---
title: Driscoll Health Plan ABA coverage (Texas Medicaid MCO).
url: "https://carelu.com/payers/driscoll-health-plan"
markdown_url: "https://carelu.com/payers/driscoll-health-plan.md"
state: TX (Texas)
payer: Driscoll Health Plan
kind: Medicaid managed care plan (MCO)
parent_program: Texas Medicaid (THSteps-CCP)
description: "How Driscoll Health Plan administers Texas Medicaid ABA in South Texas — TMPPM criteria, the statewide Texas Authorization Referral Form (TARF), and the plan's per-code prior authorization lookup portal."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Driscoll Health Plan ABA coverage (Texas Medicaid MCO).

_Payer Guide · Driscoll Health Plan · Last updated September 2026 · 5 primary sources_

> South Texas plan using the statewide TARF form; per-code PA checks via its lookup portal.

Driscoll Health Plan — the children's-hospital-affiliated plan serving STAR, STAR Kids, and CHIP across South Texas — administers the state ABA benefit with no distinct clinical policy: TMPPM criteria govern. Its operational profile is unusually low-friction for practices that already work statewide, because Driscoll uses the statewide Texas Authorization Referral Form (TARF) rather than a proprietary form, and it runs a public per-code PA lookup portal that answers "does this code need auth?" without a phone call.

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 — verify per-code on the DHP Prior Authorization Portal (driscollhealthplan.com/priorauthcheck) [1]
- **Prior auth for treatment**: Required — submit via the DHP portal or fax 1-866-741-5650 using the Texas Authorization Referral Form (TARF) [1]
- **Autism diagnosis required?**: Yes — ASD per the statewide TMPPM criteria [3]

## At a glance

- **Plan type:** Texas Medicaid MCO — STAR, STAR Kids, CHIP (South Texas)
- **Clinical rules:** TMPPM Autism Services criteria (no distinct ABA policy)
- **Prior auth:** Required — Autism (ABA) Services listed on the plan's PA portal
- **Form:** Statewide Texas Authorization Referral Form (TARF) — no proprietary form
- **Submission:** DHP portal or fax 1-866-741-5650
- **Rates:** Not published — contract-specific

## How Driscoll runs authorization

Autism (ABA) Services appear on Driscoll's Prior Authorization Requirement Portal (driscollhealthplan.com/priorauthcheck) — the plan's own tool for verifying PA requirements code by code, which is the right first stop before any submission. Requests submit through the DHP portal or by fax to 1-866-741-5650 using the Texas Authorization Referral Form. Because the TARF is the statewide form, a practice already producing TARFs for other plans has no form-conversion work here — attach the state-baseline clinical package (signed prescriber referral, recency-checked ASD diagnosis, per-code units) and follow the TMPPM's 90/90/180 cadence. [1][2]

## The state rules travel with the member

Everything on the Texas Medicaid guide applies unchanged: PA on the 97151 evaluation (24-unit cap), the April 2025 removal of the prescriber signature on 90-day extensions, the 3-year diagnosis recency rule, the 8-hour daily direct-treatment cap, credential modifiers, and the telehealth restrictions. Driscoll's only plan-specific wrinkle is workflow — verify the code on the portal, submit the TARF, track through the DHP portal. [3]

## Intake gates

The questions that decide whether a family can start with Driscoll Health Plan, and what they have to bring.

- **Age limit**: 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]
- **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. [3][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). [3][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. [3][1]
- **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. Driscoll takes the statewide Texas Authorization Referral Form (TARF) rather than a proprietary form, submitted through the DHP portal or fax 1-866-741-5650. [1][3][5]
- **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. [3][1]
- **Prior-auth decision time**: STAR and STAR Kids requests "submitted with complete supporting clinical information and documentation: Within three (3) business days from the receipt of a preauthorization request"; CHIP within 2 business days for approvals and 3 for adverse determinations; urgent "no later than 24 hours from receipt." Incomplete STAR/STAR Kids requests go through Driscoll's Lack of Information process: a letter within three business days gives the provider three business days to respond, and the process "will not exceed 10 business days/14 calendar days from date of receipt." Renewals: "DHP allows for timely submission of continuation of service requests/renewal of an existing prior authorization up to 60 days before the current prior authorization expires" and will decide, "if practicable, before the existing authorization expires" — but where a renewal needs assessments or progress notes more recent than 60 days, Driscoll will ask you to resubmit closer to the end date, which is the ABA situation. [6][7]
- **Other insurance (who pays first)**: "DHP is the payer of last resort. Providers must bill all other carriers and receive payment or denial prior to billing DHP," attaching the denial letter or EOP when the other payer denies. Driscoll is the one Texas MCO that says plainly what happens to authorization when it pays second: "Some outpatient services/procedure codes may require prior authorization regardless of DHP as secondary payer," so check the DHP Prior Authorization Portal; and "If the services are known to be a non-covered benefit by the primary payer, prior authorization is required by DHP and proof of non-coverage of benefit must accompany the claim submission." For ABA, where many commercial plans exclude or cap the benefit, get the Driscoll PA. [6][8]

## Delivery and billing rules

Coverage decides whether Driscoll Health Plan 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. [3][1][4]
- **Concurrent billing (97153 + 97155)**: 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]
- **Daily limits / MUEs**: 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. [3][1]
- **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. [3][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. [3][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. [3][1]

## What intake should collect for Driscoll Health Plan

- **Program line:** STAR / STAR Kids vs. CHIP — CHIP is excluded from the ABA benefit.
- **ASD dx + recency:** State baseline: qualified diagnoser, DSM severity, within 3 years.
- **TARF ready:** Driscoll takes the statewide Texas Authorization Referral Form — reuse your existing template.
- **Portal check per code:** Run the codes through priorauthcheck before submitting — it's the plan's own source of truth.

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

## Verification of benefits (VOB) data

How Driscoll Health Plan ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 01090 — pVerify lists two candidates — "01090 Driscoll Health Plan" (used here) and "002472 DRISCOLL CHILDRENS HEALTH PLAN" — not resolved to one.
- **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 | Yes, per Driscoll's own live PA-lookup portal (STAR, STAR Kids; excluded on CHIP/CHIP Perinate) — contradicts the "not on Texas's billable ABA code set" finding shipped for 97152 elsewhere in this file (texas-medicaid and the other 7 MCO guides); treat as a confirmed Driscoll-specific exception, not the statewide default. | Required, effective 2/1/2025, per Driscoll's PA portal (PR Behavior ID Support Assmt by 1 Tech, EA 15 Min). | — | — | 95 modifier required for telehealth visits, per Driscoll's PA portal | HO (LBA), HN (LaBA), HM (BT) — required on auth requests and claims, as applicable, 95 (telehealth) |
| 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 | Yes, per Driscoll's own live PA-lookup portal (STAR, STAR Kids; excluded on CHIP/CHIP Perinate) — contradicts the "not on Texas's billable ABA code set" finding shipped for 97157 elsewhere in this file (texas-medicaid and the other 7 MCO guides); treat as a confirmed Driscoll-specific exception, not the statewide default. | Required, effective 2/1/2025, per Driscoll's PA portal (PR Multiple Fam Group Bhv Tx Gdn Phys/QHP, EA 15 Min). | — | — | 95 modifier required for telehealth visits, per Driscoll's PA portal | HO (LBA), HN (LaBA), HM (BT) — required on auth requests and claims, as applicable, 95 (telehealth) |
| 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:** Verify per-code PA status on Driscoll's Prior Authorization Requirement Portal (driscollhealthplan.com/priorauthcheck) before submitting; Driscoll uses the statewide Texas Authorization Referral Form (TARF), not a proprietary form.
- **97152:** Driscoll's PA portal cites "TMPPM Children Services Handbook Volume 2, Section 2.3, Medicaid Autism Services Policy" as its review criteria for 97152, even though 97152 does not appear anywhere in that handbook chapter's text or in TMHP's "AUTISM SERVICES" static fee schedule (PRCR615C) — independently confirmed this pass. Verify directly with Driscoll before assuming this applies to any other Texas Medicaid plan.
- **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:** Driscoll's PA portal cites "TMPPM Children Services Handbook Volume 2, Section 2.3, Medicaid Autism Services Policy" as its review criteria for 97157, even though 97157 does not appear anywhere in that handbook chapter's text or in TMHP's "AUTISM SERVICES" static fee schedule (PRCR615C) — independently confirmed this pass. Verify directly with Driscoll before assuming this applies to any other Texas Medicaid plan.
- **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:** 1-877-455-1053
- **Phone menu path:** Regional Provider Services lines also exist: Hidalgo service area 1-855-425-3247, Nueces service area 1-877-324-3627.
- **Portal:** [Driscoll Prior Authorization Requirement Portal (Autism/ABA Services)](https://webapps.driscollhealthplan.com/priorauthcheck/?s=Autism+(ABA)+Services)
- **Fax:** 1-866-741-5650

Questions to ask on a verification call:

- Which payer ID is correct — pVerify 01090 or 002472 — for Driscoll eligibility checks?
- Does Driscoll's Availity STAR/STAR Kids eligibility route through the CHIP-specific code (74284/DCHCH), or is there a separate STAR/STAR Kids code?
- Does Driscoll support real-time (vs. batch) 270/271 eligibility?
- What's the daily/weekly unit cap and allowed POS for 97152 and 97157 — the PA portal confirms both are covered/authorization-required but doesn't show caps or POS on the entry?
- 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 0362T and 0373T billable under Driscoll's Autism Services benefit, and is there a daily/weekly unit cap for 97156 or 99366?

### 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://webapps.driscollhealthplan.com/priorauthcheck/?s=Autism+(ABA)+Services (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://driscollhealthplan.com/for-providers/ (accessed 2026-07-23)

## Common questions

### Does Driscoll Health Plan cover ABA?

Yes — the Texas Medicaid Autism Services benefit across its South Texas service areas, on TMPPM criteria, with PA required (Autism/ABA Services are listed on the plan's PA portal).

### What form does Driscoll use for ABA authorizations?

The statewide Texas Authorization Referral Form (TARF), submitted via the DHP portal or fax to 1-866-741-5650 — no proprietary plan form.

### Is Driscoll's ABA policy different from the state's?

No — it publishes no distinct ABA criteria. The TMPPM baseline governs; the plan-specific layer is the PA lookup portal and TARF workflow.

## Primary sources

1. [Driscoll Health Plan — Prior Authorization Requirement Portal (Autism/ABA Services)](https://webapps.driscollhealthplan.com/priorauthcheck/?s=Autism+(ABA)+Services)
2. [Driscoll Health Plan — For Providers](https://driscollhealthplan.com/for-providers/)
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. [BACB RBT Handbook (updated 06/2026)](https://www.bacb.com/rbt-handbook)
5. [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)
6. [Driscoll Health Plan — Provider Manual (Rev. 9/2026) (PDF)](https://driscollhealthplan.com/wp-content/uploads/DHP-Provider-Manual-September-2026.pdf)
7. [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)
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.