---
title: Blue Cross and Blue Shield of New Mexico ABA coverage (Turquoise Care MCO).
url: "https://carelu.com/payers/blue-cross-blue-shield-new-mexico"
markdown_url: "https://carelu.com/payers/blue-cross-blue-shield-new-mexico.md"
state: NM (New Mexico)
payer: Blue Cross and Blue Shield of New Mexico (Turquoise Care)
kind: Medicaid managed care plan (MCO)
parent_program: New Mexico Medicaid (Turquoise Care)
description: "How BCBSNM administers New Mexico Medicaid ABA under Turquoise Care — the shared Behavioral Health Level of Care Guidelines deferring to NMAC 8.321.2, the ABA Clinical Service Request Form and its 2-week lead time, Availity submission, and line-staff requirements."
last_reviewed: October 2026
vob_data_updated: 2026-10-15
---

# Blue Cross and Blue Shield of New Mexico ABA coverage (Turquoise Care MCO).

_Payer Guide · BCBS of New Mexico · Last updated October 2026 · 9 primary sources_

> Shared state LOC criteria; ABA Clinical Service Request Form at least 2 weeks pre-start.

Blue Cross and Blue Shield of New Mexico administers the Turquoise Care ABA benefit on the state's criteria — the Behavioral Health Level of Care Guidelines it hosts are titled for all Turquoise Care MCOs and defer throughout to NMAC 8.321.2. BCBSNM's own artifacts are operational: a 5-page ABA Clinical Service Request Form (initial and concurrent) with a firm lead-time rule — it can go in up to 60 days prior to, and must arrive at least 2 weeks before, the requested treatment start date — plus a clinical payment and coding policy (CPCP011) governing billing edits. Timeline management, not clinical criteria, is the plan-specific work here.

This plan administers the **New Mexico Medicaid (Turquoise Care)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [New Mexico Medicaid (Turquoise Care) guide](https://carelu.com/payers/new-mexico-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: State baseline applies via the shared Turquoise Care LOC guidelines — no PA on 97151 per the state fee schedule; no separate BCBSNM Medicaid assessment rule published [1][4]
- **Prior auth for treatment**: Required — BCBSNM ABA Clinical Service Request Form (initial + concurrent), submitted up to 60 days before and at least 2 weeks before the treatment start date [2]
- **Autism diagnosis required?**: State rule — ASD dx within 3 years, or the documented at-risk-for-ASD pathway (NMAC 8.321.2.13) [6]

## At a glance

- **Plan type:** Turquoise Care MCO (BCBSNM, in-house behavioral health UM)
- **Clinical rules:** Shared Turquoise Care BH Level of Care Guidelines — defer to NMAC 8.321.2
- **Treatment request:** ABA Clinical Service Request Form, ≥2 weeks (up to 60 days) before start
- **Submission:** Availity (BCBSNM standard); the ABA form also goes by fax
- **Exclusions:** ABA for educational, vocational, respite, or custodial purposes
- **Rates:** Must pay at least the state FFS ABA fee schedule (LOD #53)

## State criteria, BCBSNM paperwork

The clinical baseline is the state's: the shared Level of Care Guidelines' ABA Stage 3 section references NMAC 8.321.2 throughout, so eligibility (ASD or at-risk), the stage model, and the no-PA assessment front door match the New Mexico Medicaid guide. The BCBSNM layer is the ABA Clinical Service Request Form for treatment — 5 pages, initial and concurrent versions — with the lead-time rule that should drive your intake calendar: the form says it "can be submitted up to 60 days prior to the treatment request start date" and to "Submit forms at least two weeks before requested start date." Miss the window and the start date slips. One caution when using the form: its printed phone/fax numbers (800-851-7498, fax 877-361-7659) and its 36-month diagnostic-recency language come from the commercial/FEP context — for Turquoise Care members the state LOC criteria (3-year recency per NMAC) govern, so confirm current Medicaid routing in Availity rather than trusting the form's header. [1][2]

## Staffing, exclusions, and the adult-benefit citation trap

BCBSNM's line-staff (1:1 technician) requirements are concrete: 18 or older, HS diploma or GED, background check, 40 hours of ASD/evidence-based-practice training, and BCBA oversight of at least 5% of direct hours — worth checking against your tech roster before submitting. The member handbook excludes ABA for educational, vocational, respite, or custodial purposes, so frame goals clinically in the treatment plan. And one drafting tip for adult cases: the LOC guidelines describe ABA for members 12 months up to 21 years, while the adult expansion lives in state Supplement 24-13 — cite the supplement, not the LOC document, when requesting adult authorizations. [1][5]

## Does BCBSNM (Turquoise Care) require treatment-plan goals in a set format, such as by DSM-5 criteria?

BCBSNM's ABA Clinical Service Request Form has its own goal layout. The "Member Treatment Plan" section asks for counts of skill-acquisition goals ("focusing on the development of spontaneous social communications, adaptive skills and appropriate behaviors"): new goals, goals carried over, goals on hold, and goals mastered in the previous authorization period. It also asks for current maladaptive behaviors with frequencies, assessment-instrument scores, and a measurable fade/transition and discharge plan. The form does not organize goals by DSM-5 criteria. [2][5][8]

The state standard applies to every Turquoise Care MCO. MAD Supplement 24-13 (9/17/2024) is the state's ABA guidance. After the 97151 assessment, the BA "must select goals for intervention and determine how these goals will be measured." Goal development covers a list of skill areas: "adaptive and self-care skills, attending and social referencing, cognitive functioning, community participation, coping and tolerance skills, emotional development, family relationships, language and communication, play and leisure skills, pre-academic skills, self-advocacy and independence, self-management, social relationships, and vocational skills." Baseline performance should be measured and "treatment goals should be developed for each critical domain and specified in terms that are observable and measurable" (3.14.3). Targets are prioritized by risk to safety, independence and health (3.14.2). The required treatment-plan elements (3.19.1) include a Family Set goal, baseline data on each target behavior/symptom, interventions with approximate units per target, goals with objective progress measures for the authorization period, and measurable discharge criteria. The domains are developmental skill areas, not DSM-5 criteria. DSM or ICD is used for eligibility, and the ASD support level (Level 2/3) informs dosage. 8.321.2.13 NMAC makes the BA responsible for "selection and measurement of goals." [2][5][8]

## Does BCBSNM (Turquoise Care) require parent training, and how many hours?

BCBSNM's form makes parent hours an explicit entry. Its "Parent Involvement" section reads "The parent/caregiver is expected to participate in training sessions ____ hours per week," followed by a table of "Measurable Parent Training Goals" with baseline, current progress and expected mastery date. BCBSNM's coding policy CPCP011 (effective 3/20/2026) adds: "parent education is authorized per week for the authorization period (typically 26 weeks) for a total of 26 hours. Requests greater than one hour per week should include supporting clinical documentation." CPCP011 applies "unless otherwise provided in the member's benefit." For Turquoise Care members, the state guidance below (no PA for 97156, up to 32 units per week) is the governing Medicaid rule. Confirm with BCBSNM how the two interact on a Medicaid authorization. [2][3][5]

The state standard, which applies to every Turquoise Care MCO: Supplement 24-13 says "Every Treatment Plan must include ample units of ABA Stage 3 97156 and 97157" (3.17.1(C)). Every plan must "Include a goal of working with the Family Set" and be "Family Set-focused... with a focus on family engagement, training, and support" (3.19.1). If family members cannot attend in person, the BA must offer alternatives such as telemedicine. 97156 needs no prior authorization, with a "Maximum number of units per 97156 for entire Family Set: thirty-two 15-minute units per week," billed once for the whole Family Set. The CMS Medicaid MUE limits 97156 to sixteen 15-minute units per day, and 97157 (also no PA) to "up to sixteen 15-minute units or four hours per day." Adult recipients may receive up to thirty-two units of either code when medically warranted. Family Sets may start 97156/97157 once the recipient's assessment is scheduled. If the family cannot attend at the agreed level, "inadequate family participation" is a listed reason for poor response, and the BA must offer alternatives. [2][3][5]

## What are BCBSNM Turquoise Care’s claim filing, taxonomy and appeal rules?

BCBSNM’s Medicaid manual (July 2026): participating providers "are expected to submit claims within 90 days of the date of service," and "Services billed beyond 180 days from the date of service are not eligible for reimbursement." Claims must carry the "Taxonomy code for the billing, rendering and attending NPI submitted on the claim," matching the provider’s HCA enrollment, plus NPIs for billing, ordering, referring and rendering providers "as required." BCBSNM aims to pay clean claims within the program’s time frames and asks that duplicates not be sent before the 30-day claims payment period. Provider grievances or appeals are resolved within 30 calendar days, extendable by 14. [10]

## Intake gates

The questions that decide whether a family can start with Blue Cross and Blue Shield of New Mexico (Turquoise Care), and what they have to bring.

- **Age limit**: Follows the New Mexico Medicaid rule: NMAC 8.321.2.13 imposes no upper age limit and covers Medicaid-enrolled adults, with under-21s served through EPSDT and the at-risk pathway bounded at 12–36 months. One drafting trap: the shared Turquoise Care Level of Care Guidelines (July 2024) describe ABA for members 12 months up to 21 years, because the adult expansion arrived later in NMAC 8.321.2.13 (12/10/2024) and Supplement 24-13 — cite those, not the LOC document, on an adult request. [6][1][4]
- **Diagnosis recency**: Follows the New Mexico Medicaid rule: a presumptive ASD diagnosis from a licensed practitioner within scope must have been received within three years of the referral to stage two or three; a recipient who already carries an ASD diagnosis needs no re-evaluation but does need an ISP and a medical-necessity determination; and the at-risk pathway requires no diagnosis at all. [6][1][4]
- **Who may diagnose**: Follows the New Mexico Medicaid rule: an approved Autism Evaluation Provider confirms the presence of or risk for ASD through a comprehensive diagnostic, targeted or ASD risk evaluation, or the recipient is referred on a presumptive diagnosis from any licensed practitioner whose scope of practice allows an ASD diagnosis, received within three years of referral. [6][1][4]
- **Referral required?**: Follows the New Mexico Medicaid rule for the clinical gate — Autism Evaluation Provider evaluation, ISP, and referral to an approved ABA provider agency. BCBSNM’s own layer is a lead-time rule on the treatment request: the ABA Clinical Service Request Form (initial and concurrent versions) "can be submitted up to 60 days prior to the treatment request start date," and the form says "Submit forms at least two weeks before requested start date." One caution when using the form: its printed phone and fax numbers and its 36-month diagnostic-recency language come from the commercial and FEP context — for Turquoise Care members the state criteria (three-year recency per NMAC) govern, so confirm current Medicaid routing in Availity. [6][1][4][2]
- **Telehealth**: Follows the state rule — BCBSNM's own ABA documents checked this run (the ABA Clinical Service Request Form and the shared Turquoise Care BH Level of Care Guidelines) publish no ABA-specific telehealth policy, so the HCA rule applies. MAD Supplement 24-13 (section 3.2.1) says MAD "allows and encourages the utilization of telemedicine to deliver MAD ABA services," to bring home- and community-based ABA to rural and frontier areas, and points to 8.310.2 NMAC for the requirements: a HIPAA-compliant system with interactive audio and video in real time, with coverage "determined in a manner consistent with medicaid coverage for health care services provided through in person consultation." In-state BCBAs, BCaBAs, RBTs, BCATs and non-certified technicians need no telemedicine license; an out-of-state MD/DO diagnostician does. Supervision is expressly remote-capable: 97155 may be delivered through telemedicine when the BA directs the technician and the recipient by observing behavior or troubleshooting protocols (not when the BA joins in person), the recipient must be present, and the one-hour-per-20-hours minimum of 97155 still applies. Where an agency documents annually to the MCO or TPA that its transmission provider cannot support real-time video, store-and-forward can deliver up to 100% of direct 97155, with 30 to 60 extra minutes of 97155 added, but not for a non-certified technician. The assessment can be partly remote too: "A BA/Mentored BA bills Indirect 97151 when conducting interviews or discussing the Treatment Plan or Protocols with the Family Set delivered via telemedicine," and direct T1026 UD case supervision may happen onsite or be "delivered through telemedicine." The supplement names no POS code or modifier for ABA telemedicine, so confirm claim coding with the MCO or TPA. [5][7]
- **Prior-auth decision time**: BCBSNM’s Turquoise Care Provider Reference Manual: routine preauthorization “Decision – To be rendered within 7 calendar days from receipt of request for services”, provider notified within one working day of the decision; urgent/expedited “Decision and notification – Shall occur 24 hours after receipt of request”, with an automatic appeal on an expedited denial. Time frames “may be extended by BCBSNM to the extent allowed by law”. That sits inside its HCA contract (7 business days after complete documentation, 24-hour expedited, deemed granted if missed, and the most rigorous of that or 42 CFR 438.210(d)) — the manual’s 7 calendar days from receipt is the clock to plan against. Lead time: the ABA Clinical Service Request Form (initial and concurrent versions) says “Submit forms at least two weeks before requested start date” and that it “can be submitted up to 60 days prior to the treatment request start date”, so file each continuation between 60 days and two weeks before the current authorization ends. The form prints commercial/FEP phone and fax lines, so confirm Turquoise Care routing in Availity. [10][2][11][12]
- **Other insurance (who pays first)**: BCBSNM’s manual: “By law, the Medicaid program is the payer of last resort” — if the member has coverage “primary to Medicaid, submit a claim for payment to that plan first”. When BCBSNM is secondary, claims “must be submitted to BCBSNM within 180 days from the other insurance paid date” with the primary payer’s EOB attached, and “If the primary plan denies the claim due to the provider or member not following that plan’s prescribed procedures, including but not limited to, failure to obtain a prior authorization and untimely filing, payment will not be made” — get the commercial plan’s ABA authorization first. Its HCA contract adds that “Claims for EPSDT shall be paid at the time presented for payment by the Provider and the CONTRACTOR shall bill the responsible third party”; whether ABA is treated under that exception is not stated. The manual does not say whether BCBSNM’s own ABA prior authorization is required while it is secondary — confirm with BCBSNM UM before the first session. TRICARE pays ahead of Medicaid (10 U.S.C. 1079(i)(1) exempts title XIX plans). [10][11][13][14]
- **Diagnostic tools required** _(ask the plan)_: Follows the New Mexico Medicaid rule, which names none: NMAC 8.321.2.13 requires the diagnosis be made against the latest DSM or ICD and the at-risk criteria be measured by standardized assessments, without naming instruments. No plan-specific instrument list was found for this MCO either. [6][1][4]
  - Ask the plan: MAD Behavioral Health Policy and Billing Manual / Supplement 24-13 — hca.nm.gov blocked automated retrieval this cycle (CloudFront geo-block), so pull the MAD Behavioral Health Policy and Billing Manual and Supplement 24-13 from the HCA ABA provider page by hand, or ask the MAD ABA Manager.

## Delivery and billing rules

Coverage decides whether Blue Cross and Blue Shield of New Mexico (Turquoise Care) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: Follows the New Mexico Medicaid ratios (PA above two hours of case supervision or clinical management per 10 hours of intervention; the Supplement 24-13 97155 observation floor). CPCP011 adds the payment-side view, citing CASP 2024: 10–20% of direct hours in case supervision activities combining direct and indirect supervision, with direct supervision authorizable at a minimum of one hour per week when fewer than 10 hours of direct services are authorized — and indirect supervision treated as bundled practice expense, documented in the treatment plan but not separately reimbursable. BCBSNM’s line-staff requirements for 1:1 technicians are 18 or older, high-school diploma or GED, background check, 40 hours of ASD and evidence-based-practice training, and BCBA oversight of at least 5% of direct hours. [6][1][4][3][5]
- **Concurrent billing (97153 + 97155)**: BCBSNM’s ABA coding policy CPCP011 answers this where the state rule does not: ABA services are not reimbursable for more than one BCBA or qualified healthcare professional providing the same or similar services on the same dates of service — and the policy is explicit that this "does not refer to the technician(s) or direct service provider simultaneously rendering service with the BCBA or qualified healthcare professional." Billable supervision of a patient must be face-to-face and involves only one technician; there is no CPT code for indirect (patient not present) supervision or week-to-week treatment planning, which AMA treats as bundled practice expense. Co-treatment with a distinct service such as speech or occupational therapy is allowed where clinically indicated, documented in the treatment plan and billed with the appropriate modifier. [6][1][4][3]
- **Daily limits / MUEs**: CPCP011 supplies the ceilings the state rule omits. Providers are referred to the current CMS MUE table for the maximum units per member per date of service, with service units also limited by the authorization period, and any units beyond industry-standard coding guidelines must be justified in documentation. Named limits: treatment plans and evaluations inclusive of administration, scoring, interpretation and report write-up that exceed eight hours (32 units of 97151) may not be eligible for reimbursement; parent education is authorized at one hour per week for the authorization period, typically 26 weeks for a total of 26 hours, with more requiring supporting clinical documentation; group codes 97154 and 97158 require no fewer than 2 and no more than 8 members. Timed codes follow the 8-minute rule, and a direct treatment service performed for less than 8 minutes as the only modality that day is not reportable. [6][1][4][3]
- **Session-note signature**: CPCP011 sets a documentation bar stricter than most: substantiating documentation includes a parent or caregiver signature for each rendered service, carrying the service and code provided, the rendering provider’s name and signature, certification and credentials, the place of service, the date of service and the beginning and end times of the service; plus a written account, summary or note of the service rendered; and data points, which may be required immediately after the service and for audit. Session notes should reflect that both parties were present for the entire duration of the encounter where services are rendered under direct personal supervision. All treatment time, including beginning and ending time, must be recorded in the record with the note describing the specific procedure. [6][1][4][3]
- **Place of service**: Follows the New Mexico Medicaid rule on covered settings, with a BCBSNM claim-edit overlay: CPCP011 treats POS 10, 11 and 12 as the conventional settings, and programmes or services rendered in any other place of service — even by a licensed provider — need supporting documentation on file in the member record, including a rationale and description for the non-conventional POS code, available on request. The member handbook excludes ABA delivered for educational, vocational, respite or custodial purposes, which mirrors the state rule’s school-supplanting exclusion. [6][1][4][3]
- **Bill as provider**: Follows the New Mexico Medicaid enrolment rules, with CPCP011 governing who may appear on the claim. ABA is not reimbursable unless provided by a professional certified by the BACB as a behavior analyst, or licensed in their state as a Licensed Behavior Analyst or Licensed Psychologist. The provider who renders treatment week to week is the rendering provider and should bill; a provider who is not rendering protocol modification, parent education, assessment or report writing should not bill for services they did not personally provide. An unlicensed, non-network-credentialed or otherwise non-qualified provider cannot provide services and bill through another person’s NPI. A single modifier — HM, HN or HO — indicates the rendering provider’s level of education, training and certification when 97153 is submitted. [6][1][4][3]

## What intake should collect for Blue Cross and Blue Shield of New Mexico (Turquoise Care)

- **Realistic start date:** The request form must land at least 2 weeks (and no more than 60 days) before treatment starts — work backwards from the family's target.
- **Diagnosis or at-risk documentation:** State rule: ASD dx within 3 years of referral, or the at-risk pathway documentation — then the assessment books without PA.
- **Adult vs. child case:** Adult authorizations should cite Supplement 24-13, since the LOC guidelines only describe ages 12 months–21.
- **Tech roster compliance:** 18+, HS/GED, background check, 40 hrs training, ≥5% BCBA oversight — verify before naming line staff on the request.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How Blue Cross and Blue Shield of New Mexico (Turquoise Care) ABA benefits route and read on an eligibility check. Data last updated 2026-10-15.

### EDI routing

- **Payer ID (pVerify):** 00046 — pVerify 00046 = "BCBS of New Mexico" (Elig Y / Claim Y).
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** none (integrated Turquoise Care)
- **ABA rides on:** medical benefit — BH (incl. ABA) is administered within the integrated Turquoise Care plan (BCBSNM ABA policy CPCP011); no separate BH payer ID surfaced — ABA rides the BCBSNM Medicaid payer ID. Confirm at Turquoise Claims cutover.
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Not required (LOD #53 fee schedule: "Prior Auth: NO") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97152 | Yes | Not required (LOD #53 fee schedule: "Prior Auth: NO") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97153 | Yes | Required (LOD #53 fee schedule: "Prior Auth: YES") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97154 | Yes | Not required (LOD #53 fee schedule: "Prior Auth: NO") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97155 | Yes | Not required (LOD #53 fee schedule: "Prior Auth: NO") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97156 | Yes | Not required (LOD #53 fee schedule: "Prior Auth: NO") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97157 | Yes | Not required (LOD #53 fee schedule: "Prior Auth: NO") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97158 | Yes | Not required (LOD #53 fee schedule: "Prior Auth: NO") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 0362T | Yes | Not required (LOD #53 fee schedule: "Prior Auth: NO") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 0373T | Yes | Required (LOD #53 fee schedule: "Prior Auth: YES") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |

Code notes:

- **97151:** State baseline via the shared Turquoise Care Level of Care Guidelines (defer to NMAC 8.321.2). BCBSNM treatment requests use the ABA Clinical Service Request Form (≥2 weeks / within 30 days before start). Stage 2 BCBA assessment; done annually. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **97152, 97157, 0362T:** State baseline via the shared Turquoise Care Level of Care Guidelines (defer to NMAC 8.321.2). BCBSNM treatment requests use the ABA Clinical Service Request Form (≥2 weeks / within 30 days before start). Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **97153:** State baseline via the shared Turquoise Care Level of Care Guidelines (defer to NMAC 8.321.2). BCBSNM treatment requests use the ABA Clinical Service Request Form (≥2 weeks / within 30 days before start). Adaptive behavior treatment by protocol — the primary PA-gated code. State PA quirk (Supplement 24-13 §3.17.1(A)): comprehensive treatment averaging UNDER 20 hrs/week requires PA regardless. Also PA-gated: >2 hrs T1026 UC/UD supervision per 10 hrs Stage 3. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **97154:** State baseline via the shared Turquoise Care Level of Care Guidelines (defer to NMAC 8.321.2). BCBSNM treatment requests use the ABA Clinical Service Request Form (≥2 weeks / within 30 days before start). Group adaptive behavior treatment; UA (group 2–4) / UB (group 5–8) size modifiers. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **97155:** State baseline via the shared Turquoise Care Level of Care Guidelines (defer to NMAC 8.321.2). BCBSNM treatment requests use the ABA Clinical Service Request Form (≥2 weeks / within 30 days before start). Protocol modification / supervision; ≥1 hr per 20 hrs of Stage 3 (97153/97154/97156) required with the recipient present. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **97156:** State baseline via the shared Turquoise Care Level of Care Guidelines (defer to NMAC 8.321.2). BCBSNM treatment requests use the ABA Clinical Service Request Form (≥2 weeks / within 30 days before start). Family adaptive behavior treatment guidance. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **97158:** State baseline via the shared Turquoise Care Level of Care Guidelines (defer to NMAC 8.321.2). BCBSNM treatment requests use the ABA Clinical Service Request Form (≥2 weeks / within 30 days before start). Group family guidance; UA/UB size modifiers. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **0373T:** State baseline via the shared Turquoise Care Level of Care Guidelines (defer to NMAC 8.321.2). BCBSNM treatment requests use the ABA Clinical Service Request Form (≥2 weeks / within 30 days before start). Extra-technician / intensifying protocol. State PA quirk (Supplement 24-13 §3.17.1(A)): comprehensive treatment averaging UNDER 20 hrs/week requires PA regardless. Also PA-gated: >2 hrs T1026 UC/UD supervision per 10 hrs Stage 3. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).

### Medicaid rates

Source: Not separately published by BCBSNM. Under LOD #53 the NM Medicaid FFS ABA fee schedule (see new-mexico-medicaid rates) is the ENFORCEABLE MINIMUM BCBSNM and its sub-vendors must pay, retroactive to 1/1/2025 — so the floor is verified even though BCBSNM's actual contracted/paid rate at or above it is not published. Effective 2025-01-01 (floor).

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | ≥ $112.65 (U3) / $130.94 (U5/U4) — LOD #53 floor | 15min | — |
| 97152 | ≥ $58.33 (U3) / $65.47 (U5/U4) — LOD #53 floor | 15min | — |
| 97153 | ≥ $19.85 (U1) / $23.35 (U9) / $32.31 (U3) — LOD #53 floor | 15min | — |
| 97154 | ≥ $11.43 (U1) / $18.59 (U3) — LOD #53 floor | 15min | — |
| 97155 | ≥ $39.69 (U3) / $55.55 (U5/U4) — LOD #53 floor | 15min | — |
| 97156 | ≥ $25.78 (U3) / $35.79 (U5/U4) — LOD #53 floor | 15min | — |
| 97157 | ≥ $51.59 (U3) / $71.43 (U5/U4) — LOD #53 floor | 15min | — |
| 97158 | ≥ $12.69 (U3) / $15.88 (U5/U4) — LOD #53 floor | 15min | — |
| 0362T | ≥ $112.29 (U3) / $130.94 (U5/U4) — LOD #53 floor | 15min | — |
| 0373T | ≥ $107.13 (U3) / $119.05 (U5/U4) — LOD #53 floor | 15min | — |

### Contacts

- **Benefits by phone:** Yes
- **Provider services phone:** 1-888-349-3706 — BCBSNM Medicaid (Turquoise Care) eligibility and benefits IVR / Provider Service Unit
- **Phone menu path:** Eligibility & Benefit IVR: 1-888-349-3706 (self-service eligibility/benefits lookup)
- **Hours:** IVR: Mon–Fri 5:00 a.m.–10:30 p.m. MT, Sat 5:00 a.m.–2:30 p.m. MT
- **Portal:** [Availity](https://www.availity.com)
- **Fax:** 888-530-9809 (Behavioral Health preauthorization — outpatient service requests only)

Questions to ask on a verification call:

- Confirm whether BCBSNM supports real-time 270/271 eligibility for Turquoise Care, or only batch.
- The BCBSNM ABA Clinical Service Request Form header prints 800-851-7498 / fax 877-361-7659 — please confirm the correct Turquoise Care (Medicaid) routing number, since that header is commercial/FEP.
- Is there a published per-code daily unit cap for ABA, or only the state's program-level hour ranges?
- Are ABA-specific telehealth POS codes or modifiers used for Turquoise Care billing?
- What is the current Availity/Change Healthcare payer ID for BCBSNM Medicaid claims?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.bcbsnm.com/docs/provider/nm/standards/cpcp/2026/cpcp011-3-20-2026.pdf (accessed 2026-07-23)
- https://downloads.conduent.com/content/usa/en/document/270-payer-guide-medicaid-5010.pdf (accessed 2026-07-23)
- https://downloads.conduent.com/content/usa/en/document/eligibility-gateway-companion-guide.pdf (accessed 2026-07-23)
- https://www.hca.nm.gov/wp-content/uploads/FInal-LOD-53-Applied-Behavioral-Analysis-ABA-Fee-Schedule-Rates.pdf (accessed 2026-07-23)
- https://www.hca.nm.gov/wp-content/uploads/24-13-Supplement-ABA-Guidance.pdf (accessed 2026-07-23)
- https://www.bcbsnm.com/docs/provider/nm/medicaid-prm.pdf (accessed 2026-07-23)

## Common questions

### Does BCBS of New Mexico cover ABA under Medicaid?

Yes — as a Turquoise Care MCO it administers the state ABA benefit on the shared Level of Care Guidelines, which defer to NMAC 8.321.2. The state front door applies: no PA on the assessment, treatment requested via BCBSNM's ABA Clinical Service Request Form.

### When do I submit the BCBSNM ABA request form?

Up to 60 days before, and at least two weeks before, the requested treatment start date, via Availity or fax. The form (Oct 2025) says it "can be submitted up to 60 days prior to the treatment request start date" and to "Submit forms at least two weeks before requested start date." Build that lead time into scheduling conversations with families.

### What does BCBSNM pay for ABA?

At least the state FFS fee schedule — LOD #53 makes the published ABA rates (e.g., $32.31 per 15-min 97153 unit for a BCBA) a contractual minimum for every Turquoise Care MCO and its sub-vendors.

### Do ABA technicians need RBT certification for BCBSNM (New Mexico Medicaid)?

Follows the state rule. Not at the start. New Mexico Medicaid lets a non-certified behavior technician render ABA if they are 18 or older, have a high-school diploma, pass the New Mexico criminal background registry check, complete 4 hours of ASD training and at least 20 of the 40 RBT/BCAT training hours before serving, and then hold an RBT or BCAT certificate within their first six continuous months. If they miss that deadline they must stop until certified.

### Can BCBA supervision (97155) be done by telehealth for BCBSNM members?

Yes, under the state rule in MAD Supplement 24-13: 97155 may be delivered by real-time telemedicine with the recipient present, and by store-and-forward only where the agency documents no real-time option.

### Does BCBSNM require ABA goals to be organized by DSM-5 criteria for Turquoise Care?

No. BCBSNM's request form counts skill-acquisition goals (social communication, adaptive skills, appropriate behaviors) by status and asks for maladaptive-behavior frequencies. The state standard (Supplement 24-13) wants measurable goals for each critical developmental domain.

### How many parent training hours does BCBSNM expect?

Its request form asks how many hours per week the caregiver will train, with measurable parent goals. CPCP011 defaults to one hour per week (26 hours per 26-week authorization) and asks for documentation above that. For Turquoise Care, the state guidance allows 97156 without PA up to 32 units per week, so confirm which applies.

### What is BCBSNM Turquoise Care’s timely filing limit?

Submit within 90 days of the date of service; anything billed beyond 180 days from service is not reimbursable.

### Does BCBSNM Turquoise Care require taxonomy on the claim?

Yes, for the billing, rendering and attending NPIs, and it must match the provider’s New Mexico HCA enrollment.

## Primary sources

1. [Turquoise Care BH Level of Care Guidelines (BCBSNM-hosted)](https://www.bcbsnm.com/turquoise-care/pdf/tc-bh-level-care-guidelines-nm.pdf)
2. [BCBSNM ABA Clinical Service Request Form](https://www.bcbsnm.com/docs/provider/nm/education/forms/aba-clinical-service-request.pdf)
3. [BCBSNM CPCP011 Applied Behavioral Analysis coding policy (2026)](https://www.bcbsnm.com/docs/provider/nm/standards/cpcp/2026/cpcp011-3-20-2026.pdf)
4. [Letter of Direction #53 — ABA Fee Schedule Rates (MCO rate floor)](https://www.hca.nm.gov/wp-content/uploads/FInal-LOD-53-Applied-Behavioral-Analysis-ABA-Fee-Schedule-Rates.pdf)
5. [MAD Supplement 24-13 — ABA Guidance (adult benefit)](https://www.hca.nm.gov/wp-content/uploads/24-13-Supplement-ABA-Guidance.pdf)
6. [NMAC 8.321.2.13 Applied Behavior Analysis (Cornell LII)](https://www.law.cornell.edu/regulations/new-mexico/N-M-Admin-Code-SS-8.321.2.13)
7. [8.310.2.12(M) NMAC — Telehealth services (srca.nm.gov, amended 1/1/2025)](https://www.srca.nm.gov/parts/title08/08.310.0002.html)
8. [8.321.2.13 NMAC — Applied Behavior Analysis (srca.nm.gov)](https://www.srca.nm.gov/parts/title08/08.321.0002.html)
9. [Blue Cross and Blue Shield of New Mexico — Provider News and Updates](https://www.bcbsnm.com/provider/education-reference/education/news)
10. [BCBSNM — Medicaid (Turquoise Care) section of the Provider Reference Manual (updated July 2026)](https://www.bcbsnm.com/docs/provider/nm/medicaid-prm.pdf)
11. [Turquoise Care Medicaid Managed Care Services Agreement — BCBSNM, Amendment 5 (signed 12/2025), §§ 4.5.19.8, 4.19.11](https://www.hca.nm.gov/wp-content/uploads/TCBCBS_24-630-8000-0029_CA5_Signed.pdf)
12. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes](https://www.ecfr.gov/current/title-42/section-438.210)
13. [8.302.3 NMAC — Third Party Liability Provider Responsibilities](https://www.srca.nm.gov/parts/title08/08.302.0003.html)
14. [10 U.S.C. 1079(i)(1) — TRICARE pays after other coverage except Medicaid](https://www.govinfo.gov/content/pkg/USCODE-2023-title10/html/USCODE-2023-title10-subtitleA-partII-chap55-sec1079.htm)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.