the provider's enrollment, contact information, and license information is up to date, for all of the provider's respective service locations. Under federal rules, MCOs and DMAS are prohibited from paying claims to network providers who are not enrolled in PRSS. Additional information is provided on the MCO Provider Network Resources webpage and includes links to resources, tutorials and contact information to reach Gainwell with any provider enrollment or revalidation related questions. Dental providers should continue to enroll directly through the DMAS Dental Benefits Administrator, DentaQuest.
Virginia Medicaid Web Portal Automated Response System (ARS) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. | |
Medicall (Audio Response System) Member eligibility, claims status, payment status, service limits, service authorization status, and remittance advice. | 1-800-884-9730 or 1-800-772-9996 |
Provider Appeals DMAS launched an appeals portal in 2021. You can use this portal to file appeals and track the status of your appeals. Visit the website listed for appeal resources and to register for the portal. | |
Managed Care Programs Cardinal Care Managed Care and Program of All-Inclusive Care for the Elderly (PACE). In order to be reimbursed for services provided to a managed care enrolled individual, providers must follow their respective contract with the managed care plan/PACE provider. The managed care plan may utilize different guidelines than those described for Medicaid fee-for-service individuals. | |
Cardinal Care Managed Care | https://www.dmas.virginia.gov/for-providers/managed-care/cardinal-care-… |
PACE | |
Provider Enrollment | In-State: 804-270-5105 Out of State Toll Free: 888-829-5373 Email: VAMedicaidProviderEnrollment@gainwelltechnologies.com |
Provider HELPLINE Monday–Friday 8:00 a.m.-5:00 p.m. For provider use only, have Medicaid Provider ID Number available. | 1-804-786-6273 1-800-552-8627 |
Aetna Better Health of Virginia | https://www.aetnabetterhealth.com/virginia/providers/index.html 1-800-279-1878
|
Anthem HealthKeepers Plus | 1-800-901-0020
|
Humana Healthy Horizons Provider Services Call Center | 1-844-881-4482 (TTY: 711) |
Sentara Community Plan | 1-800-881-2166 https://www.sentarahealthplans.com/providers
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United Healthcare | 1-844-284-0146
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Acentra Health Behavioral Health and Medical Service Authorizations | https://vamedicaid.dmas.virginia.gov/sa 1-804-622-8900 |
Dental Provider DentaQuest | 1-888-912-3456 |
Fee-for-Service (POS) Prime Therapeutics
| https://www.virginiamedicaidpharmacyservices.com/ 1-800-932-6648 |