FirstCare Health Plans — SHA LLC dba FirstCare, owned by Baylor Scott & White Health Plan, serving STAR in the Lubbock service area and the large Medicaid Rural Service Area (MRSA) West, plus CHIP in Lubbock only — administers ABA on the statewide TMPPM baseline with no dedicated Autism Services provider-manual section of its own; the plan's Behavioral Health section covers mental health and substance-use benefits in detail but never mentions autism or ABA. **FirstCare exited Texas Medicaid managed care on August 31, 2026** — its site now reads “FirstCare exited the Texas Medicaid Managed Care Program on Aug. 31, 2026.” TMHP rejects claims with a date of service on or after September 1, 2026, and “Providers have 95 days to submit their claims with a DOS on or before August 31, 2026.” Confirm which STAR or CHIP plan the family has now; the rules below describe FirstCare’s handling of dates of service through the exit.
FirstCare's STAR & CHIP Notification/Prior Authorization Codes list (effective 7/1/2026) lists 97151, 97153, 97154, 97155, 97156, 97158, and 99366 as requiring authorization, filed under "Therapy services" rather than behavioral health. Notably absent from that Medicaid-specific list: 97152, 97157, 0362T, and 0373T — those four codes appear only in FirstCare's separate commercial-oriented Medical Coverage Policy #206 ("Autism Spectrum Disorder"), which explicitly defers Medicaid decisions to the TMPPM: "For Medicaid plans, please confirm coverage as outlined in the Texas Medicaid Provider Procedures Manual." That same commercial policy confirms the Texas mandate's $36,000/year ABA cap for members 10+ "do not apply to self-funded/ERISA plans, Medicaid, or Medicare" — consistent with the statewide Medicaid baseline having no dollar cap. Treat 97152/97157/0362T/0373T PA status for FirstCare Medicaid as unconfirmed rather than assuming either way.[4][5]
Requests submit through the myFirstCare Self-Service Portal (my.firstcare.com/Web) or by fax using the Texas Standard Prior Authorization Request Form — FirstCare uses the statewide form, not a proprietary one. General turnaround is 3 working days from receipt of complete clinical information, and the plan asks providers to submit at least 5 days before the anticipated service date. One routing ambiguity we could not resolve: FirstCare's own contact tables list a separate Medical PA line (1-800-884-4905, fax 1-800-248-1852) and a Behavioral Health PA line (1-855-395-9652, fax 1-844-436-8779) — since ABA codes are filed under "Therapy services" rather than "Behavioral health" on the code list, confirm which line actually processes ABA requests before your first submission. FirstCare exited Texas Medicaid on August 31, 2026, so these mechanics now matter only for open requests and claims for earlier dates of service, which TMHP says must be submitted within 95 days.[3][6][7]
Follows the Texas Medicaid rule — FirstCare'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).[8][11]
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). FirstCare does not publish whether its ABA network is open, so ask its provider relations team.[8][11]
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.[13][11][6]
FirstCare’s 2026 manual: claims "should be submitted within 95 days following the date on which the covered health services were rendered," and claims not received within 95 days "will be denied and considered waived by the provider."[13][11][6]
The questions that decide whether a family can start with FirstCare Health Plans, 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. FirstCare's own Medical Coverage Policy #206 defers Medicaid decisions to the TMPPM explicitly, and its Medicaid PA code list, not that commercial policy, is the operative gate.[8][4][5]
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. FirstCare's own Medical Coverage Policy #206 defers Medicaid decisions to the TMPPM explicitly, and its Medicaid PA code list, not that commercial policy, is the operative gate.[8][4][5]
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). FirstCare's own Medical Coverage Policy #206 defers Medicaid decisions to the TMPPM explicitly, and its Medicaid PA code list, not that commercial policy, is the operative gate.[8][4][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. FirstCare's own Medical Coverage Policy #206 defers Medicaid decisions to the TMPPM explicitly, and its Medicaid PA code list, not that commercial policy, is the operative gate.[8][4][5]
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. FirstCare's own Medical Coverage Policy #206 defers Medicaid decisions to the TMPPM explicitly, and its Medicaid PA code list, not that commercial policy, is the operative gate.[8][4][5][10]
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. FirstCare's own Medical Coverage Policy #206 defers Medicaid decisions to the TMPPM explicitly, and its Medicaid PA code list, not that commercial policy, is the operative gate.[8][4][5]
FirstCare processes authorizations "in the order received and within 3 working days of receipt of the necessary clinical information," and sends an adverse determination "Within 3 working days in writing to the provider of record and the member if the member is not hospitalized." It asks for lead time without mandating it: "we encourage providers to submit requests a minimum of five days prior to the anticipated service date" (elective admissions and procedures: at least 2 working days). The manual has no ABA-specific timing or reauthorization lead time; an incomplete request follows the state process in 1 TAC § 353.425.[6][14][15]
"Coverage under Medicaid and CHIP is secondary to all other insurance coverage, unless an exception applies under federal law. Coverage provided under Medicaid will pay benefits for Covered Services that remain unpaid after all other insurance coverage has been paid." File with FirstCare "within 95 days of the date on the primary payor's Explanation of Benefits (EOB) or Remittance Advice (RA)"; any overpayment made because FirstCare was not primary "must be refunded in full." The manual does not say whether FirstCare's ABA PA is still needed when it pays second — request it.[6][16]
Coverage decides whether FirstCare 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.[8][4][5][9]
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.[8][4][5]
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.[8][4][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.[8][4][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.[8][4][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.[8][4][5]
Yes — the Texas Medicaid Autism Services benefit for STAR members in Lubbock and MRSA West, on TMPPM criteria. FirstCare's own Medicaid PA code list confirms PA is required on 97151, 97153-97156, 97158, and 99366.
No. FirstCare exited Texas Medicaid managed care on August 31, 2026. Claims with a date of service on or after September 1, 2026 are rejected, and providers have 95 days to submit claims for dates of service on or before August 31, 2026 (TMHP update, 9/2/2026).
No — FirstCare's own commercial autism policy confirms the mandate's dollar cap applies to state-regulated commercial plans, not Medicaid, matching the no-cap statewide Medicaid baseline.
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 FirstCare’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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