Wellpoint — the Elevance plan formerly branded Amerigroup Texas, serving STAR, STAR Kids, and STAR+PLUS — administers the ABA benefit as a faithful restatement of TMPPM policy: its Texas behavioral-health provider document carries the state's modifier table (HO=LBA, HN=LaBA, HM=BT, 95=telehealth), unit caps, ages 0–20 scope, and the telehealth ban on BT/LaBA-delivered direct treatment, essentially unchanged. The January 2024 Amerigroup-to-Wellpoint rebrand changed no PA or claims processes. The plan's one genuine convenience: it accepts either its own ASD form or the state's.
The assessment PA needs a completed treatment-request form — Wellpoint accepts either its own "Treatment Plan Request Form for Autism Spectrum Disorders" or the state CCP Prior Authorization Request Form — plus a current, signed physician ABA referral and the clinical documentation the TMPPM requires. If your practice standardizes on the state CCP form across payers, Wellpoint doesn't force a conversion step: one less template to maintain. Submissions run through Availity Essentials (or phone/fax), with appeals via Availity or 833-731-2162, and treatment follows the state's 90/90/180 cadence.[1]
Wellpoint's provider doc spells out the billing edges that mirror the TMPPM: 97151 is capped at 24 units (6 hours) per evaluation; direct treatment caps at 8 hours per day; the credential-modifier table governs claims; LaBAs and BTs may not deliver via telehealth; and — explicitly — no separate reimbursement for treatment planning or report writing outside 97151, and no partial units. Practices that bill documentation time separately elsewhere should scrub that habit out of Wellpoint claims before it generates denials.[1]
Follows the Texas Medicaid rule — Wellpoint's own provider documents that we checked (October 2026) set no change-of-provider rule of their own. A family that moves to a new ABA provider outside the current group needs a new authorization request with all the documentation of an initial evaluation, plus a change-of-therapy-provider letter signed by the responsible adult giving the date therapy ended (or the last date of service) and the names of both providers (TMPPM § 2.3.9). A move to another provider within the same group keeps the same evaluation, plan of care and authorization period. If the child changes health plans, "Health plan prior authorizations do not automatically transfer," but the new MCO must continue an existing authorization it is told about, at the same amount, duration and scope, until the earliest of 90 days, the end of the authorization, or its own new decision (Managed Care Handbook § 2.8).[3][6]
Joining the network: a provider must be enrolled in Texas Medicaid before an MCO can enroll it; "Individual MCOs and DMOs have their own guidelines for contracting providers," and Medicaid enrollment "does not guarantee that an MCO or DMO will contract enroll or credential a particular provider." All Medicaid MCOs credential through the Texas Association of Health Plans' contracted credentialing verification organization (Handbook § 2.2.1). Wellpoint does not publish whether its ABA network is open, so ask its provider relations team.[3][6]
HHSC sets the claim clocks for every Texas Medicaid MCO in its Uniform Managed Care Claims Manual: a provider must file a claim with the MCO "within 95 Days from the date of service," and the MCO must deny a claim it does not receive in that window unless an exception applies (wrong plan, other insurance, newborns, newly enrolled providers). The MCO must tell the provider it "has 120 Days from the date of disposition to appeal the Claim," and must adjudicate an appealed claim within 30 days. Its performance standard is to adjudicate 98 percent of clean claims within 30 days of receipt and 99 percent within 90 days, with every claim finalized within 24 months of the date of service. When another insurer is billed first, the claim “must be refiled and received by the MCO within 95 Days from the date of disposition by the other insurance resource.” HHSC sets no weekly submission cutoff or check-run day; each MCO runs its own payment cycle. The TMPPM Managed Care Handbook repeats the 95-day rule and sends appeals to the MCO first, then to HHSC as a complaint.[8][6][9]
Wellpoint’s manual: clean claims must be "submitted and received by Wellpoint within 95 calendar days of the date of service," or within 95 days of a third-party payer’s response; a provider "has 120 days from the date of an Explanation of Payment (EOP) to file a payment dispute."[8][6][9]
The questions that decide whether a family can start with Wellpoint (formerly Amerigroup Texas), and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the Texas Medicaid (TMPPM) rule: birth through 20 years of age on the date of service, with eligibility ending the day of the 21st birthday. CHIP members are excluded from the ABA benefit.[3][1]
Follows the Texas Medicaid (TMPPM) rule: the ASD diagnosis must be made or reconfirmed within 3 years of initiation or recertification; past 3 years a comprehensive re-evaluation of ASD symptom severity levels per DSM criteria is required first.[3][1]
Follows the Texas Medicaid (TMPPM) rule: 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).[3][1]
Follows the Texas Medicaid (TMPPM) rule: a reliable, valid, standardized diagnostic assessment tool or combination of tools — the manual names the ADOS, ADI-R and CARS as examples. Screening instruments alone (STAT, M-CHAT-R) do not substitute.[3][1]
Follows the Texas Medicaid (TMPPM) rule: a signed, dated prescriber referral for the evaluation, signed within 60 calendar days before or on the anticipated evaluation date; and for treatment a signed, dated referral from a physician or allowed practitioner (MD/DO, PA, NP, or CNS with delegated authority) stating frequency and duration, signed on or before the service start date and no more than 3 months old. Since 4/1/2025 the prescriber signature is no longer required on the CCP PA form for the 90-day extension.[3][1][5]
Follows the Texas Medicaid (TMPPM) rule: synchronous audio-visual only, modifier 95, on 97151, 97155, 97156, 97158 and 99366. One-on-one direct treatment delivered to the child by a behavior technician or LaBA must be in person — telehealth is prohibited for BT/LaBA-delivered direct service.[3][1]
Wellpoint's decision table: Medicaid routine/non-urgent "3 business days"; CHIP routine "2 business days (approval) / 3 business days (adverse determination)"; Medicaid and CHIP urgent/expedited "3 calendar days"; concurrent "1 business day"; post-service "30 calendar days," with written notice "no later than the next business day following a prior authorization request determination." A request is not expedited when "The date of service is greater than one week from the request date." Incomplete requests are paused while Wellpoint asks for the missing documentation; if it does not arrive "within the designated time frame, the medical director will make a determination based on the information previously received." Lead times: initial requests "a minimum of three business days prior to the start of care"; recertifications may be submitted "at least 60 calendar days prior to the expiration of the current authorization" (the 30-day exception list names only PT/OT/speech therapy, private duty nursing and PPECC — not ABA).[9][10][11]
"Federal and state laws require Medicaid — including the STAR, STAR Kids, and STAR+PLUS programs — to be the payer of last resort." Submit to the other insurer first and attach its "EOB/EOP or rejection letter"; if Wellpoint already knows of other coverage it "will deny the claim and redirect the provider to bill the appropriate insurance carrier." Filing deadline with other insurance: "within 95 days of receiving a response from the third-party payer" (after a primary adjustment, the 95 days run from the most recent EOB). Wellpoint pays first and recovers later only for "Preventive pediatric care" and services tied to a child support enforcement action; the TMPPM's matching option is limited to THSteps medical and dental checkup providers, so bill the other coverage first for ABA. The manual does not say whether Wellpoint's PA is still needed when it is secondary — request it.[9][12][13]
Coverage decides whether Wellpoint (formerly Amerigroup Texas) 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 Texas Medicaid (TMPPM) rule: the manual sets no numeric ratio of its own, requiring LBAs to directly supervise LaBAs and behavior technicians in accordance with Texas licensure and deferring to the certifying body's minimums — for RBT-credentialed staff the BACB floor of supervision on at least 5% of service hours each month with two face-to-face contacts. Only direct supervision, where the LBA observes the LaBA or BT with the child, is reimbursable (under 97155); indirect supervision is unpaid.[3][1][4]
Follows the Texas Medicaid (TMPPM) rule: concurrent billing is prohibited — Texas Medicaid will not reimburse multiple ABA providers during one session with the child when more than one provider is present. The single exception is when the family and the child receive separate services and the child is not present in the family session. Total authorized hours may be requested under either 97153 or 97155 and billed as the code matching the service actually delivered — not both for the same clock time with the child present.[3][1]
Follows the Texas Medicaid (TMPPM) rule: direct treatment is capped at 8 hours (32 units) per day combined across 97153, 97154, 97155 and 97158; 97151 is capped at 6 hours (24 units) per evaluation and per re-evaluation; group treatment runs 2 to 8 children. Authorization periods are two consecutive 90-day terms then recertifications of up to 180 days. Wellpoint restates the same caps in its own behavioral-health provider document and adds that partial units are not payable.[1][3]
Follows the Texas Medicaid (TMPPM) rule: rendering ABA providers must sign each entry with full signature and credentials, with additional supervisory signatures per state licensure. Treatment notes carry the child's name, date of service, start and stop times, goals addressed, progress and a summary of interventions; 97155/97158 notes add protocol-modification decision points. The 97151 evaluation and the 90-day progress summary each need a dated signature from the LBA and from the parent or caregiver.[3][1]
Follows the Texas Medicaid (TMPPM) rule: home, clinic, office and community settings are payable. In schools, services delivered by a behavior technician as a shadow, an aide, or as general support are excluded; school personnel participating to coordinate care are not counted as duplicate providers, and interdisciplinary team meetings bill under 99366 against an ABA PA. BT and LaBA direct treatment must be in person in every setting.[3][1]
Follows the Texas Medicaid (TMPPM) rule: only the LBA enrolls in Texas Medicaid and bills. LaBAs and behavior technicians may not enroll — their services go out under the supervising LBA's NPI with the credential modifier identifying who rendered (HO = LBA, HN = LaBA, HM = behavior technician; 97151 takes HO only, 97155/97156/97158 take HO or HN). The LBA must directly employ or contract with every LaBA and BT on the team. Wellpoint carries the same HO/HN/HM modifier table and states there is no separate reimbursement for treatment planning or report writing outside 97151.[1][3]
Yes — the Texas Medicaid Autism Services benefit on TMPPM criteria, restated in its behavioral-health provider document: PA on evaluation and treatment, ages 0–20, credential modifiers, 8-hour daily cap.
No — Wellpoint accepts either its Treatment Plan Request Form for Autism Spectrum Disorders or the state CCP Prior Authorization Request Form, plus the signed physician referral.
No — the January 2024 rebrand changed no PA or claims processes. Documents and portals under the Amerigroup name remain valid references.
A new ABA provider outside the current group must file a new authorization with initial-evaluation documentation and a change-of-provider letter signed by the responsible adult (TMPPM § 2.3.9). A new health plan must continue an existing authorization for up to 90 days, or until it ends or the new plan decides.
It does not publish an open or closed status. Enroll in Texas Medicaid first, then apply to the plan; Medicaid enrollment does not guarantee an MCO contract. Ask provider relations.
Ninety-five days from the date of service. HHSC’s Uniform Managed Care Claims Manual sets it for every Texas Medicaid MCO, and Wellpoint’s own manual states the same deadline. Claim appeals get 120 days from the disposition date.
HHSC requires every Texas Medicaid MCO to adjudicate 98 percent of clean claims within 30 days of receipt and 99 percent within 90 days.
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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