Cook Children's Health Plan — the pediatric-focused plan affiliated with Cook Children's Health Care System, serving STAR and STAR Kids across six North Texas counties (Wise, Denton, Parker, Tarrant, Hood, and Johnson) — publishes an unusually deep ABA provider-education footprint for a Texas MCO: a dedicated 123-page "Applied Behavior Analysis" training deck plus a separate acute-PA training covering ABA mechanics in detail. Read closely, it's a faithful restatement of TMPPM §2.3 rather than a distinct plan overlay — the value here is the clarity and depth of the restatement, not a different rulebook. We found no ABA process that differs between STAR and STAR Kids in the plan's own materials.
Cook Children's own training confirms the statewide code set with granular billing notes: 97151 (evaluation/re-evaluation) caps at 6 hours/24 units with a 30-day authorization window and takes the HO modifier only; 97153 and 97154 (direct and group treatment) take no required modifier (HO/HN/HM are informational); 97155, 97156, and 97158 require an HO or HN modifier; and 99366 (interdisciplinary team meetings) takes no modifier, is reimbursable only against an F84.0 autism diagnosis, is capped at twice per year, and requires at least three licensed professionals — one of them the LBA — meeting for a minimum of 30 minutes. Direct treatment caps at 8 hours/day combined across 97153, 97154, 97155, and 97158. Telehealth (modifier 95) is allowed for 97151, 97155, 97156, 97158, and 99366; the plan's materials specifically note LaBAs and RBTs may not deliver any service remotely.[1][2]
Cook Children's runs authorization through an EpicCare Link secure provider portal, and its determination letters are delivered only through the portal's In Basket — the plan states explicitly that PA determination letters will not be faxed. Fax submission (STAR/CHIP: 682-885-8402; STAR Kids: 682-303-0005 or 844-843-0005) is offered only for providers whose portal access is still pending. The plan uses the statewide-style CCP Prior Authorization Request Form with a dedicated ABA checkbox and section. One inconsistency to route around: the plan's own materials print at least three different variants of its PA-inquiry email address across different documents — call Provider Support Services at 1-888-243-3312 to confirm the current address rather than guessing from a specific PDF.[3][4]
Follows the Texas Medicaid rule — Cook Children's Health Plan'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). Cook Children's 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.[10][8]
The questions that decide whether a family can start with Cook Children's Health Plan, 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.[5][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).[5][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.[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]
Cook Children's own ABA training restates the state rule: telehealth (modifier 95) is allowed for 97151, 97155, 97156, 97158 and 99366, and its materials specifically note that LaBAs and RBTs may not deliver any service remotely.[1][5]
Cook Children's own table: "Routine — Within 3 business days after receiving the request / Urgent — Within 1 business day after receiving the request / Inpatient (Concurrent) — Within 1 business day … / Emergent/Life Threatening — Within 1 hour after receiving the request"; a request with no priority marked defaults to routine, and "Requests submitted that are not urgent in nature, but rather submitted as urgent based on the delay in Provider submission will be processed as routine." Incomplete requests are returned listing the missing elements; the plan "must receive the requested information within three business days from the date of the letter," after which it decides "based solely on the information that we have." Cook's ABA training restates the TMPPM windows: evaluation PA "within 60 days prior to or on the requested evaluation date"; initial treatment "within 3 business days of the start of care (SOC) date"; the 90-day request is timely "within 30 days prior to the end of the current authorization period"; and a 180-day recertification "must be received no earlier than 60 days before the current authorization period expires." Late requests are denied for dates before receipt.[11][2][1]
"Medicaid is secondary when coordinating benefits with all other insurance coverage, unless an exception applies under federal law … Providers must submit claims to other health insurers for consideration prior to billing Cook Children's Health Plan"; if the plan knows of other coverage the provider did not bill, the claim denies. The secondary claim "Must be received by the health plan within ninety-five days of the disposition date on the primary insurance Explanation of Benefits (EOB)." Cook's materials do not say whether its ABA PA is still needed when it pays second — request it.[11][1][12]
Coverage decides whether Cook Children's Health Plan 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]
Cook Children's training restates the state caps and adds code-level detail: direct treatment is capped at 8 hours/day combined across 97153, 97154, 97155 and 97158; 97151 caps at 6 hours / 24 units with a 30-day authorization window; and 99366 is reimbursable only against an F84.0 diagnosis, twice per year, requiring at least three licensed professionals (one the LBA) meeting for a minimum of 30 minutes.[1][5]
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.[5][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.[5][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. Cook Children's training spells the modifier rules out: 97151 takes the HO modifier only; 97155, 97156 and 97158 require HO or HN; 97153 and 97154 take no required modifier (HO/HN/HM are informational); 99366 takes no modifier.[1][5]
Yes — the Texas Medicaid Autism Services benefit across STAR and STAR Kids in its six-county North Texas service area, on TMPPM criteria, with a dedicated 123-page ABA provider training restating the requirements in detail.
We found no distinguishing STAR Kids ABA process in the plan's own materials — the ABA policy applies uniformly across Medicaid, CHIP, and STAR Kids.
Through the EpicCare Link secure provider portal, using the Comprehensive Care Program PA form. Fax (682-885-8402 for STAR/CHIP) is available only while portal access is pending — determination letters are delivered via the portal only, not by fax.
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. 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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