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Virginia · Cardinal Care · Applied behavior analysis

One business day to sign, and Virginia now reviews ABA before and after it pays

All five Cardinal Care plans work from the same DMAS Mental Health Services Manual, and none adds session-note rules of its own. Chapter IV, revised October 2, 2026, lists what a progress note contains and says it is written, signed, and dated within one business day of the service; Appendix D says what every note describes. In December 2025, bulletin BUL-1225 warned that payments for unqualified technicians and for non-covered time will be retracted, and the 2026 Appropriation Act directs DMAS and the MCOs to review ABA payments before and after payment. The matching rule set lives in the rules library in the Penguin Health app, and we update it when DMAS changes the manual.

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In the rules libraryVirginia Medicaid ABA · eleven rules · maintained by Penguin · reviewed Oct 12, 2026

Deadline to write, sign, and date the note1 business day

Chapter IV, revised October 2, 2026.

Managed care plans, one manual5 MCOs

Anthem HealthKeepers Plus, Sentara, UnitedHealthcare, Aetna Better Health, Humana. None adds note rules.

BUL-1225, December 2025Retraction

Payments for services by unqualified technicians and for non-covered time will be retracted.

2026 Appropriation ActBefore and after

DMAS and the MCOs review ABA payments before and after payment.

What changed

Fifteen months of changes, and a review mandate at the end

Virginia has no federal audit of its ABA benefit. It has a manual that DMAS has revised repeatedly since July 2025, a bulletin that says which payments will be retracted, and a budget act that tells DMAS and the five Cardinal Care plans to look at ABA claims before and after they pay. All five plans (Anthem HealthKeepers Plus, Sentara Community Plan, UnitedHealthcare Community Plan, Aetna Better Health, and Humana Healthy Horizons) work from the DMAS manual, and none publishes session-note rules of its own.

Appendix D revisedJul 17, 2025

What every note describes. The activities provided, the child's reaction, and performance on each treatment objective addressed, for every code.
Code-specific content. Group notes state the number of participants, at most eight, and 97154 has a licensed behavior analyst on site. 97156 has the child present or a clinical reason for absence. 0362T and 0373T document the qualified professional on site, two or more technicians, the destructive behavior requiring the team, and a customized environment.
School setting. Covered only for qualified-professional observation and collaboration, never for technician direct treatment.

Source: Appendix D.

Service authorization by CPT codeOct 15, 2025

Units are authorized per CPT code from this date.

Source: DMAS service authorization update. Authorization units are a requirement on the practice; Penguin does not track them.

BUL-1225, ABA policy and regulatory clarificationsDec 2025

Retraction. Payments for services by unqualified technicians and for non-covered time will be retracted.
Non-covered time. Meals and snacks, inactive time or time spent waiting (including naps), transportation and staff travel, recreation, educational instruction, childcare or respite, and documentation without the child present.

Source: BUL-1225.

Chapter IV revised, and the 2026 Appropriation ActOct 2, 2026

The progress-note elements. The service name, the date of service, the setting, the start and end times of the service, and the signature of the staff who rendered it with credentials and the date signed.
One business day. The note is written, signed, and dated within one business day of the service.
Review before and after payment. The 2026 Appropriation Act directs DMAS and the MCOs to review ABA payments before and after payment. It also adds a 20-hour weekly cap (more under EPSDT review) and an autism diagnosis requirement, both awaiting CMS approval; DMAS's July 2026 bulletins say current processes stay in place until then.

Sources: Chapter IV; proposed Appendix D revision.

The checklist

Ten things a Virginia note has to show

Chapter IV lists the progress-note elements: the service name, the date of service, the setting, the start and end times of the service, and the signature of the staff who rendered it with credentials and the date signed, written, signed, and dated within one business day of the service. Appendix D adds what every note describes: the activities provided, the child's reaction, and performance on each treatment objective addressed, for every code. Chapter IV and BUL-1225 say which time cannot be inside the billed window.

Here is that requirement as a technician's note for a home session with a snack in the middle, each element tied to the DMAS document that requires it. The child, staff, and data are fictional.

Progress note97153 · Adaptive behavior treatment by protocol

Child: A. T. · Cardinal Care member ID TEST-00017 · DOB 06/02/2020 1
Service: Adaptive behavior treatment by protocol (97153) 1
Date of service: 10/06/2026 1
Setting: Home, Chesapeake, VA 2
Rendering staff: Nia Caldwell, RBT 8
Service time: 3:00 pm to 5:30 pm. Snack 4:00 to 4:15 not billed. 9 units billed. Arrived 2:55 pm, left 5:35 pm; not service time. 34
Others present: Father, observing. One child; not a group session. 10

Activities provided 5

Requesting with a picture card. Discrete trial training at the kitchen table, 2 blocks. 14 of 20 independent (70%); 55% on 10/02. 7
Following two-step directions. Natural environment training during play. 6 of 8 with one verbal prompt.
Tolerating denied access. Behavior plan, differential reinforcement with a first-then card. 1 protest of about 30 seconds, recovered.

Reaction and progress 6

A. was engaged for the session and initiated play twice. The RBT ran picture requesting with A.'s puzzle pieces and faded the full physical prompt to a partial prompt in the second block; A. handed the card independently in 14 of 20 trials, up from 11 of 20 on 10/02. During NET, A. followed "get your shoes and sit" with one verbal prompt in 6 of 8 chances. One protest when the tablet was removed, about 30 seconds; the first-then card ended it. A. ate a snack with her father from 4:00 to 4:15; no treatment was delivered and that time is not billed. No protocol changes.

Signed electronically: Nia Caldwell, RBT · 10/06/2026 5:41 pm 89

1
The service, the date, and the child
The service name and the date of service are two of the five Chapter IV progress-note elements, and the note names the child it is about.
Virginia Chapter IV, progress-note elements
2
The setting
Where the service happened. A school setting is covered only for qualified-professional observation and collaboration, never for technician direct treatment.
Virginia Chapter IV · Appendix D, school setting
VA-897153 or 97154 billed with place of service 03 fails.
3
Start and end times of the service
The minutes of treatment, not the minutes the child was in the building. Arrival and departure are not service times, and the billed units match the service times to the minute.
Virginia Chapter IV, progress-note elements
VA-1Times on the note, matched to the billed times.
4
Non-billable time named and left out
When the session passes through a snack, a nap, or a wait, the note says so and the billed window excludes it. Not billable: meals and snacks, inactive time or time spent waiting (including naps), transportation and staff travel, recreation, educational instruction, childcare or respite, and documentation without the child present.
Virginia Chapter IV · BUL-1225
BUL-1225Payments for non-covered time will be retracted.
5
The activities provided
What the technician did, with the technique named. Discrete trial training, natural environment training, a behavior plan: say which, on which target.
Virginia Appendix D: every note describes the activities provided
6
The child's reaction
How the child responded to each activity, in this session, on this day.
Virginia Appendix D: every note describes the child's reaction
7
Performance on each objective addressed
Data for every treatment objective the session touched, with the comparison that shows progress. Appendix D asks for this on every code, not only 97153.
Virginia Appendix D: performance on each treatment objective addressed
VA-4Activities, reaction, and performance on each objective, read from the note for every code.
8
Signed by the staff who rendered it, with credentials and the date signed
The fifth Chapter IV element. The signature belongs to the person who delivered the service, carries their credential, and is dated.
Virginia Chapter IV, progress-note elements
9
Written, signed, and dated within one business day
Chapter IV sets the deadline at one business day after the service. Penguin flags a note signed more than four calendar days after the session, which is late under any reading of one business day; it does not enforce the business-day deadline exactly.
Virginia Chapter IV, one business day
VA-3Signed more than four calendar days after the session fails.
10
What the code adds
Group notes (97154, 97157, 97158) state the number of participants, at most eight, and 97154 has a licensed behavior analyst on site. 97156 has the child present or a clinical reason for absence, with training on the child's goals. 97155 is direction or protocol work for the child; supervising staff on its own is not billable. 0362T and 0373T document the full team and are never delivered by telehealth.
Virginia Appendix D · DMAS ABA FAQ · Telehealth Supplement
VA-6, VA-7, VA-9, VA-10, VA-11One rule per code family, each read from the note.

Staff modifiers on the claim

HO for a licensed behavior analyst, HN for a licensed assistant behavior analyst, TF for other licensed mental health professionals, and none for a technician.

Requirement onlyA DMAS billing requirement. Penguin does not check modifiers.

Supervision, counted per month

A licensed professional observes each client monthly, and unlicensed staff are supervised at least twice a month. Board of Medicine regulation 18VAC85-150-120 adds at least one hour of live supervision every four weeks.

Requirement onlyA requirement on the practice, not on the note. Penguin does not track supervision for Virginia.

Telehealth coding

Telehealth uses place of service 02 when the client is not at home or 10 when the client is at home, with modifier GT (Telehealth Supplement).

Requirement onlyPenguin reads place of service for VA-8 and VA-11. It does not check the GT modifier.

What Virginia will not pay for

A session that runs through lunch is not a session

Chapter IV and BUL-1225 list the time that cannot be billed as ABA: meals and snacks, inactive time or time spent waiting (including naps), transportation and staff travel, recreation, educational instruction, childcare or respite, and documentation without the child present. BUL-1225 says payments for non-covered time will be retracted. The note has to show the minutes that were treatment.

An illustration, not a reviewed case. Lunch and a nap are inactive time, so this day supports 19 units of 97153, not 24. Under BUL-1225 the five units for non-covered time are the ones DMAS says it will retract.

Not billable as ABA

Meals and snacks.
Inactive time or time spent waiting, including naps.
Transportation and staff travel.
Recreation and educational instruction.
Childcare or respite.
Documentation without the child present.

Still treatment

A routine with an ABA technique named. A mealtime or a transition where the note says which technique was used, on which target, with data, is treatment. The rule passes it.
Time the note excludes. A snack named in the note and left out of the billed window is exactly what Chapter IV asks for.

VA-5 · No non-billable time inside the billed windowFAIL

applies_when: payer name contains the Virginia Medicaid label
rule_text: Fail when the narrative places meals and snacks, inactive time or time spent waiting (including naps), transportation and staff travel, recreation, educational instruction, childcare or respite, and documentation without the child present inside the billed start and end times. Pass a routine with an ABA technique named.
non_billable_time_inside_window: true
rationale: Narrative states "L. napped from 1:15 to 2:00" with billed time 9:00 to 3:00 and no deduction.

What the reviewer gets: the finding, the technician's educational email, and the action steps to amend the note and the claim, pre-filled with the date of service and a link to the note.

Supervision

Supervision is a monthly clock, not a percentage

Virginia does not set supervision as a share of technician hours. The manual sets it per month: a licensed professional observes each client monthly, and unlicensed staff are supervised at least twice a month. Board of Medicine regulation 18VAC85-150-120 adds at least one hour of live supervision every four weeks. These are requirements on the practice, and Penguin does not track supervision for Virginia.

What Penguin does read is the 97155 note. Appendix D and the DMAS ABA FAQ are clear that supervising staff on its own is not billable under 97155, and that without the child present the work must tie to face-to-face treatment.

Supports 97155

Direction or protocol work for the child, and the note says what it was.
The child present, or, when the child is not, work the note ties to the child's face-to-face treatment.

Does not support 97155

Supervision of staff on its own. Observing the technician, reviewing data collection, or training staff with nothing tied to the child's treatment.
A monthly observation visit written up as 97155 with no direction or protocol work in the note.

VA-10 · 97155 is tied to the child, not staff-only supervisionFAIL

applies_when: procedure code contains 97155
rule_text: Pass when the note shows direction or protocol work for the child. Fail for staff-only supervision.
tied_to_child: false
rationale: Narrative states "Observed RBT for the session and reviewed data collection procedures." Nothing tied to the child's treatment.

What the reviewer gets: the finding, the licensed behavior analyst's educational email, and the action steps to amend or rebill, pre-filled with the date of service and a link to the note.

In the rules library

Eleven Virginia rules, ready to turn on

Open the rules library in the Penguin Health app, choose Virginia Medicaid ABA, and click Add to organization. Rules your organization already has are left alone, so adding the set twice only fills gaps. After adding, edit any rule or add your own alongside them.

Each rule runs only on notes billed to Virginia Medicaid MCO plans. Penguin checks the CentralReach payer name, so a Virginia rule never fires on an Anthem commercial note in the same organization. The match is on payer names that contain the state's Medicaid label (for example "VA Medicaid MCO"), and an organization whose payer names differ edits that match after adding the set.

Penguin reads signed session notes from CentralReach, read-only, after signature and before the claim, and runs the set on every note. Deterministic rules compare record fields. AI rules are read by the AI, which returns a pass or fail with a one-sentence reason. Both means the AI reads a value off the note and a deterministic check makes the decision.

All eleven rules apply to every date of service.

Rules libraryPenguin Health app

Virginia Medicaid ABAMaintained by Penguin

Eleven rules for Cardinal Care ABA, each with QA guidance by program code.

reviewed: Oct 12, 2026
runs on: Notes billed to Virginia Medicaid MCO payers, all dates of service
sources: MHS Manual Chapter IV, rev. Oct 2, 2026 · Appendix D, rev. Jul 17, 2025 · BUL-1225 · Telehealth Services Supplement, rev. Jan 5, 2026 · DMAS ABA FAQ
watching: 20-hour weekly cap and diagnosis requirement awaiting CMS approval · Proposed Appendix D revision, Town Hall 8724

Add to organizationAdds all eleven rules and their QA guidance. Edit any rule afterward, or add your own alongside them.

Virginia requirement	What Penguin checks on every note	Virginia source	How
Start and end times are documented and match the billingVA-1 · checklist item 3	The note states the service start and end times, and they match the billed times to the minute. A child's arrival and departure are not service times.	Chapter IV	Both
Required progress-note elements are presentVA-2 · items 1, 2, 8	Service name, date, setting, start and end times, and the rendering staff signature with credentials and date, each with real content.	Chapter IV	AI
Signed within one business day of the serviceVA-3 · item 9	Flags a note signed more than four calendar days after the session, late under any reading of one business day.	Chapter IV	Deterministic
Activities, response, and progress on each objectiveVA-4 · items 5 to 7	The activities, the child's response, and performance on each objective addressed, for every code.	Appendix D	AI
No non-billable time inside the billed windowVA-5 · item 4	Meals, naps and waiting, transport, recreation, educational instruction, childcare, and documentation without the child. A routine with an ABA technique named passes.	Chapter IV; BUL-1225	AI
Group notes state the number of participants, at most 8VA-6 · item 10	97154, 97157, 97158: participant count stated and between 2 and 8.	Chapter IV	AI
97154 documents licensed behavior analyst oversight on siteVA-7 · item 10	A licensed behavior analyst on site overseeing the group.	Appendix D	AI
No 97153 and 97154 billed in a school settingVA-8 · item 2	Fails 97153 or 97154 billed with place of service 03.	Appendix D	Deterministic
97156 has the child present or a clinical reason, and targets the child's goalsVA-9 · item 10	Child present or a clinical reason for absence, with training on the child's goals.	Appendix D	AI
97155 is tied to the child, not staff-only supervisionVA-10 · Supervision	Direction or protocol work for the child; staff-only supervision fails.	Appendix D; DMAS ABA FAQ	AI
0362T and 0373T document the full team and are in personVA-11 · item 10	The four team elements, and not billed as telehealth.	Appendix D; Telehealth Supplement	AI

Every failure ships with QA guidance for that program code: an educational email, numbered action steps, and a QA email pre-filled with the date of service and a link to the note. Each reviewer action is written to a write-once audit log with seven-year retention, which is the record you hand a reviewer next time. And because the rules live in the library rather than in a template, an update from Penguin reaches every organization using the set. Billing Medicaid in more than one state? The rules library covers sixteen, including North Carolina and Pennsylvania.

Maintained by Penguin

We watch DMAS so the rules never go stale

DMAS has revised the manual, its appendix, and its telehealth supplement since July 2025, with a budget act and a proposed appendix still in motion. The Virginia set is tied to those documents, not to a template written once. Here is how it stays current, and what each change so far did to the set.

Watch

The DMAS Mental Health Services Manual (Chapter IV and Appendix D) and its revision dates, the DMAS bulletin series, the Telehealth Services Supplement, Virginia Town Hall guidance-document postings, and the Appropriation Act provisions awaiting CMS approval.

Update

We rewrite the affected rule, cite the document that changed it, and date the review. The set shows its sources and review date in the library, so you can see it is current without asking us.

Re-run

An updated rule runs in the next scheduled validation and on demand against notes you have already reviewed, so a changed requirement shows you exactly which past notes it touches.

Jul 17, 2025
Appendix D revised
The ABA appendix to the Mental Health Services Manual: what every note describes, the group, 97156, 97155, and 0362T/0373T content, and the school-setting limit.
LibraryVA-4, VA-6 through VA-11 cite this appendix.
Oct 15, 2025
Service authorization moves to units per CPT code
DMAS authorizes ABA in units per CPT code from this date.
Dec 2025
BUL-1225, ABA policy and regulatory clarifications
Payments for services by unqualified technicians and for non-covered time will be retracted. The bulletin restates the non-covered list.
LibraryVA-5 cites this bulletin alongside Chapter IV.
Jan 5, 2026
Telehealth Services Supplement revised
Telehealth uses place of service 02 or 10 with modifier GT. 0362T and 0373T are never delivered by telehealth.
LibraryVA-11 cites the supplement for the in-person requirement.
Jul 2026
DMAS bulletins on the 2026 Appropriation Act
The Act adds a 20-hour weekly cap (more under EPSDT review) and an autism diagnosis requirement, both awaiting CMS approval, and directs DMAS and the MCOs to review ABA payments before and after payment. DMAS says current processes stay in place until CMS approves.
Oct 2, 2026
Chapter IV revised
The progress-note elements and the one-business-day deadline, as this page quotes them.
LibraryVA-1, VA-2, VA-3, VA-5, and VA-6 cite this chapter.
Oct 12, 2026
Virginia set reviewed
Checked against Chapter IV as revised October 2, 2026, Appendix D as revised July 17, 2025, BUL-1225, the Telehealth Services Supplement, and the DMAS ABA FAQ. Current.
Watching
The 20-hour cap, the diagnosis requirement, and the proposed Appendix D
The cap and diagnosis requirement take effect when CMS approves them. A proposed Appendix D revision (Town Hall guidance document 8724) adds both, leaves the documentation and billing sections unchanged, takes comments through October 21, 2026, and has a planned effective date of October 22, 2026. When either lands, the set is updated and every organization using it gets the change.

Next step

Run a month of Virginia notes through Penguin

Bring one month of 97153 and 97155 notes. We add the Virginia set from the rules library, run it, show every finding beside the DMAS requirement it maps to, and hand your QA lead the fix for each one. Or get a demo account and click through Penguin on your own time first.

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This page summarizes public documents for ABA providers in Virginia and is not legal or billing advice. Requirements change; everything here, and the Virginia Medicaid ABA set in the Penguin Health rules library, was reviewed against the sources below on October 12, 2026. When a source changes, the set is updated and the review date moves with it. The example note, its client, staff, and data are fictional. CPT is a registered trademark of the American Medical Association.

DMAS Mental Health Services Manual, Chapter IV, revised October 2, 2026 (progress-note elements, the one-business-day deadline, non-billable time, group participant counts)
DMAS Mental Health Services Manual, Appendix D, Applied Behavior Analysis, revised July 17, 2025 (what every note describes, school setting, 97154, 97155, 97156, 0362T and 0373T)
DMAS Telehealth Services Supplement, revised January 5, 2026 (place of service 02 and 10 with modifier GT; 0362T and 0373T never by telehealth)
DMAS bulletin BUL-1225, ABA policy and regulatory clarifications, December 2025 (retraction of payments for unqualified technicians and non-covered time)
DMAS service authorization update, ABA, effective October 15, 2025 (units authorized per CPT code)
DMAS ABA frequently asked questions (97155 and supervision of staff)
Proposed Appendix D revision, Virginia Town Hall guidance document 8724 (diagnosis and 20-hour rules; comments through October 21, 2026; planned effective October 22, 2026)
Board of Medicine regulation 18VAC85-150-120 (one hour of live supervision every four weeks), as cited by DMAS