Community Health Choice (CHC) — the nonprofit Houston plan launched in 1997 by Harris Health System, serving STAR (Harris and Jefferson counties), STAR+PLUS, CHIP, and Marketplace lines — is one of the few Texas MCOs to publish its own dedicated ABA clinical document: a "Medical Review Guideline: Applied Behavioral Analysis (ABA) Services," newly adopted by its Medical Care Management Committee in June 2026. Read closely, it is substantially a TMPPM restatement — same diagnoser list, 3-year recency rule, 8-hour daily cap — but CHC layers its own UM machinery on top: named frequency tiers, an explicit 85%-attendance threshold on extension requests, and a named list of excluded, non-ABA interventions. CHIP is excluded from the benefit, as it is statewide.
CHC's guideline names the Texas Medicaid Provider Procedures Manual, Children's Services Handbook §2 Autism Services, as its governing authority and states it "represents the minimum requirements to determine medical necessity for ABA services." It lists 97151, 97153, 97154, 97155, 97156, and 97158 explicitly (0362T and 99366 are not mentioned in CHC's own document — rely on the TMPPM baseline for those two codes); maps its own credentialing terms to the state's (BCBA = LBA, BCaBA = LaBA, BT = behavior technician requiring RBT/BCAT/ABAT certification); and requires the evaluation PA to bundle a signed prescriber referral with both the Texas Standard Prior Authorization Form (TSPA) and the state's CCP Prior Authorization Request Form — two forms, not one, for the initial 97151 request. The 6-hour/24-unit evaluation cap and 3-year diagnosis recency rule both match the statewide baseline.[1][5]
One inconsistency worth flagging for UM before your first STAR+PLUS submission: the guideline's own "Applies To" checkboxes mark STAR and Marketplace, but leave STAR+PLUS unchecked — even though its narrative text elsewhere discusses "Medicaid members" broadly. CHC's own STAR+PLUS service-area document (below) also omits Jefferson County. Confirm STAR+PLUS applicability directly with CHC's UM department rather than assuming either way.[1][5]
CHC's 90-day extension and 180-day recertification requests both require an attendance log for the child and the parent/caregiver, plus a progress summary signed by the BCBA (LBA) and the parent — and CHC states members/caregivers are "expected to attend at least 85% of scheduled sessions"; falling below that threshold requires the ABA therapist to document why and what corrective measures were taken. Build attendance tracking into practice workflow from day one at CHC, not just at the recert deadline. The guideline also names specific interventions it does not consider ABA and will not authorize under this benefit — DIR/Floortime, TEACCH, and RDI are called out explicitly — and excludes ABA delivered as school-setting shadowing, para-professional, or companion services, along with goals limited to academic content or "performative social norms" not tied to health or safety.[1]
CHC's STAR quick reference guide confirms both target counties — Harris and Jefferson — are served under STAR. Its STAR+PLUS quick reference guide, however, lists only Harris (and eight other counties) — Jefferson does not appear on the STAR+PLUS list, consistent with the "Applies To" gap noted above. CHIP is excluded from ABA entirely, per CHC's own HHS Provider Manual ("CHIP Exclusions from Covered Services: Applied Behavior Analysis (ABA) Therapy"). PA requests submit through the secure provider portal or by fax — 713.295.2283 or 1.844.899.2495 for general STAR authorizations, with a separate behavioral-health outpatient fax at 713.576.0931 (inpatient 713.576.0932). CHC also accepts its own "Preferred Prior Authorization Form" for non-ABA requests, but the ABA guideline specifically calls for the TSPA + CCP form combination.[2][3][4]
Follows the Texas Medicaid rule — Community Health Choice'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).[5][8]
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 Health Choice does not publish whether its ABA network is open, so ask its provider relations team.[5][8]
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.[11][8][12]
Community Health Choice’s March 2026 manual: "All claims must be submitted within 95 days from the date of service. Claims not filed within 95 days from the date of service may not be considered for reimbursement."[11][8][12]
The questions that decide whether a family can start with Community Health Choice, and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the Texas Medicaid (TMPPM) rule: birth through 20 years of age on the date of service, with eligibility ending the day of the 21st birthday. CHIP members are excluded from the ABA benefit.[5][1]
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. CHC's own guideline carries the same 3-year rule.[1][5]
Follows the Texas Medicaid (TMPPM) rule, restated in Community Health Choice's own ABA Medical Review Guideline (adopted 6/2026), which names the TMPPM Children's Services Handbook §2 as its governing authority and carries the same diagnoser list.[1][5]
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.[5][1]
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.[5][1][7]
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.[5][1]
"Routine - Within three business days from the receipt of a request for a UM determination"; "Urgent - As soon as possible based on the clinical situation, but no later than one business day"; post-hospitalization or life-threatening conditions within one hour. Lack of information: Community requests the missing documentation within three business days of receipt; if it is not in by the end of the third business day the request goes to the Medical Director "no later than the seventh business day," and "Community will make a decision no later than the tenth business day after the request received date." ABA-specific windows come from Community's ABA guideline: initial treatment is authorized for 90 days and may be extended another 90 on submission of the attendance log (85% attendance expected), re-evaluations need no PA and "may occur as early as 60 days prior to the end of the current authorization period," and continuation runs in 180-day periods with the CCP form signed by the ordering practitioner.[12][1][13]
"Community Health Choice is the payer of last resort when other insurance is in effect." "Providers must submit claims to other health insurers for consideration prior to billing Community Health Choice. A copy of the other health insurer's EOB/EOP or rejection letter should be submitted with the claim," and a claim for a member with known other coverage is denied and redirected to that carrier; coverage discovered after payment is recovered post-payment. The manual states only the general 95-days-from-date-of-service filing limit and does not say whether Community's ABA PA is still needed when it pays second — request it.[12][14]
Coverage decides whether Community Health Choice 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.[5][1][6]
Follows the Texas Medicaid (TMPPM) rule: concurrent billing is prohibited — Texas Medicaid will not reimburse multiple ABA providers during one session with the child when more than one provider is present. The single exception is when the family and the child receive separate services and the child is not present in the family session. Total authorized hours may be requested under either 97153 or 97155 and billed as the code matching the service actually delivered — not both for the same clock time with the child present.[5][1]
Follows the Texas Medicaid (TMPPM) rule: direct treatment is capped at 8 hours (32 units) per day combined across 97153, 97154, 97155 and 97158; 97151 is capped at 6 hours (24 units) per evaluation and per re-evaluation; group treatment runs 2 to 8 children. TMPPM: “If services billed exceed the limitations outlined in this section, the claim will be denied, and may be appealed,” so the cap is a claim edit as well as an authorization limit. Authorization periods are two consecutive 90-day terms then recertifications of up to 180 days.[5][1]
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. CHC adds its own: 90-day extension and 180-day recertification requests each require an attendance log for the child and the parent/caregiver plus a progress summary signed by the BCBA (LBA) and by the parent, and members/caregivers are expected to attend at least 85% of scheduled sessions — below that the ABA therapist must document why and what corrective measures were taken.[1][5]
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. CHC also excludes ABA delivered as school-setting shadowing, para-professional or companion services, and goals limited to academic content or performative social norms not tied to health or safety. Its guideline separately names DIR/Floortime, TEACCH and RDI as non-ABA interventions it will not authorize under this benefit.[1][5]
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. CHC maps its credentialing terms onto the state's: BCBA = LBA, BCaBA = LaBA, and behavior technicians must hold RBT, BCAT or ABAT certification.[1][5]
Yes — the Texas Medicaid Autism Services benefit under CHC's own ABA Medical Review Guideline (adopted June 2026), which restates TMPPM criteria for STAR members in Harris and Jefferson counties. CHIP is excluded.
CHC layers its own UM machinery on the TMPPM baseline: named frequency tiers, an 85%-attendance requirement on extension and recertification requests, and an explicit list of excluded non-ABA interventions (DIR/Floortime, TEACCH, RDI).
Both the Texas Standard Prior Authorization Form (TSPA) and the state's CCP Prior Authorization Request Form, plus a signed prescriber referral — CHC's guideline requires the combination, not either form alone.
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 Health Choice’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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