Community First Health Plans — the San Antonio-based plan serving STAR, STAR Kids, and CHIP in the Bexar service delivery area — administers the state ABA benefit as a straight TMPPM pass-through, and it publishes one of the clearest MCO billing references for Texas ABA anywhere: its Autism Services Billing Guidelines page lays out the code list, the HO/HN/HM modifier crosswalk, unit caps, and the concurrent-billing rules in plain tables. Even practices that never bill Community First bookmark it as an onboarding reference for the Texas modifier system.
Community First's published guidelines make the state's billing mechanics concrete: 97151 "is not reimbursable unless evaluation was submitted for authorization of payment," capped at 24 units per period; treatment codes 97153, 97154, 97155, 97156, and 97158 plus team-meeting code 99366 are all PA-gated; direct treatment caps at 8 hours / 32 units per day combined; and the credential modifiers (HO = LBA, HN = LaBA, HM = behavior technician) map exactly to the TMPPM. The page also spells out the edges that generate denials elsewhere: no separate pre/post-evaluation billing beyond 97151, telehealth prohibited for BT/LaBA-delivered direct treatment, and concurrent billing prohibited unless the family service is delivered without the child present.[1]
The clinical rulebook is the state's: F84.0 diagnosis mandatory, ages 0 through 20, the TMPPM's PA cadence, and rates referencing 1 TAC § 355 and the Texas Medicaid fee schedule (no plan-specific rates published). Authorizations run through the Community First provider portal. Because the plan is a TMPPM digest rather than a second rulebook, a practice that has its state-baseline package tight — referral, recency-checked diagnosis, per-code units within caps — should find Community First one of the more predictable Texas submissions.[1][2]
Follows the Texas Medicaid rule — Community First's own provider documents that we checked (October 2026) set no change-of-provider rule of their own. A family that moves to a new ABA provider outside the current group needs a new authorization request with all the documentation of an initial evaluation, plus a change-of-therapy-provider letter signed by the responsible adult giving the date therapy ended (or the last date of service) and the names of both providers (TMPPM § 2.3.9). A move to another provider within the same group keeps the same evaluation, plan of care and authorization period. If the child changes health plans, "Health plan prior authorizations do not automatically transfer," but the new MCO must continue an existing authorization it is told about, at the same amount, duration and scope, until the earliest of 90 days, the end of the authorization, or its own new decision (Managed Care Handbook § 2.8).[2][5]
Joining the network: a provider must be enrolled in Texas Medicaid before an MCO can enroll it; "Individual MCOs and DMOs have their own guidelines for contracting providers," and Medicaid enrollment "does not guarantee that an MCO or DMO will contract enroll or credential a particular provider." All Medicaid MCOs credential through the Texas Association of Health Plans' contracted credentialing verification organization (Handbook § 2.2.1). Community First does not publish whether its ABA network is open, so ask its provider relations team.[2][5]
HHSC sets the claim clocks for every Texas Medicaid MCO in its Uniform Managed Care Claims Manual: a provider must file a claim with the MCO "within 95 Days from the date of service," and the MCO must deny a claim it does not receive in that window unless an exception applies (wrong plan, other insurance, newborns, newly enrolled providers). The MCO must tell the provider it "has 120 Days from the date of disposition to appeal the Claim," and must adjudicate an appealed claim within 30 days. Its performance standard is to adjudicate 98 percent of clean claims within 30 days of receipt and 99 percent within 90 days, with every claim finalized within 24 months of the date of service. When another insurer is billed first, the claim “must be refiled and received by the MCO within 95 Days from the date of disposition by the other insurance resource.” HHSC sets no weekly submission cutoff or check-run day; each MCO runs its own payment cycle. The TMPPM Managed Care Handbook repeats the 95-day rule and sends appeals to the MCO first, then to HHSC as a complaint.[7][5][8]
Community First’s STAR manual: "Providers are required to submit claims to Community First 95 days from the date of service. Claims received after the filing date will be denied payment."[7][5][8]
The questions that decide whether a family can start with Community First Health Plans, and what they have to bring. Each maps onto something intake should ask on the first call.
Ages 0 through 20, per Community First's own published Autism Services Billing Guidelines, matching the statewide THSteps-CCP rule.[1][2]
Follows the Texas Medicaid (TMPPM) rule: the ASD diagnosis must be made or reconfirmed within 3 years of initiation or recertification; past 3 years a comprehensive re-evaluation of ASD symptom severity levels per DSM criteria is required first.[2][1]
Follows the Texas Medicaid (TMPPM) rule: a developmental pediatrician, neurologist, psychiatrist, licensed psychologist, or an interdisciplinary diagnostic team (a physician, PA or NP in consultation with qualified child specialists with autism expertise).[2][1]
Follows the Texas Medicaid (TMPPM) rule: a reliable, valid, standardized diagnostic assessment tool or combination of tools — the manual names the ADOS, ADI-R and CARS as examples. Screening instruments alone (STAT, M-CHAT-R) do not substitute. Community First separately states that an F84.0 diagnosis is mandatory.[1][2]
Follows the Texas Medicaid (TMPPM) rule: a signed, dated prescriber referral for the evaluation, signed within 60 calendar days before or on the anticipated evaluation date; and for treatment a signed, dated referral from a physician or allowed practitioner (MD/DO, PA, NP, or CNS with delegated authority) stating frequency and duration, signed on or before the service start date and no more than 3 months old. Since 4/1/2025 the prescriber signature is no longer required on the CCP PA form for the 90-day extension.[2][1][4]
Follows the Texas Medicaid (TMPPM) rule: synchronous audio-visual only, modifier 95, on 97151, 97155, 97156, 97158 and 99366. One-on-one direct treatment delivered to the child by a behavior technician or LaBA must be in person — telehealth is prohibited for BT/LaBA-delivered direct service.[2][1]
Community First's STAR manual publishes no decision clock of its own, so the Texas rule governs: a Medicaid MCO must decide a nonhospitalized PA "within three business days after the organization receives the request" (Tex. Gov't Code § 540.0303), with the 1 TAC § 353.425 process for incomplete requests (written notice of what is missing within 3 business days; final decision within 3 business days after it arrives). What the manual adds: a pended request is worked with the provider and, if the information never arrives, "the services will be denied … for lack of requested information"; denials are communicated "by phone and letter … within 48 hours"; and "Pre-authorizations are generally valid for 30 days from the date issued; this timeframe may be extended based on the type of request," with "administrative denial of the claim" for services started without one. No ABA reauthorization lead time is published.[8][9][10]
"In situations where a STAR Member has other insurance, the other insurance carrier will be the primary payor. Providers must bill the third-party insurance first and then attach a copy of the Explanation of Payment (EOP) statement … Providers must file claims to Community First within 95 days of the third-party insurance EOP." Community First "will act as the payor of last resort" and "will deny payment for claims that do not include proof of prior filing with the STAR Member's third-party insurance." The manual does not say whether Community First's own ABA PA is still needed when it pays second — request it.[8][11]
Coverage decides whether Community First Health Plans pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Follows the Texas Medicaid (TMPPM) rule: the manual sets no numeric ratio of its own, requiring LBAs to directly supervise LaBAs and behavior technicians in accordance with Texas licensure and deferring to the certifying body's minimums — for RBT-credentialed staff the BACB floor of supervision on at least 5% of service hours each month with two face-to-face contacts. Only direct supervision, where the LBA observes the LaBA or BT with the child, is reimbursable (under 97155); indirect supervision is unpaid.[2][1][3]
Community First's own guidelines restate the state rule: concurrent billing is prohibited unless the family service is delivered without the child present. The page also bars separate pre- or post-evaluation billing beyond 97151.[1][2]
Community First publishes the state caps directly: direct treatment is limited to 8 hours / 32 units per day combined across 97153, 97154, 97155 and 97158, and 97151 is capped at 24 units per period and is not reimbursable unless the evaluation was submitted for authorization.[1][2]
Follows the Texas Medicaid (TMPPM) rule: rendering ABA providers must sign each entry with full signature and credentials, with additional supervisory signatures per state licensure. Treatment notes carry the child's name, date of service, start and stop times, goals addressed, progress and a summary of interventions; 97155/97158 notes add protocol-modification decision points. The 97151 evaluation and the 90-day progress summary each need a dated signature from the LBA and from the parent or caregiver.[2][1]
Follows the Texas Medicaid (TMPPM) rule: home, clinic, office and community settings are payable. In schools, services delivered by a behavior technician as a shadow, an aide, or as general support are excluded; school personnel participating to coordinate care are not counted as duplicate providers, and interdisciplinary team meetings bill under 99366 against an ABA PA. BT and LaBA direct treatment must be in person in every setting.[2][1]
Follows the Texas Medicaid (TMPPM) rule: only the LBA enrolls in Texas Medicaid and bills. LaBAs and behavior technicians may not enroll — their services go out under the supervising LBA's NPI with the credential modifier identifying who rendered (HO = LBA, HN = LaBA, HM = behavior technician; 97151 takes HO only, 97155/97156/97158 take HO or HN). The LBA must directly employ or contract with every LaBA and BT on the team. Community First publishes the crosswalk explicitly: HO = LBA, HN = LaBA, HM = behavior technician.[1][2]
Yes — the Texas Medicaid Autism Services benefit in the Bexar service area, on TMPPM criteria: F84.0 diagnosis, ages 0–20, PA on evaluation and all treatment codes, 8-hour daily cap.
Yes — the plan's billing guidelines state 97151 is not reimbursable unless the evaluation was submitted for authorization, capped at 24 units per period.
Its Autism Services Billing Guidelines page is one of the clearest public crosswalks of the Texas ABA codes, HO/HN/HM modifiers, and unit caps — a useful TMPPM digest even for other plans' cases.
A new ABA provider outside the current group must file a new authorization with initial-evaluation documentation and a change-of-provider letter signed by the responsible adult (TMPPM § 2.3.9). A new health plan must continue an existing authorization for up to 90 days, or until it ends or the new plan decides.
It does not publish an open or closed status. Enroll in Texas Medicaid first, then apply to the plan; Medicaid enrollment does not guarantee an MCO contract. Ask provider relations.
Ninety-five days from the date of service. HHSC’s Uniform Managed Care Claims Manual sets it for every Texas Medicaid MCO, and Community First’s own manual states the same deadline. Claim appeals get 120 days from the disposition date.
HHSC requires every Texas Medicaid MCO to adjudicate 98 percent of clean claims within 30 days of receipt and 99 percent within 90 days.
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.
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