---
title: Community First Health Plans ABA coverage (Texas Medicaid MCO).
url: "https://carelu.com/payers/community-first-health-plans"
markdown_url: "https://carelu.com/payers/community-first-health-plans.md"
state: TX (Texas)
payer: Community First Health Plans
kind: Medicaid managed care plan (MCO)
parent_program: Texas Medicaid (THSteps-CCP)
description: "How Community First Health Plans administers Texas Medicaid ABA in the Bexar service area — its published Autism Services Billing Guidelines, the HO/HN/HM modifier crosswalk, PA requirements, and concurrent-billing rules."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Community First Health Plans ABA coverage (Texas Medicaid MCO).

_Payer Guide · Community First (TX) · Last updated September 2026 · 4 primary sources_

> Bexar-area plan with the clearest published TX ABA billing crosswalk — a TMPPM digest.

Community First Health Plans — the San Antonio-based plan serving STAR, STAR Kids, and CHIP in the Bexar service delivery area — administers the state ABA benefit as a straight TMPPM pass-through, and it publishes one of the clearest MCO billing references for Texas ABA anywhere: its Autism Services Billing Guidelines page lays out the code list, the HO/HN/HM modifier crosswalk, unit caps, and the concurrent-billing rules in plain tables. Even practices that never bill Community First bookmark it as an onboarding reference for the Texas modifier system.

This plan administers the **Texas Medicaid (THSteps-CCP)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Texas Medicaid (THSteps-CCP) guide](https://carelu.com/payers/texas-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — 97151 not reimbursable unless the evaluation was submitted for authorization; up to 24 units per period [1]
- **Prior auth for treatment**: Required — 97153, 97154, 97155, 97156, 97158 + 99366 all PA-gated [1]
- **Autism diagnosis required?**: Yes — F84.0 diagnosis mandatory, per the plan's billing guidelines [1]

## At a glance

- **Plan type:** Texas Medicaid MCO — STAR, STAR Kids, CHIP (Bexar SDA)
- **Clinical rules:** TMPPM Autism Services criteria — billing page is a TMPPM digest
- **Prior auth:** Required — 97151 not reimbursable without an authorization on file
- **Diagnosis:** F84.0 mandatory; ages 0–20
- **Daily cap:** 8 hours / 32 units combined (97153, 97154, 97155, 97158)
- **Rates:** References 1 TAC § 355 / the Texas Medicaid fee schedule

## The billing crosswalk worth bookmarking

Community First's published guidelines make the state's billing mechanics concrete: 97151 "is not reimbursable unless evaluation was submitted for authorization of payment," capped at 24 units per period; treatment codes 97153, 97154, 97155, 97156, and 97158 plus team-meeting code 99366 are all PA-gated; direct treatment caps at 8 hours / 32 units per day combined; and the credential modifiers (HO = LBA, HN = LaBA, HM = behavior technician) map exactly to the TMPPM. The page also spells out the edges that generate denials elsewhere: no separate pre/post-evaluation billing beyond 97151, telehealth prohibited for BT/LaBA-delivered direct treatment, and concurrent billing prohibited unless the family service is delivered without the child present. [1]

## Running cases at Community First

The clinical rulebook is the state's: F84.0 diagnosis mandatory, ages 0 through 20, the TMPPM's PA cadence, and rates referencing 1 TAC § 355 and the Texas Medicaid fee schedule (no plan-specific rates published). Authorizations run through the Community First provider portal. Because the plan is a TMPPM digest rather than a second rulebook, a practice that has its state-baseline package tight — referral, recency-checked diagnosis, per-code units within caps — should find Community First one of the more predictable Texas submissions. [1][2]

## Intake gates

The questions that decide whether a family can start with Community First Health Plans, and what they have to bring.

- **Age limit**: Ages 0 through 20, per Community First's own published Autism Services Billing Guidelines, matching the statewide THSteps-CCP rule. [1][2]
- **Diagnosis recency**: 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. [2][1]
- **Who may diagnose**: 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). [2][1]
- **Diagnostic tools required**: 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. Community First separately states that an F84.0 diagnosis is mandatory. [1][2]
- **Referral required?**: 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. [2][1][4]
- **Telehealth**: 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. [2][1]
- **Prior-auth decision time**: Community First's STAR manual publishes no decision clock of its own, so the Texas rule governs: a Medicaid MCO must decide a nonhospitalized PA "within three business days after the organization receives the request" (Tex. Gov't Code § 540.0303), with the 1 TAC § 353.425 process for incomplete requests (written notice of what is missing within 3 business days; final decision within 3 business days after it arrives). What the manual adds: a pended request is worked with the provider and, if the information never arrives, "the services will be denied … for lack of requested information"; denials are communicated "by phone and letter … within 48 hours"; and "Pre-authorizations are generally valid for 30 days from the date issued; this timeframe may be extended based on the type of request," with "administrative denial of the claim" for services started without one. No ABA reauthorization lead time is published. [5][6][7]
- **Other insurance (who pays first)**: "In situations where a STAR Member has other insurance, the other insurance carrier will be the primary payor. Providers must bill the third-party insurance first and then attach a copy of the Explanation of Payment (EOP) statement … Providers must file claims to Community First within 95 days of the third-party insurance EOP." Community First "will act as the payor of last resort" and "will deny payment for claims that do not include proof of prior filing with the STAR Member's third-party insurance." The manual does not say whether Community First's own ABA PA is still needed when it pays second — request it. [5][8]

## Delivery and billing rules

Coverage decides whether Community First Health Plans 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 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. [2][1][3]
- **Concurrent billing (97153 + 97155)**: Community First's own guidelines restate the state rule: concurrent billing is prohibited unless the family service is delivered without the child present. The page also bars separate pre- or post-evaluation billing beyond 97151. [1][2]
- **Daily limits / MUEs**: Community First publishes the state caps directly: direct treatment is limited to 8 hours / 32 units per day combined across 97153, 97154, 97155 and 97158, and 97151 is capped at 24 units per period and is not reimbursable unless the evaluation was submitted for authorization. [1][2]
- **Session-note signature**: 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. [2][1]
- **Place of service**: 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. [2][1]
- **Bill as provider**: 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. Community First publishes the crosswalk explicitly: HO = LBA, HN = LaBA, HM = behavior technician. [1][2]

## What intake should collect for Community First Health Plans

- **F84.0 diagnosis + recency:** The plan states the diagnosis requirement explicitly — and the state 3-year recency rule applies.
- **PA before the evaluation:** 97151 is not reimbursable without a submitted authorization — no assess-first shortcut.
- **Session structure:** Concurrent billing is prohibited unless family services run without the child present — schedule accordingly.
- **Modifier discipline:** HO/HN/HM must match who rendered — the crosswalk on the plan's page is the reference.

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

## Verification of benefits (VOB) data

How Community First Health Plans ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 01390 — pVerify lists two candidates — "01390 Community First Health Plans" (used here) and "06106 Community First Health Plan" — not resolved to one; confirm which routes eligibility before automating.
- **Payer ID (Availity):** COMMF
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** none
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### 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:

- **97151:** Community First's own Autism Services Billing Guidelines page restates this requirement directly, plus a published HO/HN/HM modifier crosswalk and concurrent-billing rules — one of the clearest MCO-published TMPPM digests in Texas.
- **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.

### Contacts

- **Provider services phone:** 1-800-434-2347
- **Phone menu path:** Prior-authorization-specific line: 210-358-6050 (local), same toll-free/hours as above.
- **Hours:** 8:30 a.m.–5 p.m., Monday–Friday
- **Portal:** [Community First Provider Portal (HealthTrio Connect)](https://cfhpprovider.healthtrioconnect.com/)

Questions to ask on a verification call:

- Which payer ID is correct for Community First eligibility checks — pVerify 01390 or 06106?
- Does Community First support real-time (vs. batch) 270/271 eligibility?
- Is the ABA copay or coinsurance charged per visit or per day, and does the plan's out-of-pocket maximum apply?
- Are CPT codes 97152, 97157, 0362T, and 0373T billable under Community First's Autism Services benefit?
- Is there a daily/weekly unit cap for 97156 (parent/caregiver training) or 99366 (team meeting)?

### VOB data sources

- 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://communityfirsthealthplans.com/community-first-providers/medicaid-providers/autism-services-billing-guidelines/ (accessed 2026-07-23)
- https://www.tmhp.com/sites/default/files/file-library/edi/D00026_270_271_Medicaid_CHIP_Eligibility_Companion_Guide.pdf (accessed 2026-07-23; source document older than 18 months)
- 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://medicaid.communityfirsthealthplans.com/contact-us/ (accessed 2026-07-23)
- https://medicaid.communityfirsthealthplans.com/provider-prior-authorizations/ (accessed 2026-07-23)

## Common questions

### Does Community First Health Plans cover ABA?

Yes — the Texas Medicaid Autism Services benefit in the Bexar service area, on TMPPM criteria: F84.0 diagnosis, ages 0–20, PA on evaluation and all treatment codes, 8-hour daily cap.

### Does the ABA evaluation need prior authorization at Community First?

Yes — the plan's billing guidelines state 97151 is not reimbursable unless the evaluation was submitted for authorization, capped at 24 units per period.

### Why do providers outside Bexar County reference Community First's guidelines?

Its Autism Services Billing Guidelines page is one of the clearest public crosswalks of the Texas ABA codes, HO/HN/HM modifiers, and unit caps — a useful TMPPM digest even for other plans' cases.

## Primary sources

1. [Community First Health Plans — Autism Services Billing Guidelines](https://communityfirsthealthplans.com/community-first-providers/medicaid-providers/autism-services-billing-guidelines/)
2. [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)
3. [BACB RBT Handbook (updated 06/2026)](https://www.bacb.com/rbt-handbook)
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. [Community First Health Plans — STAR Provider Manual (Sept. 2025, posted 4/15/2026) (PDF)](https://medicaid.communityfirsthealthplans.com/wp-content/uploads/sites/2/2026/04/STAR_ProviderManual_2025_web_04.15.26.pdf)
6. [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)
7. [1 Tex. Admin. Code § 353.425 — MCO processing of incomplete PA requests](https://www.law.cornell.edu/regulations/texas/1-Tex-Admin-Code-SS-353-425)
8. [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)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 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.