El Paso Health — a nonprofit HMO established by the El Paso County Hospital District, rebranded from "El Paso First Health Plans" in 2017, serving STAR, CHIP, and STAR+PLUS across El Paso and Hudspeth counties — is one of the more document-rich Texas MCOs for ABA: a dedicated ABA Request Checklist and two 2026 provider memos spell out documentation requirements in more detail than most plans publish. One framing note: El Paso Health is the market's founding and longest-standing Medicaid plan, but is not the sole MCO in the El Paso service delivery area — secondary HHSC service-area sources indicate Molina and Superior also participate in STAR and/or CHIP there, so confirm current network participation for STAR+PLUS specifically rather than assuming exclusivity.
El Paso Health's ABA Request Checklist (effective 2/1/2022) lays out each PA stage: the initial evaluation (97151, capped at 6 hours/24 units, HO modifier only) needs a signed prescriber referral and comprehensive diagnostic documentation, and the resulting authorization is valid for 60 days from the requested evaluation date; the initial 90-day treatment request needs the signed evaluation/treatment plan plus the referral; a 90-day extension (billed under 97155) needs attendance logs and an LBA progress summary; and 180-day recertifications need a re-evaluation (97151 again, up to 6 hrs/24 units) that, per the checklist, "does not require prior auth, will be reviewed upon submission." Two provider memos dated 5/15/2026 add detail beyond the statewide baseline: attendance logs for both the child and the parent/caregiver are required with every extension/recert, and services fall below 85% attendance trigger a requirement for the LBA to document why and what corrective steps were taken. A separate memo specifies the ASD diagnostic evaluation must use a validated standardized tool — ADOS, ADI-R, or CARS are named — and that screening tools like the M-CHAT-R/F cannot substitute.[1][2][3]
PA requests submit through the DHP-style provider portal at secure.healthx.com/elpasoprovider, or by fax (outpatient/scheduled: 915-298-7866 or 1-844-298-7866) or phone (915-532-3778 or 1-877-532-3778 for STAR/CHIP; 1-833-742-3127 for STAR+PLUS). El Paso Health accepts the Texas Standard Prior Authorization Request Form, its own "Request for Behavioral Health Services" form, or the statewide CCP Prior Authorization Request Form. One caution: the plan's older PA Requirements Catalog (dated 2022, with code effective dates from 2019–2021) lists 97151–97158 and 99366 as "no authorization required" — that directly contradicts the current ABA Request Checklist and 2026 memos, and appears to be a stale, unmaintained document that predates the 2/1/2022 Autism Services benefit. Don't cite it; the ABA Request Checklist and current memos govern.[6][4]
The questions that decide whether a family can start with El Paso Health, 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.[5][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.[5][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).[5][1]
Stricter than the state floor in practice: El Paso Health's 5/15/2026 memo requires the ASD diagnostic evaluation to use a validated standardized tool — it names ADOS, ADI-R and CARS — and states that screening tools such as the M-CHAT-R/F cannot substitute. DSM criteria, severity level, and documented comorbid conditions and trauma history are also required.[3][2][5]
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. El Paso Health adds that the resulting evaluation authorization is valid for 60 days from the requested evaluation date.[1][5][8]
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.[5][1]
El Paso Health's prior-authorization page: "Standard/Routine Within three (3) business days after receipt of the request; Expedited/Urgent Within one (1) business day after receipt of the request; Inpatient Within one (1) business day …; Post-Stabilization Within one (1) hour." Incomplete requests: a fax "no later than 3 Business Days after the prior authorization is received" lists what is missing and when it is due; if it is not in by the end of the third business day the Medical Director reviews by the 7th business day, and a final decision comes "No later than the 10th Business Day from when the PA was received." The April 2025 manual warns that a request with "incomplete, missing, incorrect, or illegible" information is returned unentered — neither approved nor denied — and must be resubmitted. No outpatient or ABA reauthorization lead time is published (the manual's "Three (3) Days prior" rule is for elective admissions).[6][9][10]
Bill the other coverage first and file with El Paso Health "95 Days from the date of disposition by the other insurance carrier"; if the other insurer has not responded, "the Provider must allow 110 Days to elapse before submitting a claim." El Paso Health "does not process as a primary carrier if the services qualify for COB benefits unless the services have not been allowed or were denied by the primary carrier." Authorization still applies when it pays second: "For Coordination of Benefits (COB), El Paso Health pre-certification requirements will apply" — get the El Paso Health ABA PA even when commercial insurance is primary. (Quoted from the April 2025 manual; the November 2025 edition could not be opened.)[9][11]
Coverage decides whether El Paso Health 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.[5][1][7]
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.[5][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. El Paso Health's checklist confirms the 6-hour / 24-unit 97151 cap (HO modifier only) and applies it again to the re-evaluation that supports a 180-day recertification.[1][5]
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. El Paso Health adds attendance logs for both the child and the parent/caregiver with every extension and recertification, plus an LBA progress summary; falling below 85% attendance requires the LBA to document why and what corrective steps were taken.[2][1][5]
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.[5][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.[5][1]
Yes — the Texas Medicaid Autism Services benefit across STAR, CHIP, and STAR+PLUS in El Paso and Hudspeth counties, detailed in the plan's own ABA Request Checklist and 2026 documentation memos.
It's the market's founding plan, but not the only one — Molina and Superior also participate in STAR and/or CHIP there per HHSC service-area sources. Confirm the member's assigned MCO before assuming El Paso Health.
A validated standardized tool — ADOS, ADI-R, or CARS are named in the plan's own memo — plus DSM criteria, severity level, and (per a separate memo) documented comorbid conditions and trauma history. Screening tools like the M-CHAT-R/F don't substitute.
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.
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