Maryland Medical Assistance Program Applied Behavior Analysis (ABA) Provider Manual - Effective Date February 1, 2026

Sep 20, 2026

Maryland Medical Assistance Program Applied Behavior Analysis (ABA) Provider Manual sets out policy and billing instructions for ABA providers serving Medicaid enrolled participants under age 21. It defines eligibility requirements, including ASD diagnosis by a qualified health care professional and the need for comprehensive diagnostic evaluation and validated instruments. The manual explains legal and regulatory authority under COMAR, HIPAA transaction requirements, and NPI obligations. It also outlines enrollment and registration steps with Maryland Medicaid and the BHASO, and describes how ABA services are covered and reimbursed through fee-for-service arrangements.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages16

Reading Time40 min

AccessFree to download

ABA Overview

Regulatory Authority

HIPAA

National Provider Identifier (NPI)

Provider Enrollment and Registration

Background Checks

Requirements to Access ABA Services

Preauthorization of Services

Medical Assistance Payments

Documentation of Services

Covered Services

Limitations

Guidelines for Utilizing Clinic-Based ABA Services

Guidelines for School-Based ABA Services

Sentinel Events

Contact Information

ABA Fee Schedule (Effective February 1, 2026)

Maryland Medical Assistance Program Applied Behavior Analysis (ABA) Provider Manual Effective Date: February 1, 2026 Table of Contents ABA Overview 3 Regulatory Authority 3 HIPAA 4 National Provider Identifier (NPI) 4 Provider Enrollment and Registration 5 Background Checks 6 Requirements to Access ABA Services 7 Preauthorization of Services 7 Medical Assistance Payments 8 Documentation of Services 8 Covered Services 9 Limitations 10 Guidelines for Utilizing Clinic-Based ABA Services 11 Guidelines for School-Based ABA Services 12 Sentinel Events 13 Contact Information 14 ABA Fee Schedule (Effective February 1, 2026) 15 ABA Overview Effective January 1, 2017, the Maryland Department of Health (MDH) began covering medically necessary Applied Behavior Analysis (ABA) therapy services for Medicaid enrolled participants under the age of 21. In order for a child/adolescent to receive ABA therapy services, he/she must be diagnosed with an Autism Spectrum Disorder (ASD) by a qualified health care professional (QHCP); • A developmental pediatrician; • A pediatric neurologist; • A child psychiatrist; • A clinical psychologist; • A neuropsychologist; • A pediatrician; or • A nurse practitioner. The QHCP must have training and experience to diagnose ASD through the use of a comprehensive diagnostic evaluation (CDE) and with the help of validated instruments, resulting in a referral for ABA therapy services. ABA services are only available under the Early Periodic Screening, Diagnosis, and Treatment (EPSDT) program. The EPSDT program offers comprehensive and preventive health care services for individuals under age 21 who are enrolled in the Maryland Medical Assistance Program (The Program). ABA services will be covered and reimbursed by the Medical Assistance fee-for-service program through its Behavioral Health Administrative Service Organization (BHASO), Carelon Behavioral Health (Carelon) . Regulatory Authority This manual derives its legal authority from the following Code of Maryland Regulations (COMAR) . | Governing COMAR Regulations | Title | | --- | --- | | 10.09.28 | Applied Behavioral Analysis Services | | 10.09.36 | General Medical Assistance Provider Participation Criteria | | 10.09.49 | Telehealth Services | The regulations may be viewed in their entirety online at the Maryland Division of State Documents website: [https://dsd.maryland.gov/Pages/COMARSearch.aspx](https://dsd.maryland.gov/Pages/COMARSearch.aspx) Purpose The purpose of this manual is to provide policy and billing instructions for providers who render ABA services. ABA providers will bill on the CMS-1500 claim form if billing on paper or, if billing electronically, bill on the CMS 837P (professional) claim format. Providers of ABA services are reimbursed in accordance with the ABA Fee Schedule that can be found at the end of this manual or on the ABA webpage. HIPAA The Administrative Simplification provisions of the Health Insurance Portability and Accountability Act (HIPAA) of 1996 require that standard electronic health transactions be used by health plans including private, commercial, Medical Assistance (Medicaid), Medicare, health care clearinghouses and health care providers. A major intent of the law is to allow providers to meet the data needs of every insurer electronically, with one billing format, using health care industry standard sets of data and codes. In January 2009, the Federal government mandated the implementation of HIPAA-compliant 5010 transaction standards to support the mandated upgrade to the ICD-10-CM classification system. 5010 compliance allows for improved technical coordination, accommodation for evolving business needs, and consistency in reporting requirements. The 5010 compliance was implemented on July 1, 2012. Any questions regarding 5010 compliance should be directed to Carelon. More information on HIPAA may be obtained from: [https://www.hhs.go

FAQs

What are the eligibility requirements for a child or adolescent to receive ABA services under the program?

A participant must be diagnosed with Autism Spectrum Disorder (ASD) by a qualified health care professional and receive a referral for ABA therapy based on a comprehensive diagnostic evaluation using validated instruments.

What is the legal authority and regulatory basis for the manual?

The manual’s legal authority is derived from specific Code of Maryland Regulations (COMAR), including Applied Behavioral Analysis Services (10.09.28), General Medical Assistance Provider Participation Criteria (10.09.36), and Telehealth Services (10.09.49).

How must ABA providers enroll and register to receive Medicaid reimbursement?

Providers must first enroll with Maryland Medicaid to obtain a provider number, then register with the BHASO. Enrollment for group practices and qualified licensed professionals is completed through Maryland Medicaid’s ePREP portal.

Sep 20, 2026

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