Driscoll Health Plan — the children's-hospital-affiliated plan serving STAR, STAR Kids, and CHIP across South Texas — administers the state ABA benefit with no distinct clinical policy: TMPPM criteria govern. Its operational profile is unusually low-friction for practices that already work statewide, because its ABA request form is a Driscoll-branded copy of the Texas Medicaid CCP prior authorization form, and it runs a public per-code PA lookup portal that answers "does this code need auth?" without a phone call.
Autism (ABA) Services appear on Driscoll's Prior Authorization Requirement Portal (driscollhealthplan.com/priorauthcheck) — the plan's own tool for verifying PA requirements code by code, which is the right first stop before any submission. Requests submit through the DHP provider portal (Driscoll says portal requests are decided faster, since faxes "must be scanned and data entered" first, which "can take up to 24 hours") or by fax to 1-866-741-5650 on Driscoll's CCP Prior Authorization Request Form. The form has its own ABA Evaluation, ABA Re-evaluation and ABA Treatment boxes; the requesting physician or allowed practitioner completes the diagnosis and medical-necessity section and signs the certification that the child is under 21, has an ASD diagnosis and that ABA "services are or may be clinically indicated" (CNM, CNS, NP and PA may sign for the physician when delegated; signature stamps are not accepted). Attach the state-baseline clinical package (signed prescriber referral, recency-checked ASD diagnosis, per-code units) and follow the TMPPM's 90/90/180 cadence.[1][2][7]
Everything on the Texas Medicaid guide applies unchanged: PA on the 97151 evaluation (24-unit cap), the April 2025 removal of the prescriber signature on 90-day extensions, the 3-year diagnosis recency rule, the 8-hour daily direct-treatment cap, credential modifiers, and the telehealth restrictions. Driscoll's only plan-specific wrinkle is workflow — verify the code on the portal, submit the CCP PA request form, track through the DHP portal.[3]
Driscoll publishes its own change-of-provider rule (January 26, 2026 notice): when a member changes providers mid-authorization, "DHP must receive a Change of Provider letter along with either a new Texas Standard Prior Authorization Request Form (TARF)" or, for DME, a new physician order form, from the ordering provider. The letter "must be signed and dated by the member or their legally authorized representative (LAR)" and must name the previous provider, the new provider and the effective date of the change; Driscoll posts a sample Change of Provider Letter on its Forms and Checklists page. The Texas Medicaid rule sits underneath: 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).[3][6][8][9]
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). Driscoll does not publish whether its ABA network is open, so ask its provider relations team.[3][6][8][9]
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][6][11]
Driscoll’s September 2026 manual: professional CMS-1500 claims are due "95 days from the DATE OF SERVICE," and provider and administrative claim appeals "must be submitted and received within 120 days from the Explanation of Payment (EOP) date," with a written response or adjustment within 30 days.[10][6][11]
The questions that decide whether a family can start with Driscoll 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.[3][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.[3][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).[3][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.[3][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. Driscoll's own form is its CCP Prior Authorization Request Form (ABA Evaluation / Re-evaluation / Treatment boxes): the requesting physician or allowed practitioner completes the diagnosis and medical-necessity section, certifies the child is under 21 with an ASD diagnosis, and signs and dates it — CNM, CNS, NP and PA may sign for the physician when delegated, chiropractors and PhDs may not, and signature or date stamps are not accepted. The original signed form stays in the prescriber's record, a copy in the requesting provider's, and it is subject to retrospective review. Submit through the DHP portal or fax 1-866-741-5650.[1][3][5][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.[3][1]
STAR and STAR Kids requests "submitted with complete supporting clinical information and documentation: Within three (3) business days from the receipt of a preauthorization request"; CHIP within 2 business days for approvals and 3 for adverse determinations; urgent "no later than 24 hours from receipt." Incomplete STAR/STAR Kids requests go through Driscoll's Lack of Information process: a letter within three business days gives the provider three business days to respond, and the process "will not exceed 10 business days/14 calendar days from date of receipt." Renewals: "DHP allows for timely submission of continuation of service requests/renewal of an existing prior authorization up to 60 days before the current prior authorization expires" and will decide, "if practicable, before the existing authorization expires" — but where a renewal needs assessments or progress notes more recent than 60 days, Driscoll will ask you to resubmit closer to the end date, which is the ABA situation.[11][12]
"DHP is the payer of last resort. Providers must bill all other carriers and receive payment or denial prior to billing DHP," attaching the denial letter or EOP when the other payer denies. Driscoll is the one Texas MCO that says plainly what happens to authorization when it pays second: "Some outpatient services/procedure codes may require prior authorization regardless of DHP as secondary payer," so check the DHP Prior Authorization Portal; and "If the services are known to be a non-covered benefit by the primary payer, prior authorization is required by DHP and proof of non-coverage of benefit must accompany the claim submission." For ABA, where many commercial plans exclude or cap the benefit, get the Driscoll PA.[11][13]
Coverage decides whether Driscoll 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.[3][1][4]
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.[3][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.[3][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.[3][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.[3][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.[3][1]
Yes — the Texas Medicaid Autism Services benefit across its South Texas service areas, on TMPPM criteria, with PA required (Autism/ABA Services are listed on the plan's PA portal).
Driscoll's CCP Prior Authorization Request Form, with the ABA Evaluation, Re-evaluation or Treatment box checked and signed by the requesting physician or allowed practitioner, submitted through the DHP provider portal or by fax to 1-866-741-5650.
No — it publishes no distinct ABA criteria. The TMPPM baseline governs; the plan-specific layer is the PA lookup portal, its CCP PA request form and its change-of-provider letter.
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 Driscoll’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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