---
title: El Paso Health ABA coverage (Texas Medicaid MCO).
url: "https://carelu.com/payers/el-paso-health"
markdown_url: "https://carelu.com/payers/el-paso-health.md"
state: TX (Texas)
payer: El Paso Health
kind: Medicaid managed care plan (MCO)
parent_program: Texas Medicaid (THSteps-CCP)
description: "How El Paso Health (formerly El Paso First) administers Texas Medicaid ABA in the El Paso service area — its ABA Request Checklist, the 85% attendance rule, validated-diagnostic-tool requirement, and PA submission mechanics."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# El Paso Health ABA coverage (Texas Medicaid MCO).

_Payer Guide · El Paso Health · Last updated September 2026 · 8 primary sources_

> El Paso's founding Medicaid MCO (ex-El Paso First); 85% attendance rule; not the SDA's only plan.

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.

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 capped 6 hrs/24 units, HO modifier only; initial evaluation authorization valid 60 days from the requested date [1]
- **Prior auth for treatment**: Required — 90-day initial + 90-day extension (attendance logs + LBA progress summary) then up-to-180-day recerts [1]
- **Autism diagnosis required?**: Yes — ASD per TMPPM criteria; El Paso Health requires a validated diagnostic tool (ADOS, ADI-R, CARS) — screening tools alone don't qualify [3][5]

## At a glance

- **Plan type:** Texas Medicaid MCO (nonprofit, El Paso County Hospital District) — STAR, CHIP, STAR+PLUS (El Paso + Hudspeth counties)
- **Clinical rules:** TMPPM Autism Services criteria, detailed in El Paso Health's own ABA Request Checklist and 2026 provider memos
- **Prior auth:** Required — evaluation (97151, HO modifier, 6-hr/24-unit cap), treatment, extension, and recertification
- **Attendance rule:** 85%-attendance threshold on extension/recert requests, for both child and parent/caregiver sessions
- **Submission:** Portal (secure.healthx.com/elpasoprovider) or fax 915-298-7866 / 1-844-298-7866; phone 915-532-3778
- **Rates:** Not published — contract-specific

## The ABA Request Checklist and 2026 documentation memos

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]

## Submission mechanics — and an outdated document to avoid

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]

## Intake gates

The questions that decide whether a family can start with El Paso Health, 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. [5][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. [5][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). [5][1]
- **Diagnostic tools required**: 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]
- **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. El Paso Health adds that the resulting evaluation authorization is valid for 60 days from the requested evaluation date. [1][5][8]
- **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. [5][1]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: 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]

## Delivery and billing rules

Coverage decides whether El Paso Health 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. [5][1][7]
- **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. [5][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. 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]
- **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. 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]
- **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. [5][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. [5][1]

## What intake should collect for El Paso Health

- **Line of business + network check:** STAR/CHIP/STAR+PLUS — and confirm El Paso Health is the member's assigned MCO, since Molina and Superior also serve the El Paso SDA.
- **Validated diagnostic tool on file:** El Paso Health requires ADOS, ADI-R, or CARS-level documentation — a screening tool alone won't support the PA.
- **Attendance logging:** Track child and caregiver session attendance from day one — the 85% threshold gates extension and recert approval.
- **Prescriber referral:** A signed, dated referral attaches to the evaluation PA, per both the statewide rule and El Paso Health's checklist.

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

## Verification of benefits (VOB) data

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

### EDI routing

- **Payer ID (pVerify):** 00796 (branded "El Paso First Health Plans CHIP" — CHIP scope only; STAR/STAR+PLUS coverage under this code unconfirmed) — Only one pVerify entry was found — 00796, explicitly branded "El Paso First Health Plans CHIP" — despite multiple targeted searches, no separate STAR/STAR+PLUS entry exists on pVerify's list. Whether 00796 also routes STAR/STAR+PLUS eligibility (as the single Availity code EPF02 does not cover CHIP) is unconfirmed; do not assume it does.
- **Payer ID (Availity):** EPF02 (STAR/STAR+PLUS), EPF03 (CHIP), EPF37 (Healthcare Options), EPF10/EPF11 (Preferred Administrators) — Multiple line-specific codes confirmed by full agreement between El Paso Health's own "Availity/TPS Payer Identifications" PDF and Availity's independent master payer list: STAR Medicaid HMO (Premier Plan) + STAR+PLUS = EPF02; CHIP = EPF03; Healthcare Options (HCO) = EPF37; Preferred Administrators = EPF10; Preferred Administrators Children's Hospital = EPF11. Route by line of business, not a single generic code.
- **Payer ID (Change Healthcare / Optum):** N/A — El Paso Health's own documentation confirms no Change Healthcare/Optum relationship (Availity + TriZetto Provider Solutions only) — El Paso Health's own payer-ID document states explicitly its clearinghouse agreement is with Availity and TriZetto Provider Solutions (TPS) only, with no mention of Change Healthcare or Optum anywhere; also confirmed absent from Optum's official Real-Time Eligibility Payer List — a verified absence, not an unresearched gap.
- **Supports 270/271 eligibility:** Yes — Confirmed via Availity's master payer list and El Paso Health's own EDI documentation; also rides the centralized TMHP 270/271 feed as every other MCO in this file.
- **Behavioral health administrator:** none — El Paso Health's own ABA Request Checklist and 2026 documentation memos describe the plan's own PA pipeline (portal, fax, phone) throughout, with no external BH vendor named anywhere.
- **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:** El Paso Health's ABA Request Checklist (eff. 2/1/2022) caps the evaluation at 6 hrs/24 units (HO only) with the resulting authorization valid 60 days from the requested evaluation date; a 2026 memo additionally requires a validated standardized diagnostic tool (ADOS, ADI-R, or CARS named) — screening tools like the M-CHAT-R/F do not qualify. Submit via the provider portal (secure.healthx.com/elpasoprovider) or fax 915-298-7866 / 1-844-298-7866. An older 2022 PA Requirements Catalog listing these codes as 'no authorization required' is stale and superseded by the current ABA Request Checklist and 2026 memos — don't cite it.
- **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. 90-day extensions (billed under 97155) require attendance logs for both the child and the parent/caregiver plus an LBA progress summary; <85% attendance triggers a requirement for the LBA to document why and what corrective steps were taken (2026 memo).
- **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:** 1-888-310-3434 (general correspondence)
- **Phone menu path:** Telephonic PA requests (STAR): 915-532-3778.
- **Portal:** [El Paso Health Provider Portal](https://secure.healthx.com/elpasoprovider)
- **Fax:** 915-298-7866 / 1-844-298-7866 (outpatient/elective ABA PA); 915-532-2286 (general provider services)

Questions to ask on a verification call:

- Confirm which of El Paso Health's line-of-business Availity codes (EPF02 STAR/STAR+PLUS, EPF03 CHIP) applies to this specific member for 270/271 eligibility checks.
- Is the ABA copay or coinsurance charged per visit or per day, and does the plan's out-of-pocket maximum apply?
- El Paso Health's own ABA Request Checklist caps the evaluation at 6 hrs/24 units (HO only) — does this apply identically to the 60-day authorization-validity rule for re-evaluations, or does that differ per the 2026 memo?
- Are CPT codes 97152, 97157, 0362T, and 0373T billable under El Paso Health's Autism Services benefit at all?
- Is CPT 99366 billable under this plan's Autism Services benefit?

### VOB data sources

- https://elpasohealth.com/documents/ABA-REQUEST-CHECKLIST-final-2022.pdf (accessed 2026-07-23)
- https://www.elpasohealth.com/pdf/EPH%20-%20Documententaton%20for%20ABA%20Authorization%20_.pdf (accessed 2026-07-23)
- https://www.elpasohealth.com/pdf/EPH-PR-Comprehensive%20Diagnostic%20Evaluation%20for%20Autism%20Services.pdf (accessed 2026-07-23)
- https://www.elpasohealth.com/pdf/EPH-STARCHIPSTARPLUS%20Quick%20Reference%20Guide.pdf (accessed 2026-07-23)
- https://pverify.com/payer-list/ (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23)
- https://www.elpasohealth.com/documents/EPH-PR-El-Paso-Health-Payer-Identifications---Updated-09.24.pdf (accessed 2026-07-23)
- https://www.optum.com/content/dam/o4-dam/resources/pdfs/guides/optuminsight-rt-eligibility-payer-list.pdf (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)
- http://elpasohealth.com/contact-us.html (accessed 2026-07-23)

## Common questions

### Does El Paso Health cover ABA?

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.

### Is El Paso Health the only Medicaid MCO in El Paso?

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.

### What diagnostic documentation does El Paso Health require?

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.

## Primary sources

1. [El Paso Health — ABA Request Checklist (eff. 2/1/2022, PDF)](https://elpasohealth.com/documents/ABA-REQUEST-CHECKLIST-final-2022.pdf)
2. [El Paso Health — Documentation Required for ABA Authorizations (memo, 5/15/2026, PDF)](https://www.elpasohealth.com/pdf/EPH%20-%20Documententaton%20for%20ABA%20Authorization%20_.pdf)
3. [El Paso Health — Comprehensive Diagnostic Evaluation for Autism Services (memo, 5/15/2026, PDF)](https://www.elpasohealth.com/pdf/EPH-PR-Comprehensive%20Diagnostic%20Evaluation%20for%20Autism%20Services.pdf)
4. [El Paso Health — STAR/CHIP/STAR+PLUS Quick Reference Guide (PDF)](https://www.elpasohealth.com/pdf/EPH-STARCHIPSTARPLUS%20Quick%20Reference%20Guide.pdf)
5. [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)
6. [El Paso Health — Prior Authorization (provider page)](https://elpasohealth.com/providers/prior-authorization.html)
7. [BACB RBT Handbook (updated 06/2026)](https://www.bacb.com/rbt-handbook)
8. [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)
9. [El Paso Health — Provider Manual, CHIP, STAR & STAR+PLUS (April 2025) (PDF)](https://www.elpasohealth.com/pdf/EPH_SP_MCCO-COMMS_Provider%20Manual.pdf)
10. [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)
11. [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.