---
title: Presbyterian Health Plan ABA coverage (Turquoise Care MCO).
url: "https://carelu.com/payers/presbyterian-health-plan-new-mexico"
markdown_url: "https://carelu.com/payers/presbyterian-health-plan-new-mexico.md"
state: NM (New Mexico)
payer: Presbyterian Health Plan (Turquoise Care)
kind: Medicaid managed care plan (MCO)
parent_program: New Mexico Medicaid (Turquoise Care)
description: "How Presbyterian Health Plan administers New Mexico Medicaid ABA under Turquoise Care — state-criteria deference, Presbyterian's own Stage 3 and Specialty Care clinical review forms, the Medicaid BH fax and myPRES portal, and the Magellan routing trap."
last_reviewed: October 2026
vob_data_updated: 2026-10-15
---

# Presbyterian Health Plan ABA coverage (Turquoise Care MCO).

_Payer Guide · Presbyterian Health Plan · Last updated October 2026 · 9 primary sources_

> State criteria with its own Stage 3 review forms; Medicaid BH fax (505) 843-3019 — not Magellan.

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.

This plan administers the **New Mexico Medicaid (Turquoise Care)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [New Mexico Medicaid (Turquoise Care) guide](https://carelu.com/payers/new-mexico-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — stricter than the state baseline. Presbyterian's own Provider Prior Authorization Guide (09.01.2026), which its Turquoise Care manual names as the complete list of services requiring prior authorization, lists 97151, 97152 and 0362T on its Applied Behavior Analysis row for Turquoise Care, Turquoise Care Expansion ABP and Commercial, with no carve-out for any line of business. The state fee schedule marks those codes "Prior Auth: NO", but Presbyterian's list is the one its UM applies — get the assessment authorized before booking, and confirm with Turquoise Care BH UM at (505) 923-5757, option 4 then 2 [2][10][4]
- **Prior auth for treatment**: Required on every ABA treatment code — Presbyterian's PA Guide lists 97153-97158, 0373T, H2019, H0031 and H0032 for Turquoise Care, not just the state's 97153/0373T. Submit the Stage 3 ABA Clinical Review Form to Presbyterian Turquoise Care BH — fax (505) 843-3019 or the online Turquoise Care portal; BH UM line (505) 923-5757, option 4 then 2 [2][1][4]
- **Autism diagnosis required?**: State rule — ASD dx within 3 years, or the documented at-risk-for-ASD pathway (NMAC 8.321.2.13) [5]

## At a glance

- **Plan type:** Turquoise Care MCO (in-house BH UM for Medicaid)
- **Clinical rules:** State ABA criteria and stage model (NMAC 8.321.2 / Supplement 24-13)
- **Assessment auth:** REQUIRED — Presbyterian's PA Guide lists 97151/97152/0362T (stricter than the state fee schedule)
- **Treatment request:** Presbyterian's own Stage 3 ABA Clinical Review Form
- **Submission:** Fax (505) 843-3019 or the Turquoise Care online submission; myPRES portal
- **Routing trap:** Magellan = Presbyterian Medicare/commercial BH only — NOT Medicaid
- **Rates:** Must pay at least the state FFS ABA fee schedule (LOD #53)

## How Presbyterian runs ABA authorization

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]

## The Magellan routing trap

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]

## Does Presbyterian (Turquoise Care) require treatment-plan goals in a set format, such as by DSM-5 criteria?

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]

## Does Presbyterian (Turquoise Care) require parent training, and how many hours?

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]

## What are Presbyterian Turquoise Care’s claim filing, payment and appeal deadlines?

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]

## Intake gates

The questions that decide whether a family can start with Presbyterian Health Plan (Turquoise Care), and what they have to bring.

- **Age limit**: 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]
- **Diagnosis recency**: 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]
- **Who may diagnose**: 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]
- **Referral required?**: 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]
- **Telehealth**: 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]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: 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]
- **Diagnostic tools required** _(ask the plan)_: 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.

## Delivery and billing rules

Coverage decides whether Presbyterian Health Plan (Turquoise Care) pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: 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]
- **Daily limits / MUEs**: 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]
- **Place of service**: 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]
- **Bill as provider**: 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]
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: 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. [5][6][4]

## What intake should collect for Presbyterian Health Plan (Turquoise Care)

- **Line of business:** Presbyterian Medicaid (Turquoise Care, in-house BH) vs. commercial/Medicare (Magellan) — it decides where the auth goes.
- **Diagnosis or at-risk documentation:** State rule: ASD dx within 3 years of referral, or the at-risk pathway — then request the assessment authorization; Presbyterian's PA Guide gates 97151/97152 too.
- **Stage 3 form package:** Presbyterian's own ABA Clinical Review Form (Stage 3) — pull the current version from myPRES/phs.org before each request.
- **Planned weekly intensity:** The state's under-20-hrs/week comprehensive-treatment PA quirk applies here too — plan hours deliberately.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How Presbyterian Health Plan (Turquoise Care) ABA benefits route and read on an eligibility check. Data last updated 2026-10-15.

### EDI routing

- **Payer ID (pVerify):** 02154 — pVerify BO00106 = "Presbyterian Health Plan"; 02154 = "Presbyterian Health Plan-EDI" (both Elig Y).
- **Payer ID (Change Healthcare / Optum):** 77048 — Presbyterian Turquoise Care Medicaid GS03 payor ID 77048 / Loop 2010BB NM109 = NMPHP (per phs.org Turquoise Claims page). Claim.MD lists Presbyterian as PREHP.
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** none (in-house Turquoise Care BH for Medicaid) — The guide prose establishes Presbyterian handles Turquoise Care (Medicaid) BH in-house (Magellan = Medicare/commercial only). A secondary source referenced "Magellan" for Presbyterian generally, but the primary Turquoise Claims page names no BH administrator — confirm ABA auth/claims are in-house via Presbyterian Provider line (505) 923-5757.
- **ABA rides on:** medical benefit — Integrated Turquoise Care; ABA rides the Presbyterian Medicaid payer ID (77048). No separate BH payer ID surfaced.
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required — Presbyterian's Provider Prior Authorization Guide (09.01.2026) lists 97151 on its Applied Behavior Analysis row for Turquoise Care, Turquoise Care Expansion ABP and Commercial. This is stricter than the state fee schedule (LOD #53), which marks 97151 "Prior Auth: NO". | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97152 | Yes | Required — Presbyterian's Provider Prior Authorization Guide (09.01.2026) lists 97152 on its Applied Behavior Analysis row for Turquoise Care, Turquoise Care Expansion ABP and Commercial. This is stricter than the state fee schedule (LOD #53), which marks 97152 "Prior Auth: NO". | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97153 | Yes | Required — Presbyterian's Provider Prior Authorization Guide (09.01.2026) lists 97153 on its Applied Behavior Analysis row for Turquoise Care, Turquoise Care Expansion ABP and Commercial. This is stricter than the state fee schedule (LOD #53), which marks 97153 "Prior Auth: YES". | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97154 | Yes | Required — Presbyterian's Provider Prior Authorization Guide (09.01.2026) lists 97154 on its Applied Behavior Analysis row for Turquoise Care, Turquoise Care Expansion ABP and Commercial. This is stricter than the state fee schedule (LOD #53), which marks 97154 "Prior Auth: NO". | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97155 | Yes | Required — Presbyterian's Provider Prior Authorization Guide (09.01.2026) lists 97155 on its Applied Behavior Analysis row for Turquoise Care, Turquoise Care Expansion ABP and Commercial. This is stricter than the state fee schedule (LOD #53), which marks 97155 "Prior Auth: NO". | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97156 | Yes | Required — Presbyterian's Provider Prior Authorization Guide (09.01.2026) lists 97156 on its Applied Behavior Analysis row for Turquoise Care, Turquoise Care Expansion ABP and Commercial. This is stricter than the state fee schedule (LOD #53), which marks 97156 "Prior Auth: NO". | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97157 | Yes | Required — Presbyterian's Provider Prior Authorization Guide (09.01.2026) lists 97157 on its Applied Behavior Analysis row for Turquoise Care, Turquoise Care Expansion ABP and Commercial. This is stricter than the state fee schedule (LOD #53), which marks 97157 "Prior Auth: NO". | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97158 | Yes | Required — Presbyterian's Provider Prior Authorization Guide (09.01.2026) lists 97158 on its Applied Behavior Analysis row for Turquoise Care, Turquoise Care Expansion ABP and Commercial. This is stricter than the state fee schedule (LOD #53), which marks 97158 "Prior Auth: NO". | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 0362T | Yes | Required — Presbyterian's Provider Prior Authorization Guide (09.01.2026) lists 0362T on its Applied Behavior Analysis row for Turquoise Care, Turquoise Care Expansion ABP and Commercial. This is stricter than the state fee schedule (LOD #53), which marks 0362T "Prior Auth: NO". | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 0373T | Yes | Required — Presbyterian's Provider Prior Authorization Guide (09.01.2026) lists 0373T on its Applied Behavior Analysis row for Turquoise Care, Turquoise Care Expansion ABP and Commercial. This is stricter than the state fee schedule (LOD #53), which marks 0373T "Prior Auth: YES". | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |

Code notes:

- **97151:** State clinical criteria; Presbyterian's own PA list gates every ABA code, assessment included. Treatment requests use its own Stage 3 ABA Clinical Review Form (fax (505) 843-3019 or the Turquoise Care portal — NOT Magellan for Medicaid). Stage 2 BCBA assessment; done annually. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **97152, 97157, 0362T:** State clinical criteria; Presbyterian's own PA list gates every ABA code, assessment included. Treatment requests use its own Stage 3 ABA Clinical Review Form (fax (505) 843-3019 or the Turquoise Care portal — NOT Magellan for Medicaid). Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **97153:** State clinical criteria; Presbyterian's own PA list gates every ABA code, assessment included. Treatment requests use its own Stage 3 ABA Clinical Review Form (fax (505) 843-3019 or the Turquoise Care portal — NOT Magellan for Medicaid). Adaptive behavior treatment by protocol — the primary PA-gated code. State PA quirk (Supplement 24-13 §3.17.1(A)): comprehensive treatment averaging UNDER 20 hrs/week requires PA regardless. Also PA-gated: >2 hrs T1026 UC/UD supervision per 10 hrs Stage 3. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **97154:** State clinical criteria; Presbyterian's own PA list gates every ABA code, assessment included. Treatment requests use its own Stage 3 ABA Clinical Review Form (fax (505) 843-3019 or the Turquoise Care portal — NOT Magellan for Medicaid). Group adaptive behavior treatment; UA (group 2–4) / UB (group 5–8) size modifiers. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **97155:** State clinical criteria; Presbyterian's own PA list gates every ABA code, assessment included. Treatment requests use its own Stage 3 ABA Clinical Review Form (fax (505) 843-3019 or the Turquoise Care portal — NOT Magellan for Medicaid). Protocol modification / supervision; ≥1 hr per 20 hrs of Stage 3 (97153/97154/97156) required with the recipient present. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **97156:** State clinical criteria; Presbyterian's own PA list gates every ABA code, assessment included. Treatment requests use its own Stage 3 ABA Clinical Review Form (fax (505) 843-3019 or the Turquoise Care portal — NOT Magellan for Medicaid). Family adaptive behavior treatment guidance. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **97158:** State clinical criteria; Presbyterian's own PA list gates every ABA code, assessment included. Treatment requests use its own Stage 3 ABA Clinical Review Form (fax (505) 843-3019 or the Turquoise Care portal — NOT Magellan for Medicaid). Group family guidance; UA/UB size modifiers. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **0373T:** State clinical criteria; Presbyterian's own PA list gates every ABA code, assessment included. Treatment requests use its own Stage 3 ABA Clinical Review Form (fax (505) 843-3019 or the Turquoise Care portal — NOT Magellan for Medicaid). Extra-technician / intensifying protocol. State PA quirk (Supplement 24-13 §3.17.1(A)): comprehensive treatment averaging UNDER 20 hrs/week requires PA regardless. Also PA-gated: >2 hrs T1026 UC/UD supervision per 10 hrs Stage 3. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).

### Medicaid rates

Source: Not separately published by Presbyterian Health Plan. Under LOD #53 the NM Medicaid FFS ABA fee schedule (see new-mexico-medicaid rates) is the ENFORCEABLE MINIMUM Presbyterian Health Plan and its sub-vendors must pay, retroactive to 1/1/2025 — so the floor is verified even though Presbyterian Health Plan's actual contracted/paid rate at or above it is not published. Effective 2025-01-01 (floor).

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | ≥ $112.65 (U3) / $130.94 (U5/U4) — LOD #53 floor | 15min | — |
| 97152 | ≥ $58.33 (U3) / $65.47 (U5/U4) — LOD #53 floor | 15min | — |
| 97153 | ≥ $19.85 (U1) / $23.35 (U9) / $32.31 (U3) — LOD #53 floor | 15min | — |
| 97154 | ≥ $11.43 (U1) / $18.59 (U3) — LOD #53 floor | 15min | — |
| 97155 | ≥ $39.69 (U3) / $55.55 (U5/U4) — LOD #53 floor | 15min | — |
| 97156 | ≥ $25.78 (U3) / $35.79 (U5/U4) — LOD #53 floor | 15min | — |
| 97157 | ≥ $51.59 (U3) / $71.43 (U5/U4) — LOD #53 floor | 15min | — |
| 97158 | ≥ $12.69 (U3) / $15.88 (U5/U4) — LOD #53 floor | 15min | — |
| 0362T | ≥ $112.29 (U3) / $130.94 (U5/U4) — LOD #53 floor | 15min | — |
| 0373T | ≥ $107.13 (U3) / $119.05 (U5/U4) — LOD #53 floor | 15min | — |

### Contacts

- **Provider services phone:** 505-923-5757 (or 1-888-923-5757 toll-free) — Presbyterian Provider Care Unit (claims, appeals, prior authorization questions); eligibility inquiries go through the PROVIDERConnect portal
- **Hours:** Mon–Fri, 8:00 a.m.–5:00 p.m.
- **Portal:** [myPRES](https://mypres.phs.org/)
- **Fax:** (505) 843-3019 (Turquoise Care behavioral health/ABA authorization fax)

Questions to ask on a verification call:

- Confirm Turquoise Care (Medicaid) behavioral health/ABA authorizations are handled in-house — not routed to Magellan (which is Presbyterian's Medicare/commercial BH vendor only).
- Confirm whether Presbyterian supports real-time 270/271 eligibility checks.
- Is there a published per-code daily unit cap for ABA beyond the state's weekly-hour ranges?
- Are ABA-specific telehealth POS codes or modifiers used for Presbyterian Turquoise Care billing?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://www.phs.org/providers/claims/turquoise-claims (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months)
- https://downloads.conduent.com/content/usa/en/document/270-payer-guide-medicaid-5010.pdf (accessed 2026-07-23)
- https://downloads.conduent.com/content/usa/en/document/eligibility-gateway-companion-guide.pdf (accessed 2026-07-23)
- https://onbaseext.phs.org/PEL/DisplayDocument?ContentID=PEL_00179220 (accessed 2026-09-27)
- https://www.hca.nm.gov/wp-content/uploads/FInal-LOD-53-Applied-Behavioral-Analysis-ABA-Fee-Schedule-Rates.pdf (accessed 2026-07-23)
- https://www.hca.nm.gov/wp-content/uploads/24-13-Supplement-ABA-Guidance.pdf (accessed 2026-07-23)
- https://www.phs.org/providers/authorizations (accessed 2026-07-23)
- https://www.phs.org/providers/contact-us (accessed 2026-10-15)

## Common questions

### Does Presbyterian Health Plan cover ABA under Turquoise Care?

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.

### Do I send Presbyterian Medicaid ABA authorizations to Magellan?

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.

### Does Presbyterian require PA on the ABA assessment?

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.

### Do ABA technicians need RBT certification for Presbyterian (New Mexico Medicaid)?

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.

### Can BCBA supervision (97155) be done by telehealth for Presbyterian members?

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.

### Does Presbyterian require ABA goals to be organized by DSM-5 criteria for Turquoise Care?

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.

### How much parent training does Presbyterian expect for Turquoise Care?

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.

### What is Presbyterian Turquoise Care’s timely filing limit?

Ninety days from the date of service for in-network claims; corrections and appeals within 12 months of the date of service.

## Primary sources

1. [Presbyterian Health Plan — Authorizations for Providers](https://www.phs.org/providers/authorizations)
2. [Presbyterian Provider Prior Authorization Guide (09.01.2026)](https://onbaseext.phs.org/PEL/DisplayDocument?ContentID=PEL_00179220)
3. [MAD Supplement 24-13 — ABA Guidance (state criteria)](https://www.hca.nm.gov/wp-content/uploads/24-13-Supplement-ABA-Guidance.pdf)
4. [Letter of Direction #53 — ABA Fee Schedule Rates (MCO rate floor)](https://www.hca.nm.gov/wp-content/uploads/FInal-LOD-53-Applied-Behavioral-Analysis-ABA-Fee-Schedule-Rates.pdf)
5. [NMAC 8.321.2.13 Applied Behavior Analysis (Cornell LII)](https://www.law.cornell.edu/regulations/new-mexico/N-M-Admin-Code-SS-8.321.2.13)
6. [Turquoise Care BH Level of Care Guidelines (ABA Stage 3, defers to NMAC 8.321.2)](https://www.bcbsnm.com/turquoise-care/pdf/tc-bh-level-care-guidelines-nm.pdf)
7. [8.310.2.12(M) NMAC — Telehealth services (srca.nm.gov, amended 1/1/2025)](https://www.srca.nm.gov/parts/title08/08.310.0002.html)
8. [8.321.2.13 NMAC — Applied Behavior Analysis (srca.nm.gov)](https://www.srca.nm.gov/parts/title08/08.321.0002.html)
9. [Presbyterian Health Plan — Provider news and communications (Network Connection archive)](https://www.phs.org/providers/contact-us/news-and-communications)
10. [Presbyterian Turquoise Care Practitioner and Provider Manual (2026), Claims and Payment](https://onbaseext.phs.org/PEL/DisplayDocument?ContentID=OB_000000001114)
11. [Turquoise Care Medicaid Managed Care Services Agreement — Presbyterian, Amendment 5 (signed 12/2025), §§ 4.5.19.8, 4.19.11](https://www.hca.nm.gov/wp-content/uploads/TCPHP_24-630-8000-0031_CA5_Signed.pdf)
12. [8.302.3 NMAC — Third Party Liability Provider Responsibilities](https://www.srca.nm.gov/parts/title08/08.302.0003.html)
13. [10 U.S.C. 1079(i)(1) — TRICARE pays after other coverage except Medicaid](https://www.govinfo.gov/content/pkg/USCODE-2023-title10/html/USCODE-2023-title10-subtitleA-partII-chap55-sec1079.htm)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.