Presbyterian Health Plan — New Mexico's homegrown Turquoise Care MCO — administers ABA on the state's criteria, and even borrows the state's vocabulary: its own authorization paperwork is an "Applied Behavior Analysis (ABA) Clinical Review Form: Stage 3" and an "ABA Specialty Care Clinical Review Form," mirroring the NMAC stage model. The plan-specific layer is form-and-routing mechanics, with one trap worth memorizing: Presbyterian's Turquoise Care behavioral health is managed in-house — Magellan handles only Presbyterian's Medicare and commercial BH, never Medicaid.
Clinically, expect the state baseline: the ASD-or-at-risk eligibility, no-PA assessment, the 97153 treatment PA, and the service-authorization-plus-6-month-PA cadence all come from the state program (see the New Mexico Medicaid guide). Presbyterian's contribution is its paperwork: Stage 3 treatment requests go on Presbyterian's own ABA Clinical Review Form (with a separate Specialty Care version), submitted by fax to (505) 843-3019 or through the dedicated Turquoise Care online submission channel; day-to-day provider work runs through the myPRES portal. The plan mirroring the state's "Stage 3" and "Specialty Care" vocabulary on its forms is a strong signal of state-criteria deference — no distinct Presbyterian clinical policy for ABA has been published. No plan-specific hour caps have been published either; treat the state criteria as the operative limits and verify current form versions in myPRES before submitting.[1]
Presbyterian contracts Magellan for behavioral health on its Medicare and commercial lines — but Turquoise Care (Medicaid) behavioral health is handled in-house. An ABA authorization for a Medicaid member routed to Magellan goes nowhere: use the Medicaid-specific BH fax (505) 843-3019 or the Turquoise Care portal submission. Because the same family can move between Presbyterian's commercial and Medicaid products, confirm the line of business on every card before choosing the routing.[1]
The questions that decide whether a family can start with Presbyterian Health Plan (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 Presbyterian’s own paperwork on top: stage-three treatment requests go on Presbyterian’s "Applied Behavior Analysis (ABA) Clinical Review Form: Stage 3" (with a separate ABA Specialty Care Clinical Review Form), faxed to (505) 843-3019 or filed through the Turquoise Care online submission channel. The routing trap matters more than the form: Magellan handles Presbyterian’s Medicare and commercial behavioral health only, never Turquoise Care Medicaid, which is managed in-house.[5][6][4][1]
Presbyterian’s Prior Authorization Guide lists Medicaid standard requests at “7 calendar days” and expedited at “24 hours”, processed “when all necessary and relevant documentation supporting the prior authorization request is submitted”. The Turquoise Care manual sharpens the incomplete-file rule: “We will deny the prior authorization request if we do not receive all of the documentation needed to make a decision within 7 calendar days of the day the request was received” — so send the complete packet up front. “Expedited requests for Turquoise Care members are processed within 24 hours” of complete documentation. Its HCA contract (7 business days, 24-hour expedited, deemed granted, most rigorous of that or 42 CFR 438.210(d)) is the backstop. 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”. Presbyterian publishes no separate ABA lead time.[2][7][8][3]
Presbyterian’s Turquoise Care manual: “Presbyterian Turquoise Care is, by law, the payor of last resort” — bill the other plan first, get an itemized EOP, and submit within “90 calendar days of the date the other payor paid or denied the claim”, “not to exceed 210 calendar days from the date of service”; “Claims submitted without an EOP are denied”. “Coverage requirements of the other insurance plan must be satisfied”, and Presbyterian “does not make payment for services denied by another carrier when the provider or member did not follow the requirements of the primary plan”. On its own authorization when secondary: “Presbyterian Turquoise Care does not require a prior authorization or referral” when the primary does not include the benefit or has hit its annual or benefit maximum, and its “normal prior authorization guidelines and plan requirements apply when Presbyterian is acting as the primary carrier if the other carrier denied the services”. Coordination follows “CMS and NMAC regulations, the National Association of Insurance Commissioners’ guidelines”. TRICARE pays ahead of Medicaid (10 U.S.C. 1079(i)(1)).[7][8][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 Presbyterian Health Plan (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 — on the state's ABA criteria and stage model. Treatment requests use Presbyterian's own Stage 3 ABA Clinical Review Form, faxed to (505) 843-3019 or submitted through the Turquoise Care online channel.
No — Magellan handles Presbyterian's Medicare and commercial behavioral health only. Turquoise Care (Medicaid) BH is in-house: use the Medicaid fax (505) 843-3019 or the Turquoise Care portal.
No separate Presbyterian rule has been published — the state baseline applies, and the state fee schedule marks 97151/97152/0362T PA-free. Verify current requirements in myPRES if in doubt.
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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