Wellpoint Tennessee — the Elevance plan formerly branded Amerigroup — administers the TennCare ABA benefit under the shared tri-MCO program description it helped build (Wellpoint hosts the unified program documents). Clinically it's the TennCare baseline; the Wellpoint-specific layer is workflow: the Availity Interactive Care Reviewer submission path, its fax lines, an MD-order emphasis on assessment requests, and named regional ABA contacts.
Submissions go through Availity — Wellpoint's stated preferred workflow is to complete the universal tri-MCO ABA request form and attach it as the clinical documentation in the Interactive Care Reviewer; fax fallback is (866) 920-6006 (the form also lists (888) 881-6309). The assessment request needs an MD order or a licensed treating provider's recommendation. Treatment authorizations run in the standard 26-week periods, and continuation requests must report the percentage of authorized units used — under 90% on direct-treatment code 97153 requires a written explanation — plus the 97156 parent-training volume delivered.[2][1]
Wellpoint publishes named regional ABA contacts (West, Middle, and East Tennessee plus a statewide UM manager and behavioral-health liaison) with direct phones and emails in its tri-MCO update materials; provider services runs at (833) 731-2154. For an intake team, a saved contact sheet per region turns authorization questions from portal tickets into phone calls.[3]
Wellpoint’s Tennessee manual: “Timely filing is within 120 days of the date of service,” except for coordination of benefits or retroactive eligibility, and a corrected or replacement claim may be sent within 120 calendar days of the payment notice. A clean claim must include “NPI and taxonomy information for rendering, attending, and billing providers.” Disputes start with a reconsideration within 365 calendar days of the EOP date, which Wellpoint tries to resolve within 30 calendar days; independent review under Tenn. Code Ann. 56-32-126 is also available.[9][10]
TennCare’s contract with its MCOs sets the floor for every claim: a provider has “one hundred twenty (120) calendar days from the date of rendering a covered service to file a claim,” with the clock starting later for coordination-of-benefits cases and retroactive enrollment (CRA 2.12.9.28, 2.22.4.9); the MCO must pay 90% of clean claims within 30 calendar days of receipt and process 99.5% of all claims within 60 calendar days (2.22.4.2–2.22.4.3, under Tenn. Code Ann. 56-32-126). A provider who disputes a claim decision may use the TennCare Provider Independent Review of Disputed Claims process through the Tennessee Department of Commerce and Insurance (Tenn. Code Ann. 56-32-126(b)); an overturned claim must be paid within 20 calendar days of the decision (2.22.5.2). Resubmissions: the contract gives providers at least “sixty (60) days from the date of initial notice of an invalid and/or insufficient claim or one hundred twenty (120) days from the date of service, whichever is later,” to file a valid, complete claim (2.22.4.11.3), and a paid claim that needs correcting goes in as an adjustment “within 120 days of the date of payment notification” (2.22.4.11.4). With coordination of benefits, the filing clock begins on the date the third party documented resolution of the claim (2.22.4.9). Payment cycle: each MCO “shall run one (1) provider payment cycle per week, on the same day each week, as determined by the CONTRACTOR and approved in writing by TENNCARE” (A.2.22.13); the contract does not name the day or any submission cutoff, so ask the plan which day its check run closes.[9][10]
EVV does not apply to ABA. The TennCare contract requires an electronic visit verification system for personal care and home health services that require an in-home visit, as the 21st Century Cures Act requires (CRA 2.9.17.1); ABA is neither.[9][10]
No CPR or first-aid certificate is required for BCBAs or technicians in TennCare ABA. The shared TennCare MCO ABA Program Description asks for current BCBA certification with MCO credential verification, a Tennessee Licensed Behavior Analyst licence for the analyst, BACB-compliant RBTs, and a Crisis/Emergency Plan “in accordance with BACB best practices”; it names no CPR or first-aid training. Tennessee’s behavior-analyst licensing rules (1180-05) carry none either. The only CPR and first-aid requirement in the TennCare MCO contract is for workers hired through consumer direction in CHOICES and ECF CHOICES (CRA 2.9.8.7.7), not ABA staff. An employer or the setting (a school or day program) can still require it.[6][7][10]
Graphs are required. The universal ABA request form that Wellpoint uses tells providers to “attach cumulative graphs/charts of baseline data and current progress; current behavioral support plan and treatment plan including symptoms and behaviors requiring treatment, skills to be addressed, baseline measures and current progress, along with a proposed schedule of services,” including the goals achieved within the authorization period and any barriers. The shared program description lists the same “cumulative graphs/charts of baseline data and current progress” among its treatment-plan expectations, wants functioning re-measured “via standardized tools at least every two years,” and says the treatment plan “should be dated within 30 days of start date.” Neither document sets a separate data-recency window. Codes: the form's code rows are CPT 97151 through 97158 (with practitioner level noted, such as “97153 BA or RBT”); neither document lists a HCPCS H-code such as H0031 or H0032 for ABA.[2][1]
The questions that decide whether a family can start with Wellpoint Tennessee (formerly Amerigroup), and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the TennCare rule: EPSDT covers “children from birth through age 20 who have TennCare,” and the shared tri-MCO program description Wellpoint hosts sets no age floor or ceiling of its own. Wellpoint publishes no deviating age rule.[5][1]
Follows the TennCare rule: no recency limit on the ASD diagnosis, with updated evaluation of functioning via standardized tools expected “at least every two years.” The universal form Wellpoint hosts asks for the date the diagnosis was initially rendered and whether a standard assessment was used in it. Authorizations then run in 26-week periods.[1][2]
Follows the TennCare rule — the diagnosis must be issued by “a qualified health professional, practicing within their scope, with training in assessment of individuals with ASD and/or other neurodevelopmental concerns,” and a TN-licensed clinician must document medical necessity. Wellpoint names no additional credential; its emphasis falls on the ordering provider instead (see referral).[1][2]
Follows the TennCare rule — no named instrument. The diagnosis must be validated by a documented comprehensive assessment against DSM-5-TR criteria, and the ABA assessment must include direct observation, file review, informant interviews and standardized assessments across cognition, communication, social, adaptive and behavioral domains. At continuation the universal form asks providers to “list Standardized Assessments used to validate progress and include scores,” with page references.[1][2]
Required, with Wellpoint’s own emphasis: the assessment request needs an MD order or a licensed treating provider’s recommendation, landing on the universal form’s “Doctor’s Order Attached” checkbox alongside the diagnostic report. Wellpoint’s stated preferred workflow is to complete the universal tri-MCO form and attach it as the clinical documentation in Availity’s Interactive Care Reviewer; fax fallback is (866) 920-6006, with (888) 881-6309 also listed on the form. No validity window is published for the order.[2][1]
Follows the TennCare rule: telehealth is requested and authorized per code via the “Indicate if Hours are telehealth” checkbox that appears on every ABA code row of the universal form Wellpoint hosts, with Telehealth also listed among the places of service. No Wellpoint-Tennessee-specific ABA telehealth policy was located, so the shared program description’s cautions — clinical appropriateness protocols by model, HIPAA-compliant technology, demonstrated provider competence — are the operative standard. The checkbox sits on the assessment rows (97151, 97152) as well as on 97155, so assessment and BCBA-supervision hours can be requested as telehealth code by code. The form and program description set no cap on remote supervision; the BACB supervision requirements they incorporate still apply.[2][1]
Wellpoint's TennCare manual: "The decision regarding an authorization request for service must be made within 14 calendar days (seven (7) calendar days as of 1/1/26) for a standard request or 72 hours for expedited." The TennCare contract counts the 7 days from receipt of the request. It allows up to 14 more calendar days if the family or provider asks, or if the MCO justifies needing more information. ABA is requested on the shared tri-MCO form in 26-week authorization periods. Wellpoint publishes no reauthorization lead time.[9][10][11]
Wellpoint and its providers agree "the Medicaid program will be the payer of last resort." Providers "should bill the third party prior to billing Wellpoint." Wellpoint's secondary payment is the lesser of the primary's allowed amount and its own. A secondary claim "without the primary carrier's EOP will be denied stating the member has other insurance." One exception matters most for ABA: Wellpoint pays and pursues "When the services are rendered to a child under the age of 21 who does not have Medicare, including preventive, EPSDT and pediatric care." For a child, Wellpoint pays and then recovers from the other plan. The October 2026 manual says nothing about skipping Wellpoint's own authorization when other insurance is primary, so ask Wellpoint utilization management whether its own ABA authorization is needed when a commercial plan is primary. TRICARE by statute pays only after other coverage "except in the case of a plan administered under title XIX" (Medicaid), so TRICARE goes before TennCare. CHAMPVA is the reverse: "If you are eligible under Medicaid, CHAMPVA will pay first."[9][10][12][13]
Coverage decides whether Wellpoint Tennessee (formerly Amerigroup) 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 TennCare rule: direct ABA must be provided by or supervised by a TN Licensed Behavior Analyst (or a health professional permissible under TN law); unlicensed persons deliver “under the extended authority and direction of a TN LBA” and may not represent themselves as behavior analysts; and RBTs with their supervising BCBAs must comply with all current BACB supervision requirements, which sets the floor at 5% of monthly service hours and two face-to-face contacts. Wellpoint publishes no ratio of its own. Non-client-specific administrative supervision and technician training remain non-covered.[1]
No per-day ceiling, no annual limit and no fixed weekly cap — units are requested per week and per 26-week authorization period in 15-minute increments and justified against the severity/unit guide. The back-end constraint is Wellpoint’s signature rule: continuation must report units utilized divided by units approved times 100, and “if under 90% utilized, please explain,” measured on 97153 direct care. The form also asks for the volume of parent training (97156) delivered per week or per month.[2][1]
Wellpoint’s Tennessee provider manual (December 2025) adopts the NCQA record standards: "All entries in the medical record contain the author’s identification. Author identification may be a handwritten signature, unique electronic identifier or initials," "All entries are dated," and "The record is legible to someone other than the writer." The universal request form Wellpoint hosts adds a request-level rule — the signature “may be the signature of the person completing the form; however, it should note that is on behalf of the current treating provider” — with an attestation that all the information is in the member’s medical record. No session-note signing deadline is published.[9][2]
Follows the TennCare rule: Clinic, Home, Community, School, Telehealth and Other are all on the universal form’s place-of-service grid, and medically necessary school-based behavioral health services “are not required to be included in a child’s Individualized educational plan (IEP) in order to be reimbursable.” Non-covered regardless of setting: IEP services and functioning as an educational aide, provider travel time, transport in lieu of a caregiver, live-in help, billing while the member sleeps, and accompanying the member to outside activities not in the treatment plan.[2][1]
Follows the TennCare rule — the claim rides on the Group NPI (or the Servicing Provider NPI for a solo practitioner) captured on the universal form, with the supervisor’s name and credentials recorded alongside and a TN Medicaid ID required if out of network. Practitioner level is expressed as a modifier: HO for analyst-delivered codes, HM for technician-delivered, 97153 split between them. Rates sit in the Wellpoint participating-provider agreement, since TennCare publishes no ABA fee schedule.[2]
Not answered for 97153 with 97155 — the program description Wellpoint hosts bars only two overlaps (more than one licensed analyst serving the member during a specific time interval, and ABA delivered simultaneously with OT, speech, PT or psychotherapy), and the universal form lets both codes be requested in one authorization without an overlap rule.[1][2]
Ask the plan: Wellpoint TN provider services (833) 731-2154 or the named regional ABA contacts published in the tri-MCO update materials; Wellpoint’s own reimbursement policies on provider.wellpoint.com.
TennCare requires each plan to run at least one provider payment cycle a week, on the same day each week, as the plan sets and TennCare approves. The contract and the plan's manual do not publish the day or a submission cutoff time, so ask provider services which day the check run closes. Clean claims must be paid within 30 days (90% of them) and almost all claims processed within 60 days.
Yes. The universal ABA request form asks for cumulative graphs or charts of baseline data and current progress, with the current behavior support and treatment plans and the goals met during the authorization period. Functioning should be re-measured with standardized tools at least every two years.
No H-codes are published for ABA. The universal ABA request form is built on CPT 97151–97158, and the shared program description lists no HCPCS codes.
Yes — Wellpoint (formerly Amerigroup) administers the TennCare ABA benefit under the shared tri-MCO program description: EPSDT members under 21, PA on assessment and treatment, TN LBA licensure.
Complete the universal tri-MCO ABA request form and attach it as clinical documentation in Availity's Interactive Care Reviewer; fax fallback (866) 920-6006. The assessment request needs an MD order or treating-provider recommendation.
Clinically, no — it's the shared TennCare baseline. The plan-specific layer is workflow: Availity ICR, fax lines, the MD-order emphasis, and the sub-90% unit-utilization explanation rule at continuation.
It can be requested. The universal TennCare ABA request form has an "Indicate if Hours are telehealth" checkbox on every code row, including the 97151/97152 assessment and 97155 supervision, so telehealth hours are authorized code by code. The shared program description asks providers to judge clinical appropriateness and use HIPAA-compliant technology.
The shared TennCare program description sets credential expectations for "RBT paraprofessionals": RBTs and their supervising BCBAs "must comply with ALL of the current Behavior Analyst Certification Board (BACB) requirements for credentialing, ethics, competency, supervision, and maintenance of the RBT credential." Direct ABA must be delivered or supervised by a TN Licensed Behavior Analyst. Technicians do not bill under their own NPI: the universal form collects the group (or solo servicing) NPI, and technician codes carry the HM modifier.
120 days from the date of service; corrected claims within 120 calendar days of the payment notice; reconsiderations within 365 calendar days of the EOP (Wellpoint Tennessee provider manual).
Not in any published source. The shared TennCare MCO ABA Program Description and Tennessee’s licensing rules (1180-05) name no CPR or first-aid training for ABA staff; the TennCare MCO contract requires it only for consumer-directed CHOICES and ECF CHOICES workers. Your employer may still require it.
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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