FirstCare Health Plans — SHA LLC dba FirstCare, owned by Baylor Scott & White Health Plan, serving STAR in the Lubbock service area and the large Medicaid Rural Service Area (MRSA) West, plus CHIP in Lubbock only — administers ABA on the statewide TMPPM baseline with no dedicated Autism Services provider-manual section of its own; the plan's Behavioral Health section covers mental health and substance-use benefits in detail but never mentions autism or ABA. **The fact that matters most before building any workflow around FirstCare: the plan's own site states "Our plans end on Aug. 31, 2026, subject to regulatory approval"** — confirm current enrollment and transition guidance with FirstCare and HHSC before treating this as a stable long-term payer relationship.
FirstCare's STAR & CHIP Notification/Prior Authorization Codes list (effective 7/1/2026) lists 97151, 97153, 97154, 97155, 97156, 97158, and 99366 as requiring authorization, filed under "Therapy services" rather than behavioral health. Notably absent from that Medicaid-specific list: 97152, 97157, 0362T, and 0373T — those four codes appear only in FirstCare's separate commercial-oriented Medical Coverage Policy #206 ("Autism Spectrum Disorder"), which explicitly defers Medicaid decisions to the TMPPM: "For Medicaid plans, please confirm coverage as outlined in the Texas Medicaid Provider Procedures Manual." That same commercial policy confirms the Texas mandate's $36,000/year ABA cap for members 10+ "do not apply to self-funded/ERISA plans, Medicaid, or Medicare" — consistent with the statewide Medicaid baseline having no dollar cap. Treat 97152/97157/0362T/0373T PA status for FirstCare Medicaid as unconfirmed rather than assuming either way.[1][2]
Requests submit through the myFirstCare Self-Service Portal (my.firstcare.com/Web) or by fax using the Texas Standard Prior Authorization Request Form — FirstCare uses the statewide form, not a proprietary one. General turnaround is 3 working days from receipt of complete clinical information, and the plan asks providers to submit at least 5 days before the anticipated service date. One routing ambiguity we could not resolve: FirstCare's own contact tables list a separate Medical PA line (1-800-884-4905, fax 1-800-248-1852) and a Behavioral Health PA line (1-855-395-9652, fax 1-844-436-8779) — since ABA codes are filed under "Therapy services" rather than "Behavioral health" on the code list, confirm which line actually processes ABA requests before your first submission. And plan around the closure date directly: FirstCare's STAR page states its plans end August 31, 2026 pending regulatory approval — verify current transition guidance for any active caseload well before that date.[3][4]
The questions that decide whether a family can start with FirstCare Health Plans, 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. FirstCare's own Medical Coverage Policy #206 defers Medicaid decisions to the TMPPM explicitly, and its Medicaid PA code list, not that commercial policy, is the operative gate.[5][1][2]
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. FirstCare's own Medical Coverage Policy #206 defers Medicaid decisions to the TMPPM explicitly, and its Medicaid PA code list, not that commercial policy, is the operative gate.[5][1][2]
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). FirstCare's own Medical Coverage Policy #206 defers Medicaid decisions to the TMPPM explicitly, and its Medicaid PA code list, not that commercial policy, is the operative gate.[5][1][2]
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. FirstCare's own Medical Coverage Policy #206 defers Medicaid decisions to the TMPPM explicitly, and its Medicaid PA code list, not that commercial policy, is the operative gate.[5][1][2]
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. FirstCare's own Medical Coverage Policy #206 defers Medicaid decisions to the TMPPM explicitly, and its Medicaid PA code list, not that commercial policy, is the operative gate.[5][1][2][7]
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. FirstCare's own Medical Coverage Policy #206 defers Medicaid decisions to the TMPPM explicitly, and its Medicaid PA code list, not that commercial policy, is the operative gate.[5][1][2]
FirstCare processes authorizations "in the order received and within 3 working days of receipt of the necessary clinical information," and sends an adverse determination "Within 3 working days in writing to the provider of record and the member if the member is not hospitalized." It asks for lead time without mandating it: "we encourage providers to submit requests a minimum of five days prior to the anticipated service date" (elective admissions and procedures: at least 2 working days). The manual has no ABA-specific timing or reauthorization lead time; an incomplete request follows the state process in 1 TAC § 353.425.[3][8][9]
"Coverage under Medicaid and CHIP is secondary to all other insurance coverage, unless an exception applies under federal law. Coverage provided under Medicaid will pay benefits for Covered Services that remain unpaid after all other insurance coverage has been paid." File with FirstCare "within 95 days of the date on the primary payor's Explanation of Benefits (EOB) or Remittance Advice (RA)"; any overpayment made because FirstCare was not primary "must be refunded in full." The manual does not say whether FirstCare's ABA PA is still needed when it pays second — request it.[3][10]
Coverage decides whether FirstCare Health Plans 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][2][6]
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][2]
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.[5][1][2]
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.[5][1][2]
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][2]
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][2]
Yes — the Texas Medicaid Autism Services benefit for STAR members in Lubbock and MRSA West, on TMPPM criteria. FirstCare's own Medicaid PA code list confirms PA is required on 97151, 97153-97156, 97158, and 99366.
FirstCare's own site states its plans end August 31, 2026, subject to regulatory approval — confirm current enrollment and transition status directly with FirstCare or HHSC before building a long-term care plan around this payer.
No — FirstCare's own commercial autism policy confirms the mandate's dollar cap applies to state-regulated commercial plans, not Medicaid, matching the no-cap statewide Medicaid baseline.
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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