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Issue 8 |
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👋 Hey there!
The 2027 coding guidance is less about the new code than about its limits. 97180 finally pays for an analyst's time away from the client, but it is billed once a week and covers five activities. Writing session notes, QA review and general staff training are not among them. 97155 now needs a technician in the room. And 0362T and 0373T stop being valid on January 1 with no grace period, so any authorization that runs past December 31 on those codes needs replacement units requested now. Three states also changed how they check your enrollment, each on its own clock. Utah's revalidation letters give 60 days, South Carolina's give 30, and Illinois sends its notices only to your IMPACT email. Miss one and the result is disenrollment or termination, not a reminder. If you bill Virginia Medicaid, comments on the 20-hour ABA draft close Wednesday. CMS's May EPSDT guide says hourly maximums "may not be applied" to children's services, and a comment can cite it.
⭐ Featured This Week
The 2027 ABA Coding Guide Is Out: 97180 Bills Weekly, and Not for Session Notes ABA Coding CoalitionThe Coalition's 2027 guidance says 97180 is billed once a week and excludes session notes, QA and general training; 97155 now needs a technician; 0362T and 0373T are invalid from January 1, with no grace period. Read Full Article → 🎧 Listen
📚 Research Digest
Six Meta-Analyses, 2,241 Children: Early ABA Lifted IQ and Adaptive Behavior ReichowSix meta-analyses covering 36 studies and 2,241 young autistic children found comprehensive ABA beat comparison conditions on IQ (mean differences above 11.98 points in three) and adaptive behavior. Evidence on social and communication outcomes was thinner and more variable. Read more → 🎧 Listen
⚖ Legislation Tracker
Maryland Denies ABA Claims Unless an Enrolled Individual Is the Referring NPI Maryland Medical Assistance ProgramFor dates of service on or after July 1, Maryland Medicaid denies ABA claims when Field 17b lacks an individual referring practitioner's NPI, or that practitioner wasn't actively enrolled on the date of service. A group or facility NPI is denied. Read more → 🎧 ListenHighmark's Pennsylvania ABA Policy Now Lists Eight Reasons Therapy Can End Highmark Commercial Medical Policy V-37-045Since June 29, Highmark's Pennsylvania commercial ABA policy lists eight discontinuation triggers, requires a health-and-safety goal for school-based sessions, adds signer-relationship and who-was-present to notes, and excludes sleeping time, travel and ABA overlapping speech or OT. Read more → 🎧 ListenUtah Made ABA Providers 'High Risk.' Revalidation Notices Give 60 Days. Utah Department of Health and Human ServicesUtah Medicaid now screens ABA providers as high risk. Revalidation notices started mailing in September; you get 60 days to disclose 5%+ owners, submit their fingerprint background checks and pay $750, or face termination. Read more → 🎧 ListenMassHealth Proposes Holding ABA Rates at 2024 Levels From December 1 Massachusetts EOHHSEOHHS proposes keeping MassHealth ABA rates unchanged for dates of service from December 1, 2026: 97153 stays $16.37 per 15 minutes and 97155 $30.73, the levels set in 2024. Testimony closed June 17; final adoption isn't yet published. Read more → 🎧 ListenVirginia Medicaid Takes Provider Appeals Online Only From Nov. 5. Fax Stops Jan. 1 Virginia DMAS bulletinFrom November 5, Virginia Medicaid accepts provider appeals only through its AIMS portal. Mail, email and fax still work until December 31. From January 1, they're refused unless DMAS grants a good-cause exception. Read more → 🎧 ListenHighmark Sets New Commercial 97153 Rates in PA, DE and WV on Friday Highmark Provider News: Reimbursement Update: CPT CoFrom October 16, Highmark pays new commercial PPO rates for 97153 in Pennsylvania ($16.59 office, $15.73 non-office), West Virginia ($14.53, $13.78) and Delaware ($15.73). It doesn't publish the old rates. Read more → 🎧 ListenMichigan Finalizes Its ABA Rewrite: No Physical Exam, Six-Month Progress Reports Michigan Department of Health and Human ServicesMichigan's final bulletin MMP 26-18, issued October 1, drops the physical exam before BHT/ABA, ends routine diagnostic re-evaluations, and requires six-month progress reports measured with a standardized tool such as VB-MAPP or ABLLS-R. Read more → 🎧 ListenOregon Put ABA Utilization Limits on Its Medicaid Cut List, Worth $16 Million Oregon Health AuthorityOHA's 2027-29 budget lists a $16 million option, needing federal approval, to authorize ABA to HERC Guideline Note 75, which already caps initial EIBI at six months and excludes intensive ABA from age 13. Read more → 🎧 ListenSouth Carolina Is Revalidating ABA Providers Now. Each Letter Gives 30 Days. South Carolina DHHS Medicaid Bulletin MB# 26-027: PrSouth Carolina Medicaid's MB# 26-027 puts ABA providers on a 12-month rapid revalidation track with fingerprints and site visits. Each mailed letter gives 30 days. Letters began August 12, so the earliest deadlines have passed. Read more → 🎧 ListenIllinois Moves ABA Providers to a Two-Year Medicaid Revalidation Cycle Illinois HFS Provider Notice: Updated Provider RevalIllinois HFS says ABA providers must revalidate within a new two-year cycle instead of every five years. Notices go only to your IMPACT email, and a missed cycle end date means disenrollment with no retroactive fix. Read more → 🎧 ListenCMS's EPSDT Guide Rules Out Hourly Maximums and SD-Based Limits for Under-21s CMS: EPSDT Guide for States: Coverage in the MedicaiCMS's May 2026 EPSDT guide says hourly maximums and standard-deviation limits "may not be applied" to children's Medicaid services; soft limits are allowed if care beyond them is covered. Virginia's 20-hour ABA draft takes comments until October 21. Read more → 🎧 ListenOklahoma Will Reopen ABA Claims Lost to Contract Delays. Ask by January 31. OHCA Provider Letter 2026-18: OHCA Contracting DelayOHCA Provider Letter 2026-18 lets providers recover SoonerCare and SoonerSelect claims denied or never filed because contracting ran late, including groups waiting to add RBTs. File the exception form by January 31, 2027. Read more → 🎧 Listen📤 Pass it on Know someone in ABA who should be reading this? We will send them one invitation from you — and nothing else unless they subscribe. Invite a colleague →
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