Molina Healthcare is new to New Mexico: it entered with the Turquoise Care launch on July 1, 2024 (alongside UnitedHealthcare, as Western Sky/Centene exited). As a Turquoise Care MCO it is bound by the shared Behavioral Health Level of Care Guidelines and the LOD #53 rate floor — but unlike the other three plans, Molina has published no New Mexico-specific ABA clinical policy or code-level PA list we could verify. The honest operating posture: assume the state baseline clinically, submit PAs electronically through Availity Essentials as Molina requires, and confirm ABA code-level requirements in the portal before the first request.
Verified: Molina is a Turquoise Care MCO bound by the state's ABA criteria and the LOD #53 rate floor, its provider manual requires electronic PA submission, and Availity Essentials is the mandated primary channel (a contract-compliance item, not a preference). Not verified: any Molina-specific ABA clinical policy, PA form, or code-level PA list for New Mexico — we found none published. That gap cuts both ways: the state baseline (no PA on 97151, PA on 97153, the under-20-hrs quirk) should govern via the shared Level of Care Guidelines, but until Molina publishes its ABA mechanics, run a code-level PA check in Availity for each new case and get the answer in writing. As the newest plan alongside UHC, expect member churn from the Western Sky exit — verify plan identity on any card that predates July 2024.[1][2]
Whatever Molina's internal mechanics turn out to be, two things are anchored at the state level and enforceable: the clinical criteria (NMAC 8.321.2.13 and Supplement 24-13 — the ASD-or-at-risk eligibility, adult benefit, stage model, and authorization cadence) and the rates. Letter of Direction #53 directs every Turquoise Care MCO to pay providers no less than the Medicaid FFS ABA fee schedule, retroactive to 1/1/2025, and it binds sub-vendors too. If a Molina contract or remittance comes in under the published schedule, LOD #53 is the citation to raise.[4][3]
The questions that decide whether a family can start with Molina Healthcare of New Mexico (Turquoise Care), and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the New Mexico Medicaid rule: NMAC 8.321.2.13 imposes no upper age limit and covers Medicaid-enrolled adults, with under-21s served through EPSDT and the at-risk pathway bounded at 12–36 months. One drafting trap: the shared Turquoise Care Level of Care Guidelines (July 2024) describe ABA for members 12 months up to 21 years, because the adult expansion arrived later in NMAC 8.321.2.13 (12/10/2024) and Supplement 24-13 — cite those, not the LOC document, on an adult request.[5][6][4]
Follows the New Mexico Medicaid rule: a presumptive ASD diagnosis from a licensed practitioner within scope must have been received within three years of the referral to stage two or three; a recipient who already carries an ASD diagnosis needs no re-evaluation but does need an ISP and a medical-necessity determination; and the at-risk pathway requires no diagnosis at all.[5][6][4]
Follows the New Mexico Medicaid rule: an approved Autism Evaluation Provider confirms the presence of or risk for ASD through a comprehensive diagnostic, targeted or ASD risk evaluation, or the recipient is referred on a presumptive diagnosis from any licensed practitioner whose scope of practice allows an ASD diagnosis, received within three years of referral.[5][6][4]
Follows the New Mexico Medicaid rule — Autism Evaluation Provider evaluation, ISP and referral to an approved ABA provider agency, with the ISP and evaluation accompanying the stage-three PA request. Molina publishes no New Mexico-specific ABA clinical policy, PA form or code-level PA list, and its provider manual requires electronic prior authorization submission through Availity Essentials as the mandated primary channel — run a code-level PA check there for each new case and keep the answer in writing.[5][6][4][1]
Molina’s manual publishes no day count of its own: it decides “as promptly as the Member’s health requires and no later than contractual and regulatory requirements”, expedited when a standard timeframe “could jeopardize a Member’s life or health”. So its HCA contract governs: it requires the plan to “adjudicate standard prior authorization requests within seven (7) Business Days after receipt of all necessary and relevant documentation”, and requests are “deemed granted for determinations not made within the seven (7) Business Day turn-around time” (extension up to 14 calendar days on request or with justification); expedited decisions come “no later than twenty-four (24) hours after the receipt of all necessary and relevant documentation”, also deemed granted if missed. Federal floor on top: for rating periods that start on or after January 1, 2026, 42 CFR 438.210(d) caps standard decisions at “7 calendar days after receiving the request for service” (extendable up to 14 more calendar days), and expedited at 72 hours. The contract binds the plan to “the most rigorous standards” of the NM Prior Authorization Act, NCQA, HCA regulation or 438.210(d), so plan against 7 calendar days from receipt and the 24-hour state expedited clock. Reauthorization: Supplement 24-13 sets no day count, only that the ABA Treatment Plan Update and Progress Report “must be prepared and submitted to the MCO or TPA prior to the end of the recipient’s Prior Authorization period”.[1][7][8][3]
Molina’s manual: “Medicaid is always the payer of last resort”; “If third-party liability can be established, Providers must bill the primary payer and submit a primary explanation of benefits (EOB) to Molina for secondary claim processing”, reimbursed “based on the state regulatory COB methodology”. Timely filing for a secondary claim: “Other carrier’s EOB when Molina is the secondary payer” — one year from the date of service. Molina “will pay claims for prenatal care and preventive pediatric care and then” seek reimbursement from third parties. The HCA contract makes Medicaid “the payer of last resort” and adds the trap: the plan “shall deny payment on a Claim that has been denied by a third-party payer when the reason for denial is the Provider’s or Member’s failure to follow prescribed procedures, including but not limited to failure to obtain prior authorization” — so secure the commercial plan’s ABA authorization first. The same contract says “Claims for EPSDT shall be paid at the time presented for payment by the Provider and the CONTRACTOR shall bill the responsible third party”; whether an ABA claim is handled under that EPSDT pay-and-chase exception is not spelled out, so confirm with the plan before skipping the primary. TRICARE also pays ahead of Medicaid: its own secondary-payer rule exempts “a plan administered under title XIX”. The manual does not say whether Molina’s own ABA prior authorization is required while it is secondary — confirm with Molina UM.[1][7][9][10]
Follows the New Mexico Medicaid rule, which names none: NMAC 8.321.2.13 requires the diagnosis be made against the latest DSM or ICD and the at-risk criteria be measured by standardized assessments, without naming instruments. No plan-specific instrument list was found for this MCO either.[5][6][4]
Ask the plan: MAD Behavioral Health Policy and Billing Manual / Supplement 24-13 — hca.nm.gov blocked automated retrieval this cycle (CloudFront geo-block), so pull the MAD Behavioral Health Policy and Billing Manual and Supplement 24-13 from the HCA ABA provider page by hand, or ask the MAD ABA Manager.
No verified rule. NMAC 8.321.2.13 carries no telehealth provision for ABA and the shared Turquoise Care Level of Care Guidelines set none for ABA Stage 3, and no plan-specific ABA telehealth policy was found for this MCO.[5][6][4]
Ask the plan: The plan’s provider portal or behavioral health UM line, plus the MAD Behavioral Health Policy and Billing Manual — hca.nm.gov blocked automated retrieval this cycle (CloudFront geo-block), so pull the MAD Behavioral Health Policy and Billing Manual and Supplement 24-13 from the HCA ABA provider page by hand, or ask the MAD ABA Manager.
Coverage decides whether Molina Healthcare of New Mexico (Turquoise Care) 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 New Mexico Medicaid rule: every stage-three service requires clinical management, a BCaBA or technician implementing the plan requires case supervision from their BA or supervising BAA, and prior authorization is triggered where more than two hours of case supervision, or two hours of clinical management, per 10 hours of intervention is requested. Certification-maintenance supervision is not MAD-reimbursable.[5][6][4]
Follows the New Mexico Medicaid rule: no per-day unit ceiling, with authorization-gated intensity thresholds instead — including the inverted quirk that comprehensive treatment averaging under 20 hours a week requires prior authorization — and PA on supervision or clinical management above two hours per 10 hours of stage-three service. No plan-specific hour caps were found for this MCO.[5][6][4]
Follows the New Mexico Medicaid rule: school-setting activities with the potential to supplant educational services are excluded; a residential facility that is not itself an ABA provider must contract a MAD-enrolled ABA provider to render on site; treatment foster care is not treated as out-of-home placement; and out-of-home placement is otherwise an exclusion under the shared Turquoise Care Level of Care Guidelines apart from time-limited transition services.[5][6][4]
Follows the New Mexico Medicaid rule: reimbursement goes to the MAD-enrolled ABA provider, behavior analysts enrol as Provider Type 445 / Specialty 099 and technicians as Provider Type 430 / Specialty 098 on the MAD-877 and MAD-878 attestations, and every practitioner must clear a New Mexico criminal background registry check before rendering. Letter of Direction #53 makes the state fee-for-service ABA fee schedule the contractual minimum this MCO and its sub-vendors must pay.[5][6][4]
Not resolved. NMAC publishes no same-clock-time billing rule for ABA and defers to the MAD Behavioral Health Policy and Billing Manual; no plan-specific concurrent-billing rule was found for this MCO.[5][6][4]
Blocked on: The plan’s provider portal or claims line, plus the MAD Behavioral Health Policy and Billing Manual — hca.nm.gov blocked automated retrieval this cycle (CloudFront geo-block), so pull the MAD Behavioral Health Policy and Billing Manual and Supplement 24-13 from the HCA ABA provider page by hand, or ask the MAD ABA Manager.
Not resolved at the state level: NMAC makes the supervising behavior analyst responsible for treatment plan formulation and documentation but defers session-note mechanics to the MAD Behavioral Health Policy and Billing Manual, and no plan-specific documentation standard was found for this MCO.[5][6][4]
Blocked on: MAD Behavioral Health Policy and Billing Manual (ABA documentation requirements) — hca.nm.gov blocked automated retrieval this cycle (CloudFront geo-block), so pull the MAD Behavioral Health Policy and Billing Manual and Supplement 24-13 from the HCA ABA provider page by hand, or ask the MAD ABA Manager.
Yes — as a Turquoise Care MCO it administers the state ABA benefit under the shared Level of Care Guidelines and NMAC criteria. Molina has published no NM-specific ABA policy, so verify code-level PA requirements in Availity Essentials.
Electronically through Availity Essentials — Molina's mandated primary submission channel. Since no ABA-specific PA list is published, confirm which codes require authorization in the portal and keep the answer on file.
At least the state FFS ABA fee schedule — LOD #53 makes the published rates a minimum for all Turquoise Care MCOs and their sub-vendors, retroactive to January 1, 2025.
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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