Presbyterian Health Plan — New Mexico's homegrown Turquoise Care MCO — administers ABA on the state's criteria, and even borrows the state's vocabulary: its own authorization paperwork is an "Applied Behavior Analysis (ABA) Clinical Review Form: Stage 3" and an "ABA Specialty Care Clinical Review Form," mirroring the NMAC stage model. The plan-specific layer is form-and-routing mechanics, with one trap worth memorizing: Presbyterian's Turquoise Care behavioral health is managed in-house — Magellan handles only Presbyterian's Medicare and commercial BH, never Medicaid.
Clinically, expect the state baseline: the ASD-or-at-risk eligibility and the service-authorization-plus-6-month-PA cadence come from the state program (see the New Mexico Medicaid guide). Prior authorization is where Presbyterian is stricter: its Provider Prior Authorization Guide (09.01.2026) lists every ABA code for Turquoise Care — 97151, 97152 and 0362T assessment codes included, plus 97153-97158, 0373T, H2019, H0031 and H0032 — where the state fee schedule gates only 97153 and 0373T. Book the assessment only after it is authorized. Presbyterian's contribution is its paperwork: Stage 3 treatment requests go on Presbyterian's own ABA Clinical Review Form (with a separate Specialty Care version), submitted by fax to (505) 843-3019 or through the dedicated Turquoise Care online submission channel; day-to-day provider work runs through the myPRES portal. The plan mirroring the state's "Stage 3" and "Specialty Care" vocabulary on its forms is a strong signal of state-criteria deference — no distinct Presbyterian clinical policy for ABA has been published. No plan-specific hour caps have been published either; treat the state criteria as the operative limits and verify current form versions in myPRES before submitting.[1][2]
Presbyterian contracts Magellan for behavioral health on its Medicare and commercial lines — but Turquoise Care (Medicaid) behavioral health is handled in-house. An ABA authorization for a Medicaid member routed to Magellan goes nowhere: use the Medicaid-specific BH fax (505) 843-3019 or the Turquoise Care portal submission. Because the same family can move between Presbyterian's commercial and Medicaid products, confirm the line of business on every card before choosing the routing.[1]
Presbyterian publishes no ABA goal format of its own. Its Turquoise Care practitioner manual describes the ABA benefit only in general terms, and its Prior Authorization Guide (09.01.2026) lists the ABA codes without treatment-plan criteria. The state standard below governs.[3][8]
The state standard applies to every Turquoise Care MCO. 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."[3][8]
Presbyterian publishes no parent-training hours of its own. Its Prior Authorization Guide (09.01.2026, p. 48) lists 97156 and 97157 among the ABA codes in its Applied Behavior Analysis entry, for Turquoise Care, Turquoise Care Expansion and Commercial. Check the guide or the authorization line for whether a Medicaid 97156 request is needed, since the state guidance makes 97156 PA-free.[2][3]
The state standard, which applies to every Turquoise Care MCO: 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.[2][3]
Presbyterian’s 2026 manual: "Presbyterian requires that all claims from in-network providers are received within 90 days of the date of service." Resubmissions, corrections and adjustment requests must arrive within 12 months of the date of service, and "A provider has 12 months from the date of service to file an appeal regarding a claim," resolved within 30 calendar days. Clean electronic claims "will be reimbursed within 30 days of receipt," clean paper claims within 45. Providers with more than one Turquoise Care provider type on an NPI must report the NPI and taxonomy matching their New Mexico Medicaid registration, or the claim can be denied.[10]
The questions that decide whether a family can start with Presbyterian Health Plan (Turquoise Care), and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the New Mexico Medicaid rule: NMAC 8.321.2.13 imposes no upper age limit and covers Medicaid-enrolled adults, with under-21s served through EPSDT and the at-risk pathway bounded at 12–36 months. One drafting trap: the shared Turquoise Care Level of Care Guidelines (July 2024) describe ABA for members 12 months up to 21 years, because the adult expansion arrived later in NMAC 8.321.2.13 (12/10/2024) and Supplement 24-13 — cite those, not the LOC document, on an adult request.[5][6][4]
Follows the New Mexico Medicaid rule: a presumptive ASD diagnosis from a licensed practitioner within scope must have been received within three years of the referral to stage two or three; a recipient who already carries an ASD diagnosis needs no re-evaluation but does need an ISP and a medical-necessity determination; and the at-risk pathway requires no diagnosis at all.[5][6][4]
Follows the New Mexico Medicaid rule: an approved Autism Evaluation Provider confirms the presence of or risk for ASD through a comprehensive diagnostic, targeted or ASD risk evaluation, or the recipient is referred on a presumptive diagnosis from any licensed practitioner whose scope of practice allows an ASD diagnosis, received within three years of referral.[5][6][4]
Follows the New Mexico Medicaid rule — Autism Evaluation Provider evaluation, ISP, and referral to an approved ABA provider agency — with Presbyterian’s own paperwork on top: stage-three treatment requests go on Presbyterian’s "Applied Behavior Analysis (ABA) Clinical Review Form: Stage 3" (with a separate ABA Specialty Care Clinical Review Form), faxed to (505) 843-3019 or filed through the Turquoise Care online submission channel. The routing trap matters more than the form: Magellan handles Presbyterian’s Medicare and commercial behavioral health only, never Turquoise Care Medicaid, which is managed in-house.[5][6][4][1]
Follows the state rule — Presbyterian's own ABA documents checked this run (the 2026 Turquoise Care Practitioner and Provider Manual, whose telehealth section is general, and the 09.01.2026 Prior Authorization Guide) publish no ABA-specific telehealth policy, so the HCA rule applies. 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.[3][7]
Presbyterian’s Prior Authorization Guide lists Medicaid standard requests at “7 calendar days” and expedited at “24 hours”, processed “when all necessary and relevant documentation supporting the prior authorization request is submitted”. The Turquoise Care manual sharpens the incomplete-file rule: “We will deny the prior authorization request if we do not receive all of the documentation needed to make a decision within 7 calendar days of the day the request was received” — so send the complete packet up front. “Expedited requests for Turquoise Care members are processed within 24 hours” of complete documentation. Its HCA contract (7 business days, 24-hour expedited, deemed granted, most rigorous of that or 42 CFR 438.210(d)) is the backstop. 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”. Presbyterian publishes no separate ABA lead time.[2][10][11][3]
Presbyterian’s Turquoise Care manual: “Presbyterian Turquoise Care is, by law, the payor of last resort” — bill the other plan first, get an itemized EOP, and submit within “90 calendar days of the date the other payor paid or denied the claim”, “not to exceed 210 calendar days from the date of service”; “Claims submitted without an EOP are denied”. “Coverage requirements of the other insurance plan must be satisfied”, and Presbyterian “does not make payment for services denied by another carrier when the provider or member did not follow the requirements of the primary plan”. On its own authorization when secondary: “Presbyterian Turquoise Care does not require a prior authorization or referral” when the primary does not include the benefit or has hit its annual or benefit maximum, and its “normal prior authorization guidelines and plan requirements apply when Presbyterian is acting as the primary carrier if the other carrier denied the services”. Coordination follows “CMS and NMAC regulations, the National Association of Insurance Commissioners’ guidelines”. TRICARE pays ahead of Medicaid (10 U.S.C. 1079(i)(1)).[10][11][12][13]
Follows the New Mexico Medicaid rule, which names none: NMAC 8.321.2.13 requires the diagnosis be made against the latest DSM or ICD and the at-risk criteria be measured by standardized assessments, without naming instruments. No plan-specific instrument list was found for this MCO either.[5][6][4]
Ask the plan: MAD Behavioral Health Policy and Billing Manual / Supplement 24-13 — 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 Presbyterian Health Plan (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.
Follows the New Mexico Medicaid rule: every stage-three service requires clinical management, a BCaBA or technician implementing the plan requires case supervision from their BA or supervising BAA, and prior authorization is triggered where more than two hours of case supervision, or two hours of clinical management, per 10 hours of intervention is requested. Certification-maintenance supervision is not MAD-reimbursable.[5][6][4]
Follows the New Mexico Medicaid rule: no per-day unit ceiling, with authorization-gated intensity thresholds instead — including the inverted quirk that comprehensive treatment averaging under 20 hours a week requires prior authorization — and PA on supervision or clinical management above two hours per 10 hours of stage-three service. No plan-specific hour caps were found for this MCO.[5][6][4]
Follows the New Mexico Medicaid rule: school-setting activities with the potential to supplant educational services are excluded; a residential facility that is not itself an ABA provider must contract a MAD-enrolled ABA provider to render on site; treatment foster care is not treated as out-of-home placement; and out-of-home placement is otherwise an exclusion under the shared Turquoise Care Level of Care Guidelines apart from time-limited transition services.[5][6][4]
Follows the New Mexico Medicaid rule: reimbursement goes to the MAD-enrolled ABA provider, behavior analysts enrol as Provider Type 445 / Specialty 099 and technicians as Provider Type 430 / Specialty 098 on the MAD-877 and MAD-878 attestations, and every practitioner must clear a New Mexico criminal background registry check before rendering. Letter of Direction #53 makes the state fee-for-service ABA fee schedule the contractual minimum this MCO and its sub-vendors must pay.[5][6][4]
Not resolved. NMAC publishes no same-clock-time billing rule for ABA and defers to the MAD Behavioral Health Policy and Billing Manual; no plan-specific concurrent-billing rule was found for this MCO.[5][6][4]
Blocked on: The plan’s provider portal or claims line, plus the MAD Behavioral Health Policy and Billing Manual — 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.
Not resolved at the state level: NMAC makes the supervising behavior analyst responsible for treatment plan formulation and documentation but defers session-note mechanics to the MAD Behavioral Health Policy and Billing Manual, and no plan-specific documentation standard was found for this MCO.[5][6][4]
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 — on the state's ABA criteria and stage model. Treatment requests use Presbyterian's own Stage 3 ABA Clinical Review Form, faxed to (505) 843-3019 or submitted through the Turquoise Care online channel.
No — Magellan handles Presbyterian's Medicare and commercial behavioral health only. Turquoise Care (Medicaid) BH is in-house: use the Medicaid fax (505) 843-3019 or the Turquoise Care portal.
Yes. Presbyterian's Provider Prior Authorization Guide (09.01.2026) lists 97151, 97152 and 0362T on its Applied Behavior Analysis row for Turquoise Care, Turquoise Care Expansion ABP and Commercial — stricter than the state fee schedule, which marks those codes PA-free. Confirm with Turquoise Care BH UM at (505) 923-5757, option 4 then 2.
Follows the state rule. 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.
Yes, under the state rule in MAD Supplement 24-13: 97155 may be delivered by real-time telemedicine with the recipient present, and by store-and-forward only where the agency documents no real-time option.
Presbyterian publishes no format of its own; the state standard (Supplement 24-13) applies — measurable goals for each critical developmental domain, prioritized by safety risk, not DSM-5 criteria.
Presbyterian publishes no figure; the state rule applies — every plan "must include ample units" of 97156/97157, with 97156 up to 32 units per week for the Family Set. Presbyterian's PA guide lists 97156/97157 among its ABA codes, so confirm whether a request is needed.
Ninety days from the date of service for in-network claims; corrections and appeals within 12 months of the date of 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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