New Mexico Medicaid runs one of the most expansive ABA benefits in the country. Under NMAC 8.321.2.13 and MAD Supplement 24-13, coverage isn't limited to a strict autism diagnosis — recipients with a well-documented RISK for developing ASD qualify through a dedicated at-risk pathway — and there is no upper age limit: New Mexico operates an explicit adult ABA benefit beyond EPSDT. The front door is fast, too: the 97151 assessment needs no prior authorization. Since July 1, 2024 the benefit is administered by four Turquoise Care MCOs (BCBS of New Mexico, Molina, Presbyterian, UnitedHealthcare Community Plan), with fee-for-service and a Third-Party Assessor for non-MCO recipients — and Letter of Direction #53 makes the published FFS fee schedule a rate floor every MCO must meet.
NMAC 8.321.2.13 and Supplement 24-13 cover two populations: recipients 12 months and older with a well-documented ASD diagnosis, and recipients with a well-documented risk for developing ASD — the at-risk pathway, for children roughly 12–36 months with developmental delays, some ASD characteristics, and a genetic risk factor such as an older sibling with ASD or Fragile X. Don't screen out a family just because the diagnosis isn't final. The benefit runs on a three-stage model: Stage 1 is an Autism Evaluation Provider evaluation (CDE, targeted, or risk evaluation plus an Integrated Service Plan), Stage 2 is the BCBA behavior/functional assessment (97151, done annually), Stage 3 is treatment.[3][4]
The other headline: no upper age limit. New Mexico runs an explicit adult ABA benefit across Stages 1–3, beyond EPSDT — rare enough that adult inquiries should be treated as viable leads, not exceptions. Recency rules to capture at intake: the diagnosis must come from an Autism Evaluation Provider/Practitioner or licensed practitioner within scope, within 3 years of the service referral; adults need ASD confirmation by a "Grace Exception Practitioner" within the last 3 years.[3][4]
The state fee schedule marks 97151, 97152, and 0362T "Prior Auth: NO" — so once eligibility is verified, the Stage 2 assessment can be booked immediately, no authorization packet required. Adults can access Stage 2 without PA as well (a CDE is not required for adults unless medically warranted). PA lands essentially only on treatment: 97153 (adaptive behavior treatment by protocol) is "Prior Auth: YES," while 97155 and 97156 are PA-free.[5][4]
Supplement 24-13 layers a two-part authorization model: a Service Authorization approves ABA for 3 years (ages 12 months–8) or 6 years (8+), and within it Prior Authorizations of the treatment plan recur every 6 months (annually for adults inside a 6-year service authorization). Then the quirk that inverts the usual intensity logic: comprehensive treatment rendered at LESS than 20 hours/week on average requires PA from the MCO/TPA (3.17.1(A)) — scrutiny lands on under-dosed programs, not high-hour ones. Also PA-gated: more than 2 hours of case supervision or clinical management (T1026 UC/UD) per 10 hours of Stage 3 services. Comprehensive programs are contemplated at 30–40 hrs/week, focused programs at 10–25, and adult comprehensive services range 10–40 hrs/week.[5][4]
New Mexico publishes credential-tiered ABA rates, flagged with modifiers: U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician — explicitly allowed with or without a bachelor's degree). Per 15-minute unit, effective 1/1/2025: 97151 pays $130.94 (U5/U4) and $112.65 (U3); 97153 pays $38.02 / $37.99 / $32.31 / $23.35 / $19.85 down the tiers; 97155 pays $55.55 (U5/U4) and $39.69 (U3); 97156 pays $35.79 (U5/U4) and $25.78 (U3). T1026 with UC/UD modifiers pays $142.84/hour for BA-level practitioners ($109.27 for a supervising BCaBA) — at least 1 hour each of clinical management and case supervision is expected per 10 hours of Stage 3 service — and the ISP Update (T1026 HI HK) pays $206.33.[5][6]
What makes these numbers unusually load-bearing: Letter of Direction #53 (3/21/2025) directs the Turquoise Care MCOs to pay providers no less than the Medicaid FFS fee schedule — a statewide rate floor that also binds MCO sub-vendors, with adjustments and back-payments ordered retroactive to 1/1/2025. In New Mexico, the fee schedule isn't a benchmark; it's a contractual minimum you can hold every MCO to.[5][6]
Turquoise Care launched July 1, 2024 with four MCOs: Blue Cross and Blue Shield of New Mexico, Molina (new to the state), Presbyterian Health Plan, and UnitedHealthcare Community Plan (also new, with ABA administered by Optum). Non-MCO recipients run fee-for-service, with MAD's Third-Party Assessor handling authorizations. Clinically the MCOs defer to the state's NMAC criteria and stage model — the shared Behavioral Health Level of Care Guidelines reference NMAC 8.321.2 throughout — so what changes per plan is submission machinery: portals, forms, and fax lines (see the per-MCO guides). Stage 3 staffing is notably broad: BCBA/BCBA-D, BCaBA, BACB RBTs, BICC BCATs, and non-certified behavior technicians under supervision with an HCA practitioner attestation. New Mexico has no behavior analyst licensure law, so BACB certification plus the attestation and background check is the credentialing gate.[4][6]
New Mexico still has no behavior analyst license as of mid-2026 — the state is absent from the BACB's licensure table — so Medicaid credentialing runs entirely on certification plus MAD attestations, with dedicated provider types: BCBAs/BCBA-Ds enroll individually as Provider Type 445, Specialty 099 via the MAD-877 attestation (current BACB certificate attached; any certification-status change reported immediately to the agency, the MAD ABA Manager, and each contracted MCO), and technicians as Provider Type 430, Specialty 098 via MAD-878. At the technician tier New Mexico is unusually broad: Supplement 24-13 accepts BACB RBTs, BICC Board Certified Autism Technicians (BCATs), AND a time-limited non-certified behavior technician on-ramp. A non-certified BT must be 18+ with a high school diploma or equivalent, clear the New Mexico criminal background registry check, and complete 4 hours of ASD training plus at least 20 hours of the RBT/BCAT training BEFORE rendering any Stage 2/3 services — then finish the full 40-hour training within 90 days, the remaining testing-approval requirements within 180 days, and secure the RBT or BCAT certificate within six continuous months, or stop rendering until certified. The BACB's own floor still applies to RBT candidates (18+, high-school education, 40-hour training, competency assessment, and a criminal background check plus abuse-registry check within 180 days before applying).[4][8][9][10][11][12][13][14][15]
Background screening is embedded in every practitioner definition — BA, Mentored BA, BA Candidate, BCaBA, RBT/BCAT, non-certified BT, and Specialty Care Practitioner must each "successfully complete a New Mexico criminal background registry check" before rendering, restated in NMAC 8.321.2.13 and attested on the MAD forms; the agency application (Part 6, Staff Documents) additionally requires a written background-check compliance policy covering ALL employees as a condition of MAD approval. That same Agency Manual Instructions document, confirmed fully readable and current as of this review, also sets Part 7's mock-file requirements by age band for the agency-application review — separate mock case files for 12mo–3yr (at-risk, pre-diagnosis), 12mo–5yr (diagnosed), school-age, 18–21, and adult 21+ — mirroring Supplement 24-13's stage model exactly. The state's screening machinery is the Caregivers Criminal History Screening Program under 8.370.5 NMAC (effective 7/1/2024): an Employee Abuse Registry check prior to hire, fingerprints submitted to CCHSP within 20 calendar days of the first day of employment, conditional supervised work permitted while the fingerprint check is pending, a defined disqualifying-felony list, and a statewide-only re-screen for staff cleared nationally within the prior 12 months. One honest caveat: 8.370.5's covered-entity list is facility- and waiver-oriented (it excludes outpatient treatment facilities), and the MAD ABA documents require the "criminal background registry check" by name without citing it — so whether an outpatient ABA agency must specifically use CCHSP versus an equivalent criminal-background-plus-registry check isn't explicitly resolved in any published document; treat CCHSP + EAR as the state's screening infrastructure and confirm the accepted mechanism with HCA/MAD at enrollment. No ABA-specific OIG/SAM exclusion-screening language appears in the state ABA documents; federal exclusion screening rides on standard Medicaid enrollment.[4][8][9][10][11][12][13][14][15]
Supervision comes as billable ratios, not just principles: Supplement 24-13 requires at least four 15-minute units (one hour) of 97155 — rendered by the BA, Mentored BA, or Supervising BCaBA with the recipient present — for every eighty units (20 hours) of combined 97153/97154/97156, a ~5% direct-observation floor required in specific amounts with no PA needed, plus one to two units of T1026 UD clinical management per eighty units of Stage 3 services (except 97155). Certification-maintenance supervision required by the BACB/BICC is explicitly NOT reimbursable by MAD (RBTs still owe the BACB 5% monthly supervision with two face-to-face contacts). Staffing plans must also absorb the Mentored BA rule — a BCBA certified less than three years is supervised by a BA with 3+ years of supervision experience through a two-year mentorship — and a BCaBA may supervise technicians only when approved by their supervising BA. At the plan level, the four Turquoise Care MCOs work off the state baseline: the attestations themselves ask which MCOs each practitioner is contracted with, and BCBSNM enrolls ABA staff via the HCA-approved Behavioral Health Roster template rather than per-practitioner applications. No MCO-added screening or training extras were found — though Molina's NM provider manual couldn't be retrieved, so verify Molina credentialing specifics directly.[4][8][9][10][11][12][13][14][15]
MAD Supplement 24-13 sets rules for ending services, not for moving an authorization between agencies. Before stopping services for lack of progress, the agency must work the barriers with the MCO care coordinator. A short halt (about a month) can be agreed and restarted on a set date. Otherwise the agency may terminate, and "Unless medically warranted for immediate discharge, discharge date must be at least 30 calendar days from the date the recipient or Family Set is notified in writing."[4]
Restarting is a new start: "the BA will complete ABA Stage 2 services and submit a new 6-month prior authorization," and if the gap runs past the last Service Authorization period a new Service Authorization is needed too. The terminating agency "is not obligated to accept the recipient back" and "may refer the recipient to another AP agency." The supplement does not say whether an existing prior authorization moves to a new agency when a family switches; ask the MCO (or the TPA for fee-for-service) before the first session with the new agency.[4]
MAD Supplement 24-13 (9/17/2024) is the state's ABA guidance. After the 97151 assessment, the BA "must select goals for intervention and determine how these goals will be measured." Goal development covers a list of skill areas: "adaptive and self-care skills, attending and social referencing, cognitive functioning, community participation, coping and tolerance skills, emotional development, family relationships, language and communication, play and leisure skills, pre-academic skills, self-advocacy and independence, self-management, social relationships, and vocational skills." Baseline performance should be measured and "treatment goals should be developed for each critical domain and specified in terms that are observable and measurable" (3.14.3). Targets are prioritized by risk to safety, independence and health (3.14.2). The required treatment-plan elements (3.19.1) include a Family Set goal, baseline data on each target behavior/symptom, interventions with approximate units per target, goals with objective progress measures for the authorization period, and measurable discharge criteria. The domains are developmental skill areas, not DSM-5 criteria. DSM or ICD is used for eligibility, and the ASD support level (Level 2/3) informs dosage. 8.321.2.13 NMAC makes the BA responsible for "selection and measurement of goals."[4][18]
Yes, and the guidance gives numbers. Supplement 24-13 says "Every Treatment Plan must include ample units of ABA Stage 3 97156 and 97157" (3.17.1(C)). Every plan must "Include a goal of working with the Family Set" and be "Family Set-focused... with a focus on family engagement, training, and support" (3.19.1). If family members cannot attend in person, the BA must offer alternatives such as telemedicine. 97156 needs no prior authorization, with a "Maximum number of units per 97156 for entire Family Set: thirty-two 15-minute units per week," billed once for the whole Family Set. The CMS Medicaid MUE limits 97156 to sixteen 15-minute units per day, and 97157 (also no PA) to "up to sixteen 15-minute units or four hours per day." Adult recipients may receive up to thirty-two units of either code when medically warranted. Family Sets may start 97156/97157 once the recipient's assessment is scheduled. If the family cannot attend at the agreed level, "inadequate family participation" is a listed reason for poor response, and the BA must offer alternatives.[4]
For fee-for-service claims, 8.302.2.11 NMAC: "Claims for services must be received within 90 calendar days of the date of service unless an alternative filing limit is stated." When another payer is primary, the claim must arrive within 90 calendar days of that payer’s payment or denial, never more than 210 days from the date of service. Filing limits are not waived for a provider’s misunderstanding, short staffing or failure to track pending claims. Turquoise Care members’ claims go to their MCO under that plan’s manual.[1][2][20]
Federal rules bind New Mexico Medicaid’s own fee-for-service payments: the agency "must pay 90 percent of all clean claims from practitioners, who are in individual or group practice or who practice in shared health facilities, within 30 days of the date of receipt" and 99 percent within 90 days, with the date of receipt being the agency’s date stamp and the date of payment the date of the check or other payment (42 CFR 447.45(d)(2), (3), (5), (6)). The same rule makes 12 months from the date of service the outer limit any state may allow for filing (42 CFR 447.45(d)(1)). Managed care plans are held to the same 90/99 percent clean-claim standard through their state contracts (42 CFR 447.46).[1][2][20]
The questions that decide whether a family can start with New Mexico Medicaid (Turquoise Care), and what they have to bring. Each maps onto something intake should ask on the first call.
No upper age limit. NMAC 8.321.2.13 says it outright: "There is no age requirement to receive ABA services and ABA is a covered benefit for medicaid enrolled adults." Recipients under 21 receive ABA as part of EPSDT (42 CFR § 441.57), and MAD Supplement 24-13 runs an explicit adult benefit across all three stages. At the bottom end the diagnosed pathway opens at 12 months and the at-risk pathway is bounded at 12–36 months of age.[3][4]
New Mexico is not a strict-diagnosis state, so the recency rule attaches to the referral rather than to a required diagnosis. NMAC 8.321.2.13 lets a recipient be referred for stage two and three services on a presumptive diagnosis of ASD by a licensed practitioner whose scope of practice allows them to render it, and "This diagnosis must have been received within three years of referral to stage two or three services." Where the recipient already carries an ASD diagnosis, diagnostic re-evaluation is not necessary — but an Integrated Service Plan and a medical-necessity determination for ABA are still required. Per the guide’s reading of Supplement 24-13, adults need ASD confirmation by a Grace Exception Practitioner within the last 3 years. The at-risk pathway needs no diagnosis at all.[3][4]
Confirmation of the presence of — or risk for — ASD normally comes from an approved Autism Evaluation Provider (AEP) through a comprehensive diagnostic evaluation; a targeted evaluation is used when a fully diagnosed recipient presents with behaviors changed from the last CDE, and an ASD risk evaluation when the at-risk criteria in Subsection C are met. To avoid delaying stage two and three, a recipient may instead be referred with a presumptive ASD diagnosis from any licensed practitioner whose scope of practice allows them to render an ASD diagnosis, received within three years of the referral.[3]
Yes, and it is the structural gate in New Mexico. Stage one is an evaluation by an approved Autism Evaluation Provider, who "must" develop an Integrated Service Plan (ISP) together with a referral to an approved ABA provider agency. The ISP and the CDE or targeted evaluation must accompany every stage-three prior authorization request, alongside the ABA treatment plan. The alternative front door, built into the rule to avoid delay, is a referral on a presumptive ASD diagnosis from a licensed practitioner within scope, received within three years of referral.[3]
Allowed. MAD Supplement 24-13 (section 3.2.1) says MAD "allows and encourages the utilization of telemedicine to deliver MAD ABA services," to bring home- and community-based ABA to rural and frontier areas, and points to 8.310.2 NMAC for the requirements: a HIPAA-compliant system with interactive audio and video in real time, with coverage "determined in a manner consistent with medicaid coverage for health care services provided through in person consultation." In-state BCBAs, BCaBAs, RBTs, BCATs and non-certified technicians need no telemedicine license; an out-of-state MD/DO diagnostician does. Supervision is expressly remote-capable: 97155 may be delivered through telemedicine when the BA directs the technician and the recipient by observing behavior or troubleshooting protocols (not when the BA joins in person), the recipient must be present, and the one-hour-per-20-hours minimum of 97155 still applies. Where an agency documents annually to the MCO or TPA that its transmission provider cannot support real-time video, store-and-forward can deliver up to 100% of direct 97155, with 30 to 60 extra minutes of 97155 added, but not for a non-certified technician. The assessment can be partly remote too: "A BA/Mentored BA bills Indirect 97151 when conducting interviews or discussing the Treatment Plan or Protocols with the Family Set delivered via telemedicine," and direct T1026 UD case supervision may happen onsite or be "delivered through telemedicine." The supplement names no POS code or modifier for ABA telemedicine, so confirm claim coding with the MCO or TPA.[4][17]
Depends on who holds the member. MCO members (all four Turquoise Care plans): the HCA contract requires each plan to “adjudicate standard prior authorization requests within seven (7) Business Days after receipt of all necessary and relevant documentation”, and requests are “deemed granted for determinations not made within the seven (7) Business Day turn-around time” (extension up to 14 calendar days on request or with justification); expedited decisions come “no later than twenty-four (24) hours after the receipt of all necessary and relevant documentation”, also deemed granted if missed. The same clause binds each MCO to “the most rigorous standards” of the NM Prior Authorization Act, NCQA, HCA regulation or 42 CFR 438.210(d) — and for rating periods starting on or after January 1, 2026, 438.210(d) caps standard decisions at 7 calendar days after the request is received (72 hours expedited), so plan against 7 calendar days from receipt. Fee-for-service members (MAD’s Third-Party Assessor): 42 CFR 440.230(e), beginning January 1, 2026, requires standard decisions “in no case later than 7 calendar days after receiving the request” and expedited within 72 hours, extendable up to 14 calendar days. Reauthorization: Supplement 24-13 sets no day count, only that the ABA Treatment Plan Update and Progress Report “must be prepared and submitted to the MCO or TPA prior to the end of the recipient’s Prior Authorization period”.[23][24][25][26][4]
Medicaid pays last. The TPL rule: “When providers are aware of the existence of health insurance or health plan coverage for eligible recipients, the providers must seek payment from the insurance carrier before seeking payment from medicaid”; Medicaid then pays at most its allowed amount less the other payer’s payment, capped at the co-pay, co-insurance or deductible the primary calculated, and the family cannot be billed the rest. Policies delivered in New Mexico, “including employee retirement income security Act (ERISA) plans”, may not exclude or limit benefits because the child is Medicaid-eligible. The HCA contract makes Medicaid “the payer of last resort” and adds the trap: the plan “shall deny payment on a Claim that has been denied by a third-party payer when the reason for denial is the Provider’s or Member’s failure to follow prescribed procedures, including but not limited to failure to obtain prior authorization” — so secure the commercial plan’s ABA authorization first. The same contract says “Claims for EPSDT shall be paid at the time presented for payment by the Provider and the CONTRACTOR shall bill the responsible third party”; whether an ABA claim is handled under that EPSDT pay-and-chase exception is not spelled out, so confirm with the plan before skipping the primary. TRICARE also pays ahead of Medicaid: its own secondary-payer rule exempts “a plan administered under title XIX”. The rule also lists pay-and-chase (no cost avoidance) for “preventive services for children including early and periodic screening, diagnosis and treatment services”. Neither the rule nor the contract says whether Medicaid’s own ABA prior authorization is still needed when Medicaid is secondary — see the per-MCO guides (Presbyterian publishes an answer).[27][23][28][29]
NMAC 8.321.2.13 names no required diagnostic instrument. The diagnosis is made against the latest DSM or ICD by the AEP, and the at-risk criteria require developmental differences and delays "as measured by standardized assessments" without naming which. Instrument-level requirements, if MAD publishes any, sit in the Behavioral Health Policy and Billing Manual and Supplement 24-13 rather than in the rule.[3]
Ask the plan: MAD Behavioral Health Policy and Billing Manual / Supplement 24-13 via the HCA ABA provider information page — hca.nm.gov blocked automated retrieval this cycle (CloudFront geo-block), so pull the MAD Behavioral Health Policy and Billing Manual and Supplement 24-13 from the HCA ABA provider page by hand, or ask the MAD ABA Manager.
Coverage decides whether New Mexico Medicaid (Turquoise Care) 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.
All stage-three services require clinical management, and where a behavior analyst assistant (BCaBA) or behavior technician implements the treatment plan, that person requires case supervision from their BA or supervising BAA. NMAC turns the ratio into an authorization trigger: the prior authorization request must state the hours of case supervision requested per week if more than two hours of supervision per 10 hours of intervention is sought, and likewise for clinical management above two hours per 10. Per the guide’s reading of Supplement 24-13 the billable floor runs the other way too — at least four 15-minute units (one hour) of 97155, rendered by the BA, Mentored BA or supervising BCaBA with the recipient present, for every eighty units (20 hours) of combined 97153/97154/97156, roughly a 5% direct-observation floor, plus one to two units of T1026 UD clinical management per eighty units of stage-three service. Supervision required only to maintain BACB or BICC certification is explicitly not reimbursable by MAD.[3][4]
MAD publishes no per-day unit ceiling for ABA. The limits that bite are authorization-gated intensity thresholds, and one of them inverts the usual logic: per the guide’s reading of Supplement 24-13 (3.17.1(A)), comprehensive treatment rendered at LESS than 20 hours a week on average requires prior authorization from the MCO or the third-party assessor — scrutiny lands on under-dosed programmes rather than high-hour ones. Contemplated bands are 30–40 hours a week for comprehensive, 10–25 for focused, and 10–40 for adult comprehensive services. Requests above two hours of case supervision, or two hours of clinical management, per 10 hours of stage-three intervention also require PA, and the PA request must document hours allocated to other services in the ISP so the UR contractor can judge whether the requested intensity is feasible. Underneath the program rule sit federal claim edits, which are a different thing from the authorization: section 6507 of the Affordable Care Act requires state Medicaid programs to apply CMS’s Medicaid NCCI methodologies, including medically unlikely edits (MUEs), to fee-for-service claims (a state may ask CMS to deactivate an individual edit; for managed care plans it is optional). CMS’s published Medicaid MUE table for practitioner services, dates of service October 1 – December 31, 2026, sets the per-provider, per-member, per-day values at 97151 32 units, 97152 16, 97153 32, 97154 18, 97155 24, 97156 16, 97157 16, 97158 16, 0362T 16 and 0373T 32. MAD publishes no per-code edit of its own; the authorization sets the units.[21][22][3][4]
NMAC sets the boundaries by exclusion and by setting. Not covered: activities that take place in school settings and have the potential to supplant educational services. Residential and institutional settings are handled explicitly — where a recipient is in a residential facility that is not itself an enrolled ABA provider, the facility must locate a MAD-enrolled stage two and three ABA provider and agree terms allowing that provider to render services on site. Treatment foster care is not treated as a residential facility, so ABA may be delivered outside the TFC agency; a recipient in a residential treatment centre, accredited residential treatment centre or group home may receive ABA to the extent the residential provider can deliver it. The shared Turquoise Care Level of Care Guidelines add that out-of-home placement is otherwise an exclusion, apart from time-limited ABA authorized for transition back to a community provider.[3][16]
Reimbursement for ABA stage two and three services is made to the MAD-enrolled ABA provider, never to a residential facility hosting the service. Practitioners enrol by type: behavior analysts (BCBA or BCBA-D, or an ABPP behavior-and-cognitive-psychology psychologist tested in the ABA component) as Provider Type 445, Specialty 099 on the MAD-877 attestation, and technicians as Provider Type 430, Specialty 098 on the MAD-878 — with any change in certification status reported immediately to the agency, the MAD ABA Manager and each contracted MCO. Every provider and practitioner must successfully complete a New Mexico criminal background registry check before rendering. Under Letter of Direction #53 the Turquoise Care MCOs, and their sub-vendors, must pay no less than the Medicaid fee-for-service ABA fee schedule.[3][8][9][5]
Not resolved in the rule text. NMAC 8.321.2.13 publishes no same-clock-time billing rule for ABA, and it defers billing instructions to the MAD Behavioral Health Policy and Billing Manual. What is clear is that the model assumes concurrent delivery: the 97155 observation floor is expressed as units rendered with the recipient present against units of 97153/97154/97156, which is supervision alongside direct service. Whether both are payable for the same clock minutes still needs the billing manual.[3][4]
Blocked on: MAD Behavioral Health Policy and Billing Manual, ABA billing instructions — hca.nm.gov blocked automated retrieval this cycle (CloudFront geo-block), so pull the MAD Behavioral Health Policy and Billing Manual and Supplement 24-13 from the HCA ABA provider page by hand, or ask the MAD ABA Manager.
NMAC assigns responsibility but not signature mechanics: the supervising behavior analyst is responsible for the recipient’s assessment, the selection and measurement of goals, and treatment plan formulation and documentation, and the rule then defers to the MAD Behavioral Health Policy and Billing Manual for documentation detail. Who must sign a session note, and within what window, is not stated in the rule.[3]
Blocked on: MAD Behavioral Health Policy and Billing Manual (ABA documentation requirements) — hca.nm.gov blocked automated retrieval this cycle (CloudFront geo-block), so pull the MAD Behavioral Health Policy and Billing Manual and Supplement 24-13 from the HCA ABA provider page by hand, or ask the MAD ABA Manager.
Yes — for recipients 12 months and older with an ASD diagnosis, for young children with a documented risk for developing ASD (no final diagnosis required), and for adults with no upper age limit. Coverage runs through the four Turquoise Care MCOs or FFS with the state's Third-Party Assessor.
No — 97151, 97152, and 0362T are marked "Prior Auth: NO" on the state fee schedule. PA applies essentially only to treatment: 97153 requires it, and comprehensive programs averaging under 20 hours/week need PA regardless.
Not strictly. Alongside diagnosed ASD, NMAC 8.321.2.13 covers recipients aged roughly 12–36 months with a well-documented RISK for ASD — developmental delays, some ASD characteristics, and a genetic risk factor such as an older sibling with ASD or Fragile X.
Published, credential-tiered rates per 15-minute unit (eff. 1/1/2025): 97153 pays $32.31 for a BCBA, $23.35 BCaBA, $19.85 behavior technician; 97151 pays $112.65 (BCBA) to $130.94 (BCBA-D/psychologist). Per LOD #53, these FFS rates are the minimum every Turquoise Care MCO must pay.
Yes. MAD Supplement 24-13 allows and encourages telemedicine for ABA services, real-time audio and video per 8.310.2 NMAC, and expressly lets 97155 supervision be delivered remotely with the recipient present (store-and-forward in documented no-broadband cases). The BA also bills indirect 97151 for family interviews and treatment-plan discussions held by telemedicine. Confirm POS and modifier with the MCO or TPA.
The supplement covers termination, not transfer: a terminating agency gives at least 30 days' written notice and may refer the family to another agency, and a restart means a new Stage 2 assessment and a new 6-month prior authorization. Ask the MCO or TPA whether an existing authorization can move.
Not at the start. New Mexico Medicaid lets a non-certified behavior technician render ABA if they are 18 or older, have a high-school diploma, pass the New Mexico criminal background registry check, complete 4 hours of ASD training and at least 20 of the 40 RBT/BCAT training hours before serving, and then hold an RBT or BCAT certificate within their first six continuous months. If they miss that deadline they must stop until certified.
No. Supplement 24-13 asks for observable, measurable goals for each critical domain — developmental skill areas such as language and communication, adaptive and self-care, social relationships, coping and tolerance — prioritized by safety risk. DSM/ICD governs eligibility, not the goal structure.
Every treatment plan "must include ample units" of 97156 and 97157 and a Family Set goal. 97156 needs no PA, up to 32 units (8 hours) per week for the whole Family Set and 16 units per day; 97157 is up to 16 units (4 hours) per day.
Ninety calendar days from the date of service for fee-for-service claims (8.302.2.11 NMAC); with a primary payer, 90 days from its EOB and no more than 210 days from service.
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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