---
title: "Texas Medicaid ABA coverage: the intake guide."
url: "https://carelu.com/payers/texas-medicaid"
markdown_url: "https://carelu.com/payers/texas-medicaid.md"
state: TX (Texas)
payer: Texas Medicaid (THSteps-CCP)
kind: State Medicaid program
description: "How Texas Medicaid covers ABA under the THSteps-CCP Autism Services benefit — prior authorization on evaluation and treatment, the 90/90/180-day cadence, the April 2025 signature change, the 3-year diagnosis recency rule, September 2025 rates, and the STAR/STAR Kids/STAR Health MCO landscape."
last_reviewed: October 2026
vob_data_updated: 2026-10-15
---

# Texas Medicaid ABA coverage: the intake guide.

_Payer Guide · Texas Medicaid · Last updated October 2026 · 17 primary sources_

> THSteps-CCP EPSDT ages 0–20; PA on everything, 90/90/180 cadence, 3-yr dx recency.

Texas Medicaid added ABA as a defined benefit on February 1, 2022 — "Autism Services" under the Texas Health Steps Comprehensive Care Program (THSteps-CCP), the state's EPSDT vehicle. It is one statewide rulebook: HHSC writes the medical-necessity criteria into the Texas Medicaid Provider Procedures Manual (TMPPM), and every delivery channel — fee-for-service through TMHP and all the STAR, STAR Kids, and STAR Health managed-care plans — applies the same criteria. The benefit covers ages birth through 20 (eligibility ends on the 21st birthday; CHIP is explicitly excluded), requires prior authorization on everything from the initial evaluation forward, and runs on a distinctive 90/90/180-day authorization cadence. The MCO guides below cover per-plan submission mechanics; the clinical rules on this page apply everywhere.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — CCP PA form with signed prescriber referral + ASD dx (made/reconfirmed within 3 years); 97151 capped at 24 units [3]
- **Prior auth for treatment**: Required — two 90-day initial periods, then 180-day recerts; since 4/1/2025 no prescriber signature on the 90-day extension [3][4]
- **Autism diagnosis required?**: Yes — ASD (F84.0); diagnosis alone doesn't establish medical necessity [3]

## At a glance

- **Covers ABA?:** Yes — ages birth through 20, via THSteps-CCP (EPSDT); CHIP excluded
- **Assessment auth:** Required — 97151 (24 units / 6 hrs max), CCP PA form + signed prescriber referral
- **Treatment auth:** Required — 90-day initial + 90-day extension, then 180-day recertifications
- **Diagnosis recency:** ASD dx (DSM criteria + severity level) made or reconfirmed within the past 3 years
- **Rates (per 15 min):** 97153: $14.50 · 97151: $27.56 · 97155: $20.08–$25.10 (eff. 9/1/2025, ~11.5% increase)
- **Fee schedule:** Published — TMHP Autism Services static fee schedule (run 9/14/2026); the 9/1/2025 rates are still the current rows
- **Daily cap:** 8 hours (32 units) of direct treatment across 97153, 97154, 97155, 97158
- **Delivery:** FFS via TMHP + STAR / STAR Kids / STAR Health MCOs — identical TMPPM criteria
- **Staff screening:** BTs need RBT, BCAT, or ABAT cert (no Medicaid enrollment); monthly LEIE + HHSC-OIG exclusion checks on all staff

## The benefit and who qualifies

Autism Services is an EPSDT benefit: THSteps-CCP covers medically necessary ABA for members from birth through age 20, with eligibility ending on the 21st birthday. The gate is an ASD diagnosis — but not any diagnosis, from anyone, at any time. The TMPPM requires the diagnosis to come from a developmental pediatrician, neurologist, psychiatrist, licensed psychologist, or an interdisciplinary team (a physician, PA, or NP in consultation with qualified child specialists with autism expertise), documented with DSM diagnostic criteria and a symptom severity level, and made or reconfirmed within the 3 years before the PA request. A diagnosis alone is not sufficient to establish medical necessity — the evaluation builds that case. For intake, the 3-year recency rule is the trap to screen for early: a child diagnosed at 2 who shows up at 7 needs a diagnostic reconfirmation before the PA can go in. [2][3]

## The authorization cadence: eval → 90 → 90 → 180

Everything is prior-authorized. The ABA evaluation (97151, limited to 24 units / 6 hours per evaluation, billed with the HO modifier by the LBA) needs a PA that includes a signed referral from the prescribing provider plus the diagnosis documentation, submitted on the CCP Prior Authorization Request Form. Treatment then authorizes in two consecutive 90-day periods — the initial 180-day treatment plan must be signed and dated by the prescribing provider — followed by recertifications in increments of up to 180 days. [3][4]

The friction-reducer worth knowing: effective April 1, 2025, TMHP dropped the prescribing-provider signature requirement on the CCP PA form for the 90-day treatment extension. The initial plan still needs the prescriber's signature, but the mid-cycle extension no longer stalls on chasing a physician's pen — a real cycle-time win for practices that learned the benefit in its first three years. What a renewal must carry: the 90-day extension needs “an attendance log that also includes a calculation of the percentage of planned sessions completed for the child or youth and their parent or caregiver, and a progress summary”; the 180-day recertification rests on the 97151 re-evaluation, which also carries the attendance log. The TMPPM does not ask for graphs in the request itself, but every session note must include “direct observation measures that record data during every treatment session to allow the LBA to graph data across time for analysis.” [3][4]

## Rates, modifiers, and who can enroll

HHSC raised ABA rates roughly 11.5% across the board effective September 1, 2025 — the first adjustment since the benefit launched. Per 15-minute unit: 97151 evaluation pays $27.56 (was $24.71); 97153 direct treatment by a behavior technician pays $14.50 (was $13.00); 97155 protocol modification pays $20.08–$25.10 and 97156 family training $18.40–$23.01, tiered by credential modifier. Texas flags credentials with modifiers — HO for the Licensed Behavior Analyst (LBA), HN for the Licensed assistant Behavior Analyst (LaBA), HM for behavior technicians — though 97153 itself takes no credential modifier. Two structural notes: only LBAs can enroll in Texas Medicaid (LaBAs and BTs bill under the LBA's supervision), and MCO reimbursement is contract-specific even though it generally tracks the HHSC fee schedule. The rate figures here come from the HHSC rate-hearing packet; confirm current values in the TMHP Online Fee Lookup before building revenue models. The code set is CPT only: TMPPM § 2.3.12 lists 97151 (evaluation and re-evaluation), 97153 and 97155 (individual), 97154 and 97158 (group), 97156 (caregiver training) and 99366 (interdisciplinary team meeting) as the procedure codes that “may be reimbursed” for ABA; 97152, 97157, 0362T, 0373T and HCPCS H-codes such as H0031, H0032 or H2019 are not on that list. [3][5][15][6]

## Delivery rules: hour caps, telehealth, and the MCO landscape

Direct treatment is capped at 8 hours (32 units) per day combined across 97153, 97154, 97155, and 97158. Telehealth (synchronous audio-visual, modifier 95) is allowed for 97151, 97155, 97156, 97158, and 99366 — but 1:1 direct treatment delivered by a BT or LaBA must be in person; no telehealth. Interdisciplinary team meetings are billable under 99366 with an ABA PA on file. [3][14][2]

On the delivery side, Texas runs a hybrid: fee-for-service through TMHP, and managed care through STAR (most children), STAR Kids (disability-related Medicaid), and STAR Health (foster care, statewide through Superior). Texas has 15+ Medicaid MCOs across its service delivery areas — including BCBSTX, Community Health Choice, Cook Children's, El Paso Health, and Parkland alongside the plans profiled below — and all of them apply the same TMPPM criteria. What varies per plan is the PA intake machinery: forms, portals, fax lines. Capture the child's plan at intake and use the matching MCO guide. HHSC's January 2026 service-area roster confirms the per-plan footprints throughout this section are still current — e.g., Harris County STAR runs through Community Health Choice, Molina, Texas Children's, United, and Wellpoint; Bexar STAR through Aetna, Community First, Superior, and Wellpoint — superseding the September 2024 archived copy this directory previously rested on. [3][14][2]

## Staffing & credentialing: who you can hire, and what they must clear

Texas certifies behavior technicians but doesn't license them. The TMPPM (§ 2.3.6.3) requires every BT to hold one of three certifications — RBT, BCAT, or ABAT — so the RBT is accepted but explicitly not the only pathway. BTs may not enroll in Texas Medicaid (they render under the enrolled LBA), may not use "therapist" in their job title when interacting with Medicaid families, and may not conduct assessments or modify the treatment plan. There's no state license, registry, or training-hour add-on for BTs: Occupations Code § 506.054 exempts a person designated as a behavior technician from behavior analyst licensure when working under the authority and direction of an LBA or LaBA, so the certification requirement comes from Medicaid policy, not licensure law. For the RBT pathway, the BACB's own floor is what screens your hires: 18+, high-school education, a criminal background check and abuse-registry check no more than 180 days before applying, the 40-hour training, a competency assessment, and the exam. [3][7][8][9][10][11][12][13]

The agency-level screening that actually binds a standalone ABA practice is exclusion screening, not the long-term-care registries. As a condition of enrollment, all providers must screen every employee and contractor every month against both the federal HHS-OIG LEIE and the Texas HHSC-OIG exclusion list (TMPPM Vol. 1, § 1.3.1) — build this into payroll-cycle compliance, not just onboarding. The Employee Misconduct Registry, by contrast, applies only to the facility types listed in Health & Safety Code § 253.001 (nursing facilities, HCSSAs, assisted living, ICF/IID, and similar) — a standalone ABA agency isn't on that list, so EMR pre-hire checks aren't legally required unless you also hold one of those licenses. Fingerprinting is similarly narrow: it attaches at provider enrollment, only for high categorical-risk providers and owners with a 5%+ interest (via IdentoGO, with proof uploaded to PEMS within 30 days of application) — individually licensed behavior analysts are not designated high-risk. At the supervisor level, TDLR requires every LBA and LaBA applicant to pass a criminal history background check as a condition of licensure. [3][7][8][9][10][11][12][13]

Supervision structure follows enrollment structure. Only the LBA enrolls and bills; the LBA must directly employ or contract with every LaBA and BT on the team, and LaBAs can't practice independently — by statute they must be supervised by an LBA per their certifying body's requirements. The TMPPM makes LBAs the direct supervisors of LaBAs and BTs but sets no numeric ratio of its own, deferring to certifying-body minimums — which makes the BACB standard the operative floor for RBT-credentialed staff: supervision of at least 5% of service hours each month, with at least two face-to-face contacts per month (one observing service delivery, one individual). One billing wrinkle to plan around: only direct supervision — the LBA observing the LaBA or BT with the client — is reimbursable, under 97155; indirect supervision (caseload review, data discussion) is unpaid time. And BTs and LaBAs must deliver 1:1 treatment in person — no remote service delivery. MCOs mirror this baseline (Texas Children's Health Plan's autism guideline repeats it nearly verbatim), but only TCHP was checked in depth — confirm each MCO's provider manual for staff-level extras at contracting. [3][7][8][9][10][11][12][13]

## What is the Texas Medicaid ABA fee schedule?

TMHP publishes it. The static Autism Services fee schedule (file PRCR615C, run 9/14/2026) lists these per-unit Medicaid fees for clients aged 0–20: 97151-HO $27.56, 97153 $14.50, 97155-HN $20.08, 97155-HO $25.10, 97156-HN $18.40 and 97156-HO $23.01, all effective 9/1/2025; 97154 $1.63, 97158-HN $2.25 and 97158-HO $2.81, effective 3/1/2024; and 99366 team conferences $33.96 (non-facility). Every row shows a last pricing review of 9/1/2025, so the September 2025 increase is still the current rate set. The schedule notes that Medicaid rates are reviewed every two years or as necessary, and the TMPPM says autism services are reimbursed under 1 TAC § 355. For the fee on a particular date of service, use the TMHP Online Fee Lookup. [15][3][6]

## Is the Texas Medicaid ABA network open to new providers?

Fee-for-service participation means enrolling in Texas Medicaid through TMHP, and only the LBA enrolls (LaBAs and behavior technicians may not). Managed care is a second step with its own gate. The TMPPM's Medicaid Managed Care Handbook says providers "must be enrolled in Texas Medicaid before they can be enrolled by an MCO," that "Individual MCOs and DMOs have their own guidelines for contracting providers," and that "Enrollment in Texas Medicaid does not guarantee that an MCO or DMO will contract enroll or credential a particular provider." Every Medicaid MCO credentials through the Texas Association of Health Plans' contracted credentialing verification organization. Whether a given plan is adding ABA providers is therefore a question for that plan's provider relations team. Where no in-network provider is available, the MCO "must allow a referral to an out-of-network Medicaid provider," requested by an in-network provider and decided within five business days at most. [16][3]

## What happens when a family switches ABA providers or plans?

Changing ABA agencies restarts the authorization. Under TMPPM § 2.3.9, when a provider or client stops therapy during an authorized period and the client goes to a new provider outside the current group, "the new provider must start a new request for authorization and submit all documentation required for an initial evaluation." That includes a change-of-therapy-provider letter signed by the responsible adult, giving the date therapy ended with the previous provider (or the last date of service) and the names of both providers. A move to another performing provider within the same group keeps the same evaluation and plan of care, and the authorization period does not change. A gap of 180 days or more with no ABA treatment or re-evaluation also means starting over with an initial request. [3][16]

Changing health plans works differently. "Health plan prior authorizations do not automatically transfer with a client who moves to another plan," but once the client or provider tells the new MCO about an existing prior authorization, the new MCO must continue the services at the same amount, duration and scope until the earliest of: 90 days after the transition, the end of the current authorization, or its own assessment and new decision. [3][16]

## What is the Texas Medicaid timely filing limit, and what goes on the claim?

TMHP must receive a fee-for-service claim within 95 days of each date of service; appeals of denied claims and adjustment requests must reach TMHP within 120 days of the disposition date on the Remittance and Status (R&S) Report. A 95-day or 120-day deadline that falls on a weekend or holiday moves to the next business day. The federal 365-day limit still caps exceptions such as retroactive eligibility (95 days from the eligibility add date, within 365 days of service). [18][16]

Claims must carry the provider’s complete name, physical address with ZIP+4, NPI, taxonomy code and benefit code (if applicable). Paper claims must show an NPI and taxonomy code for both the billing and the performing provider, and a claim missing either is denied. For a child in a STAR or STAR Kids plan, the claim goes to that MCO instead, which must also receive it within 95 days of the date of service. [18][16]

## Intake gates

The questions that decide whether a family can start with Texas Medicaid (THSteps-CCP), and what they have to bring.

- **Age limit**: Birth through 20 years of age on the date of service; clients become ineligible for CCP services the day of their 21st birthday. CHIP is excluded from the ABA benefit entirely. [3]
- **Diagnosis recency**: The ASD diagnosis must be made or reconfirmed within 3 years of initiation or recertification. Past 3 years the TMPPM requires a comprehensive re-evaluation of ASD symptom severity levels per DSM criteria before the PA can proceed. [3]
- **Who may diagnose**: A developmental pediatrician, neurologist, psychiatrist, licensed psychologist, or an interdisciplinary diagnostic team (a physician, PA or NP in consultation with qualified child specialists with autism expertise). The diagnosis must be documented with DSM criteria and a symptom severity level. [3]
- **Diagnostic tools required**: A reliable, valid, standardized diagnostic assessment tool or combination of tools — the TMPPM names the Autism Diagnostic Observation Schedule, the ADI-R and the Childhood Autism Rating Scale as examples. Screening tools alone (STAT, M-CHAT-R) cannot replace a validated diagnostic instrument. [3]
- **Referral required?**: Two signed referrals. For the evaluation: a signed, dated referral from the prescribing provider, signed within 60 calendar days prior to or on the anticipated evaluation date. For treatment: a signed, dated referral from a physician or allowed practitioner (MD/DO, PA, NP, or CNS with properly delegated authority) outlining the frequency and duration of treatment, with a signature current to the service dates — on or before the service start date and no older than three months. Since 4/1/2025 the prescriber signature is no longer required on the CCP PA form for the 90-day treatment extension; the initial 180-day treatment plan still needs it. The LBA’s assessment and treatment plan must also name "the referring prescribing provider." On the claim, TMPPM § 6.4.2.4 says "All Texas Medicaid claims for services that require a physician order or referral must include the ordering or referring provider’s NPI," and that prescriber must be enrolled in Texas Medicaid (as a billing or performing provider, or with an ordering/referring-only enrollment); claims without it, or with an unenrolled NPI, "may be subject to retrospective review and denial." On the CMS-1500 the name goes in block 17 with qualifier DN (referring) and the NPI in 17b. TMHP publishes no separate ABA order form; the referral rides with the CCP prior authorization request. [3][4][18]
- **Telehealth**: Synchronous audio-visual only, modifier 95, and only on 97151, 97155, 97156, 97158 and 99366. That list covers the assessment: 97151 is the initial evaluation and the re-evaluation done every 180 days, both by the LBA. It also covers 97155 when the LBA directly supervises a BT or LaBA working with the child. "LaBAs and RBTs may not deliver any service remotely," and one-on-one services delivered directly to the child by a behavior technician or LaBA must be in person — the TMPPM prohibits telehealth for BT/LaBA-delivered direct service. On the claim the telehealth marker is the modifier: the Telecommunication Services Handbook says “Telemedicine and telehealth services must be billed with modifier 95” and names no telehealth place-of-service code (no POS 02 or 10 rule); the Autism Services section says its remote-delivery rules “supersede” that handbook. [1][3]
- **Prior-auth decision time**: Fee-for-service through TMHP: when a CCP request needs physician review, TMHP's Physician Reviewer "will complete the review within three business days of receipt of the completed prior authorization request," with "an additional three business days" when a peer-to-peer with the prescriber is needed. The clock runs from a COMPLETE request: an incomplete one is held while TMHP makes at least three contact attempts, and if the missing information "is not received within 14 business days of the request receipt date, the request will be denied as 'incomplete.'" The federal ceiling for state agencies since 1/1/2026 is 7 calendar days standard and 72 hours expedited (42 CFR 440.230(e)), unless state law sets a shorter one. The windows that actually cost money are the provider-side ones in § 2.3.11: the evaluation PA goes in within 60 days before or on the evaluation date; initial treatment within 3 business days of the start-of-care date (later requests are denied for dates before receipt); the 90-day extension is timely "within 30 days prior to the end of the current authorization period"; and a 180-day recertification must be received "no earlier than 60 days before the current authorization period expires" — anything filed after the end date is denied for the gap. Managed-care members follow their MCO's clock (Texas law: 3 business days, see the MCO guides). [3][19][20]
- **Other insurance (who pays first)**: Medicaid is the payer of last resort: a provider "must seek reimbursement from available third party insurance that the provider knows about or should know about before billing Texas Medicaid." Bill the commercial plan (or TRICARE, which the TMPPM lists as a third party resource) first, then file with TMHP within 95 days of the other insurer's payment or denial and within 365 days of the date of service, with the EOB's disposition date; if the other insurer has not answered after 110 days, TMHP will consider the claim. Get the Medicaid PA even when Medicaid is secondary — § 5.1.4: "If a client's primary coverage is private insurance and Medicaid is secondary but prior authorization is required for Medicaid reimbursement, providers must follow the guidelines and requirements listed in the handbook for that service." The one bill-Medicaid-first option in Section 8 ("THSteps medical and dental providers are not required to bill other insurance before billing Medicaid") names only THSteps medical and dental (checkup) providers; ABA is a CCP service, so bill the other coverage first. Exceptions to last-resort: in STAR Health (foster care) "Medicaid is primary … Providers must not bill other health insurance unless there is a court order," and CHAMPVA pays before Medicaid. The family owes nothing past the other insurer's payment for a Medicaid-covered service. [21][22][23][24]

## Delivery and billing rules

Coverage decides whether Texas Medicaid (THSteps-CCP) 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**: The TMPPM sets no numeric ratio of its own: LBAs must directly supervise LaBAs and behavior technicians in accordance with Texas state licensure, which makes the certifying body's floor operative — for RBT-credentialed staff, the BACB minimum of supervision on at least 5% of service hours each calendar month with two face-to-face contacts. Only direct supervision, where the LBA directly observes the LaBA or BT providing services with the child, is reimbursable, under 97155; indirect supervision (caseload review, data discussion) is unpaid time. The LBA may deliver 97155 by synchronous audio-visual telehealth (modifier 95), and 97155 may be used when directly supervising a BT or LaBA working with the child; the supervised staff themselves may not deliver any service remotely ("LaBAs and RBTs may not deliver any service remotely"). [3][8]
- **Concurrent billing (97153 + 97155)**: Prohibited: Texas Medicaid will not reimburse multiple ABA providers during one ABA session with the child when more than one ABA provider is present. The one exception is when the family and the child are receiving separate services and the child is not present in the family session. Providers may request total authorized hours under either 97153 or 97155 and bill the code matching the service actually delivered, but not both for the same clock time with the child present. The autism section does not address ABA billed during a speech, occupational or physical therapy session; it requires the treatment plan to coordinate with an SLP, OT or PT where a co-morbid condition calls for it. [3]
- **Daily limits / MUEs**: Direct treatment is limited to 8 hours (32 units) per day, inclusive of 97153, 97154, 97155 and 97158. The 97151 evaluation and each re-evaluation are limited to 6 hours (24 units). Group treatment requires at least 2 and no more than 8 children. These are claim edits as well as authorization limits: “If services billed exceed the limitations outlined in this section, the claim will be denied, and may be appealed.” Authorization runs as two consecutive 90-day periods, then recertifications in increments of up to 180 days. [3]
- **Session-note signature**: Rendering ABA providers must sign each entry with full signature and credentials, and additional supervisory signatures must be made in accordance with state licensure requirements. Treatment notes for 97153/97154 carry the child's name, date of service, start and stop times, treatment goals addressed, progress and a summary of activities and interventions; 97155/97158 notes add protocol-modification decision points and progress assessments. The 97151 evaluation and the post-90-day progress summary each require a dated signature from the LBA and from the parent or caregiver. [3]
- **Place of service**: Home, clinic, office and community settings are payable, and ABA may be delivered across settings. Schools are permitted for coordination of care — school personnel of the same discipline participating to coordinate care are not treated as duplicates, and interdisciplinary team meetings bill under 99366 with an ABA PA on file — but services delivered by a behavior technician in the school setting as a shadow, an aide, or to provide general support are excluded. BT and LaBA direct treatment must be in person in any setting. [3]
- **Bill as provider**: Only the LBA enrolls in Texas Medicaid and bills. LaBAs and behavior technicians may not enroll; their services are billed under the supervising LBA's NPI with the credential modifier identifying the rendering staff level — HO for the LBA, HN for the LaBA, HM for the behavior technician. 97151 takes the HO modifier only; 97155, 97156 and 97158 take HO or HN; 97153 takes no required credential modifier. The 97155 supervision claim likewise goes out under the LBA's NPI. [3]

## What intake should collect for Texas Medicaid (THSteps-CCP)

- **Program & plan:** FFS vs. STAR / STAR Kids / STAR Health, and which MCO — same clinical rules, different PA machinery.
- **ASD diagnosis + date:** Diagnoser type matters (TMPPM list), and the dx must be made or reconfirmed within 3 years — screen recency at intake.
- **Prescriber referral:** A signed referral from the prescribing provider attaches to the evaluation PA — chase it first, not last.
- **Age check:** Benefit runs birth through 20 and ends on the 21st birthday; CHIP members are excluded entirely.
- **Supervising LBA:** Only LBAs enroll in Texas Medicaid — confirm the enrolled LBA who will bill for the team.

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

## Verification of benefits (VOB) data

How Texas Medicaid (THSteps-CCP) ABA benefits route and read on an eligibility check. Data last updated 2026-10-15.

### EDI routing

- **Payer ID (pVerify):** 00186
- **Supports 270/271 eligibility:** Yes
- **Real-time eligibility:** Yes
- **Behavioral health administrator:** none
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No
- **Where the 271 carries MCO enrollment:** 2110C EB loop carries the base eligibility/benefit segment (EB01='1' covered / 'I' non-covered, EB04='OT', EB05=program short code, e.g. 'STAR'); the Managed Care Plan Code itself is REF02 in the SAME loop's REF segment where REF01='18' (per §11: 'Texas Medicaid will send "18" in REF01 to indicate the presence of a...Managed Care Plan Code in the REF02 element'). A separate 2120C loop, present only for members with an assigned PCP or provider lock-in, carries the Primary Care Physician's name — NOT the MCO name.
- **Eligibility span granularity:** Date range, not a fixed monthly bucket — DTP*356 (coverage begin) and DTP*357 (coverage end) in D8 (CCYYMMDD) format on the 'Covered Managed Care' EB segment carry the actual enrollment span, which can run for any number of days/months per the companion guide's own example (20141001–20150430).

Managed-care codes returned in the 271:

| Code | Meaning |
| --- | --- |
| 1 | STAR (EB05 short code: STAR) |
| 2 | STAR PLUS (EB05 short code: STRP) |
| 6 | Foster Care Managed Care / STAR Health (EB05 short code: STRH) |
| 7 | Children's Medicaid Dental Services (EB05 short code: DENT) |
| 8 | CHIP (EB05 short code: CHIPMCO) |
| 9 | CHIP Dental (EB05 short code: CHIPDENT) |
| K | STAR Kids (EB05 short code: STRK) |

### How the 271 reports ABA benefits

- **ABA benefit bucket (service type code):** MH
- **Deductible applies to ABA:** no
- **Cost-share type:** plan-dependent
- **271 response quality for ABA:** high

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes — ABA Initial Evaluation / Re-evaluation, by the LBA | Required — CCP PA form + signed prescriber referral; not reimbursable unless the evaluation was submitted for authorization of payment; must be billed within 30 calendar days of the first date of service | 24 units (6 hours) per evaluation or re-evaluation event per per evaluation event; re-evaluations authorized no more than once every 180 days | office, home, clinic, community | Yes — 95 modifier, synchronous audio-visual only, delivered by the LBA (LaBAs and BTs/RBTs may not deliver any service remotely) | HO (required — LBA only) |
| 97152 | Not confirmed (see code notes) | — | — | — | — | — |
| 97153 | Yes — direct 1:1 ABA treatment (BT-complexity level), delivered per treatment-plan protocol | Required — covered under the treatment authorization (90-day initial + 90-day extension, then 180-day recertifications; no prescriber signature on the 90-day extension since 4/1/2025) | Shares the 8-hour (32-unit) combined daily direct-treatment cap, shared with 97153, 97154, 97155, and 97158 (TMPPM §2.3.12). per day | office, home, clinic, community | No — 1:1 direct treatment must be delivered in person | No modifier required (HO/HN/HM may be reported for information only) |
| 97154 | Yes — direct group ABA treatment (BT-complexity level; group is 2–8 children/youth) | Required — covered under the treatment authorization (90-day initial + 90-day extension, then 180-day recertifications) | Shares the 8-hour (32-unit) combined daily direct-treatment cap, shared with 97153, 97154, 97155, and 97158 (TMPPM §2.3.12). per day | office, home, clinic, community | No — group direct treatment must be delivered in person | No modifier required (HO/HN/HM may be reported for information only) |
| 97155 | Yes — protocol modification / direct 1:1 time by the LBA (or delegated LaBA) | Required — covered under the treatment authorization (90-day initial + 90-day extension, then 180-day recertifications) | Shares the 8-hour (32-unit) combined daily direct-treatment cap, shared with 97153, 97154, 97155, and 97158 (TMPPM §2.3.12). per day | office, home, clinic, community | Yes — 95 modifier, synchronous audio-visual, delivered by the LBA only | HO or HN (one required) |
| 97156 | Yes — parent/caregiver education & training, by the LBA (or delegated LaBA) | Required — covered under the treatment authorization | — | office, home, clinic, community | Yes — 95 modifier, synchronous audio-visual, delivered by the LBA (LaBAs may not deliver this — or any — service via telehealth, even by delegation) | HO or HN (one required) |
| 97157 | Not confirmed (see code notes) | — | — | — | — | — |
| 97158 | Yes — group protocol modification, by the LBA (or delegated LaBA) | Required — covered under the treatment authorization | Shares the 8-hour (32-unit) combined daily direct-treatment cap, shared with 97153, 97154, 97155, and 97158 (TMPPM §2.3.12). per day | office, home, clinic, community | Yes — 95 modifier, synchronous audio-visual, delivered by the LBA only | HO or HN (one required) |
| 99366 | Yes — interdisciplinary team meeting, attended by qualified nonphysician health-care providers | Not separately authorized — reimbursable when a PA for ABA evaluation, re-evaluation, or treatment is already on file; reimbursement limited to primary diagnosis F84 | — | office, home, clinic, community, remote participation for team members (95 modifier) | Yes — 95 modifier for remote participation by team members | No modifier required (95 for remote participation) |
| 0362T | Not confirmed (see code notes) | — | — | — | — | — |
| 0373T | Not confirmed (see code notes) | — | — | — | — | — |

Code notes:

- **97152:** 97152 does not appear anywhere in the TMPPM Children's Services Handbook §2.3 Autism Services or in TMHP's "AUTISM SERVICES" static fee schedule (PRCR615C) — cross-checked against both independently. Texas's actual THSteps-CCP Autism Services billable code set appears to be limited to 97151, 97153, 97154, 97155, 97156, 97158, and 99366. Verify via: TMHP provider relations / Online Fee Lookup — confirm whether this code is billable under Texas Medicaid THSteps-CCP Autism Services at all, under a different program, or not covered.
- **97153:** Either 97153 or 97155 may be billed for direct individual treatment hours — bill the code matching who delivered the session.
- **97154:** Either 97154 or 97158 may be billed for direct group treatment hours.
- **97155:** Also the code used to bill the required progress summary submitted after the first 90 days of treatment. Only DIRECT supervision (LBA observing the LaBA/BT with the client) is reimbursable under this code — indirect supervision (caseload review, data discussion) is not billable.
- **97156:** Continued treatment authorization considers caregiver attendance at ≥85% of planned sessions.
- **97157:** 97157 does not appear anywhere in the TMPPM Children's Services Handbook §2.3 Autism Services or in TMHP's "AUTISM SERVICES" static fee schedule (PRCR615C) — cross-checked against both independently. Texas's actual THSteps-CCP Autism Services billable code set appears to be limited to 97151, 97153, 97154, 97155, 97156, 97158, and 99366. Verify via: TMHP provider relations / Online Fee Lookup — confirm whether this code is billable under Texas Medicaid THSteps-CCP Autism Services at all, under a different program, or not covered.
- **99366:** School-district personnel may participate and count toward the 3-participant licensed-professional minimum but are not separately reimbursable.
- **0362T:** 0362T does not appear anywhere in the TMPPM Children's Services Handbook §2.3 Autism Services or in TMHP's "AUTISM SERVICES" static fee schedule (PRCR615C) — cross-checked against both independently. Texas's actual THSteps-CCP Autism Services billable code set appears to be limited to 97151, 97153, 97154, 97155, 97156, 97158, and 99366. Verify via: TMHP provider relations / Online Fee Lookup — confirm whether this code is billable under Texas Medicaid THSteps-CCP Autism Services at all, under a different program, or not covered.
- **0373T:** 0373T does not appear anywhere in the TMPPM Children's Services Handbook §2.3 Autism Services or in TMHP's "AUTISM SERVICES" static fee schedule (PRCR615C) — cross-checked against both independently. Texas's actual THSteps-CCP Autism Services billable code set appears to be limited to 97151, 97153, 97154, 97155, 97156, 97158, and 99366. Verify via: TMHP provider relations / Online Fee Lookup — confirm whether this code is billable under Texas Medicaid THSteps-CCP Autism Services at all, under a different program, or not covered.

### Medicaid rates

Source: TMHP static fee schedule "AUTISM SERVICES" (PRCR615C), Licensed Behavior Analyst (LBA) provider type; cross-confirmed against the HHSC 9/1/2025 rate-adjustment packet already cited in texas.ts prose. Effective 2025-09-01.

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | $27.56 per 15-min unit (HO modifier only) | 15min | — |
| 97153 | $14.50 per 15-min unit (no modifier required) | 15min | — |
| 97154 | $1.63 per 15-min unit (no modifier required; rate last reviewed 3/1/2024, unchanged in the 9/1/2025 action) | 15min | — |
| 97155 | Modifier-tiered — see modifierTiers | 15min | HN: $20.08 (LaBA); HO: $25.10 (LBA) |
| 97156 | Modifier-tiered — see modifierTiers | 15min | HN: $18.40 (LaBA); HO: $23.01 (LBA) |
| 97158 | Modifier-tiered — see modifierTiers (rates last reviewed 3/1/2024, unchanged in the 9/1/2025 action) | 15min | HN: $2.25 (LaBA); HO: $2.81 (LBA) |
| 99366 | $33.96 per encounter (no modifier required; LBA provider type; rate last reviewed 3/1/2024) | per encounter | — |

### Contacts

- **Provider services phone:** 800-925-9126
- **Phone menu path:** Contact Center menu routes by topic — ask for "Authorizations" or "Eligibility"; a separate Third Party Resource (insurance verification) line runs 8 a.m.–5 p.m. CT. EDI/TexMedConnect technical issues route to the EDI Help Desk (1-888-863-3638), already cited in this guide's edi.verifyVia.
- **Hours:** 7 a.m.–7 p.m. Central Time, Monday–Friday
- **Portal:** [TMHP.com / TexMedConnect provider portal](https://www.tmhp.com/)

Questions to ask on a verification call:

- Do you have a distinct Availity or Change Healthcare payer ID for Texas Medicaid/TMHP 270/271 eligibility checks, separate from pVerify code 00186?
- Beyond the STAR/STAR Kids/CHIP program code carried in EB05, is there a fixed lookup table mapping REF02 codes to specific MCO names (e.g., Superior vs. Wellpoint), or does the MCO name only ever appear as free text?
- Is the Autism Services copay or coinsurance charged per visit or per day, and does the member's out-of-pocket maximum apply to this benefit?
- Are CPT codes 97152, 97157, 0362T, and 0373T billable under THSteps-CCP Autism Services at all, under a different program, or not covered?
- Is there a daily or weekly unit cap for 97156 (parent/caregiver training) or 99366 (interdisciplinary team meeting)?

### VOB data sources

- https://www.tmhp.com/sites/default/files/file-library/edi/D00026_270_271_Medicaid_CHIP_Eligibility_Companion_Guide.pdf (accessed 2026-07-23)
- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23)
- https://www.tmhp.com/sites/default/files/microsites/provider-manuals/tmppm/html/TMPPM/2_04_Childrens_Services/2_04_Childrens_Services.htm (accessed 2026-07-23)
- https://public.tmhp.com/FeeSchedules/StaticFeeSchedule/FeeSchedules.aspx?fn=%5C%5Ctmhp.net%5CFeeSchedule%5CPROD%5CStatic%5CTexas_Medicaid_Fee_Schedule_PRCR615C.pdf (accessed 2026-07-23)
- https://pfd.hhs.texas.gov/sites/default/files/documents/2025/9-1-2025-fee-adj-fetal-med-applied-behavior-dental-rate.pdf (accessed 2026-07-23)
- https://public.tmhp.com/FeeSchedules/OnlineFeeLookup/FeeScheduleSearch.aspx (accessed 2026-07-23)
- https://www.tmhp.com/contact (accessed 2026-07-23)

## Common questions

### Does Texas Medicaid cover ABA therapy?

Yes — since February 1, 2022, as the Autism Services benefit under THSteps-CCP (EPSDT), for members from birth through age 20 with an ASD diagnosis. Everything requires prior authorization, from the evaluation forward. CHIP is excluded.

### How recent does the autism diagnosis need to be?

The diagnosis — with DSM criteria and a symptom severity level — must be made or reconfirmed within the 3 years before the PA request. Older diagnoses need reconfirmation before the evaluation PA can be approved.

### What changed on April 1, 2025?

TMHP removed the prescribing-provider signature requirement from the CCP PA form for the 90-day treatment extension. The initial 180-day treatment plan still needs the prescriber's signature; the mid-cycle extension no longer does.

### What does Texas Medicaid pay for ABA?

Effective September 1, 2025 (an ~11.5% increase): 97153 direct treatment pays $14.50 per 15-minute unit, 97151 evaluation $27.56, 97155 $20.08–$25.10 and 97156 $18.40–$23.01 depending on the LaBA/LBA modifier tier. Confirm current values in the TMHP Online Fee Lookup.

### Where is the Texas Medicaid ABA fee schedule?

TMHP publishes a static Autism Services fee schedule (PRCR615C). The run dated 9/14/2026 still carries the 9/1/2025 rates: 97153 $14.50, 97151-HO $27.56, 97155 $20.08/$25.10 and 97156 $18.40/$23.01 per unit. Use the TMHP Online Fee Lookup for a specific date of service.

### Can the ABA assessment be done by telehealth under Texas Medicaid?

Yes, by the LBA. 97151 (initial evaluation and re-evaluation) is on the TMPPM telehealth list with modifier 95, synchronous audio-visual only, along with 97155, 97156, 97158 and 99366.

### Can BCBA supervision of the RBT be done remotely?

The LBA can deliver 97155, including direct supervision of a BT working with the child, by synchronous audio-visual telehealth with modifier 95. The BT's own sessions must be in person, and only direct supervision is paid.

### Do behavior technicians enroll with Texas Medicaid?

No. BTs must hold RBT, BCAT or ABAT certification but "may not enroll in Texas Medicaid," and neither may LaBAs. Only the LBA enrolls, and BT services are billed under that LBA.

### What happens to the authorization if a family switches ABA providers?

A new provider outside the current group must submit a new authorization request with initial-evaluation documentation and a change-of-provider letter signed by the responsible adult. A move within the same group keeps the evaluation, plan of care and authorization period.

### Is the Texas Medicaid ABA network open?

LBAs enroll in Texas Medicaid through TMHP. Each MCO then decides on contracting, and Medicaid enrollment does not guarantee an MCO contract, so ask each plan's provider relations about its ABA network.

### What is the timely filing limit for Texas Medicaid ABA claims?

Ninety-five days from each date of service, for TMHP fee-for-service claims and for claims to a Texas Medicaid MCO alike. Appeals to TMHP are due within 120 days of the R&S Report disposition date.

### Does Texas Medicaid require a taxonomy code on the claim?

Yes. TMHP requires the NPI and taxonomy code for the billing and the performing provider on paper claims, and asks for NPI, taxonomy and benefit code on every claim. A paper claim without them is denied.

### Does the referring doctor have to be on Texas Medicaid ABA claims?

Yes. ABA needs a prescriber referral, and TMPPM § 6.4.2.4 requires every claim for a service that needs a physician order or referral to carry the ordering or referring provider’s NPI (CMS-1500 block 17 with qualifier DN, NPI in 17b). That prescriber must be enrolled in Texas Medicaid, at least as an ordering/referring-only provider; a missing or unenrolled NPI can lead to denial on retrospective review.

## Primary sources

1. [TMPPM Telecommunication Services Handbook (Vol. 2)](https://www.tmhp.com/sites/default/files/microsites/provider-manuals/tmppm/html/TMPPM/2_19_Telecommunication_Srvs/2_19_Telecommunication_Srvs.htm)
2. [TMHP — HHSC Release of Autism Services Benefits (eff. 2/1/2022)](https://www.tmhp.com/news/2021-07-30-hhsc-release-autism-services-benefits-effective-february-1-2022)
3. [TMPPM Children's Services Handbook, § 2.3 Autism Services](https://www.tmhp.com/sites/default/files/microsites/provider-manuals/tmppm/html/TMPPM/2_04_Childrens_Services/2_04_Childrens_Services.htm)
4. [TMHP — Update to a PA Requirement for Autism Services (eff. 4/1/2025)](https://www.tmhp.com/news/2025-02-14-update-prior-authorization-requirement-autism-services-effective-april-1-2025)
5. [HHSC Provider Finance — ABA fee adjustment packet (eff. 9/1/2025)](https://pfd.hhs.texas.gov/sites/default/files/documents/2025/9-1-2025-fee-adj-fetal-med-applied-behavior-dental-rate.pdf)
6. [TMHP Online Fee Lookup](https://public.tmhp.com/FeeSchedules/Default.aspx)
7. [Tex. Occ. Code § 506.054 — Paraprofessional licensure exemption](https://texas.public.law/statutes/tex._occ._code_section_506.054)
8. [BACB RBT Handbook (updated 06/2026)](https://www.bacb.com/rbt-handbook)
9. [TMPPM Vol. 1, Provider Enrollment and Responsibilities, § 1.3.1 (monthly exclusion screening)](https://www.tmhp.com/sites/default/files/microsites/provider-manuals/tmppm/html/TMPPM/1_01_Provider_Enrollment/1_01_Provider_Enrollment.htm)
10. [Tex. Health & Safety Code § 253.001 — EMR covered facility types](https://texas.public.law/statutes/tex._health_and_safety_code_section_253.001)
11. [TMHP — Texas Medicaid Provider Fingerprinting Requirement FAQ (D00412)](https://www.tmhp.com/sites/default/files/file-library/topics/provider-enrollment/texas-medicaid-provider-fingerprinting-requirement-FAQ.pdf)
12. [TDLR — How to Apply for a Behavior Analyst License](https://www.tdlr.texas.gov/bhv/bhvapply.htm)
13. [Tex. Occ. Code § 506.254 — Licensed Assistant Behavior Analyst](https://texas.public.law/statutes/tex._occ._code_section_506.254)
14. [HHSC — Managed Care Service Areas: MCOs Serving Clients (rev. Jan 2026)](https://hhs.texas.gov/sites/default/files/documents/services/health/medicaid-chip/programs/managed-care-service-areas-map.pdf)
15. [TMHP — Texas Medicaid Fee Schedule: Autism Services (PRCR615C, run 9/14/2026) (PDF)](https://public.tmhp.com/FeeSchedules/StaticFeeSchedule/FeeSchedules.aspx?fn=%5c%5ctmhp.net%5cFeeSchedule%5cPROD%5cStatic%5cTexas_Medicaid_Fee_Schedule_PRCR615C.pdf)
16. [TMPPM Medicaid Managed Care Handbook, §§ 2.2.1 (enrollment, contracting, credentialing), 2.6.3 (out-of-network) and 2.8 (authorizations when a client changes plans)](https://www.tmhp.com/sites/default/files/microsites/provider-manuals/tmppm/html/TMPPM/2_12_Medicaid_Managed_Care/2_12_Medicaid_Managed_Care.htm)
17. [TMHP — News (index of all Texas Medicaid provider news and notices)](https://www.tmhp.com/news)
18. [TMPPM Vol. 1, Section 6: Claims Filing, § 6.1.4 Claims Filing Deadlines](https://www.tmhp.com/sites/default/files/microsites/provider-manuals/tmppm/html/TMPPM/1_06_Claims_Filing/1_06_Claims_Filing.htm)
19. [42 CFR § 440.230(e) — State Medicaid agency PA timeframes (from 1/1/2026)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-440/subpart-B/section-440.230)
20. [Tex. Gov't Code § 540.0303 — MCO PA determinations for nonhospitalized recipients (eff. 4/1/2025)](https://texas.public.law/statutes/tex._gov't_code_section_540.0303)
21. [TMPPM Vol. 1, Section 8: Third Party Liability (TPL)](https://www.tmhp.com/sites/default/files/microsites/provider-manuals/tmppm/html/TMPPM/1_08_Third_Party_Liability/1_08_Third_Party_Liability.htm)
22. [TMPPM Vol. 1, Section 5: Prior Authorization, § 5.1.4 (clients with private insurance)](https://www.tmhp.com/sites/default/files/microsites/provider-manuals/tmppm/html/TMPPM/1_05_Prior_Authorization/1_05_Prior_Authorization.htm)
23. [42 CFR § 433.139 — Medicaid payment of claims involving third party liability](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
24. [VA — CHAMPVA Guidebook (updated Jan. 1, 2025) (PDF)](https://www.va.gov/files/2025-12/CHAMPVA-Guidebook.pdf)

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.