---
title: "TennCare (Tennessee Medicaid) ABA coverage: the intake guide."
url: "https://carelu.com/payers/tenncare-tennessee-medicaid"
markdown_url: "https://carelu.com/payers/tenncare-tennessee-medicaid.md"
state: TN (Tennessee)
payer: TennCare (Tennessee Medicaid)
kind: State Medicaid program
description: "How TennCare (Tennessee Medicaid) covers ABA for autism under EPSDT — one unified tri-MCO program description and universal request form, prior authorization, LBA licensure, 6-month reviews, and why no ABA rates are published."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# TennCare (Tennessee Medicaid) ABA coverage: the intake guide.

_Payer Guide · TennCare · Last updated September 2026 · 10 primary sources_

> Through age 21 via EPSDT, no annual limit, LBA licensure, one tri-MCO program.

TennCare, Tennessee's Medicaid program, covers ABA for children with autism through the EPSDT benefit — administered entirely through its three managed care organizations. Tennessee is a strong ABA-demand state, and unusually, its MCOs run one deliberately unified ABA program: since a 2024 tri-MCO workgroup (with TennCare and Vanderbilt TRIAD), BlueCare, UnitedHealthcare, and Wellpoint share a single program description and a single universal request form. The clinical rules are the same everywhere; what changes per plan is the submission mechanics — each MCO has its own guide below.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — Universal ABA Request Form ("Assessment Request") with diagnostic report + doctor's order, to the member's MCO [3][2]
- **Prior auth for treatment**: Required — 6-month (26-week) authorization periods; continuation must report % of units used [3][2]
- **Autism diagnosis required?**: ASD or another qualifying DSM-5-TR diagnosis — not strictly autism-only [2][3]

## At a glance

- **Covers ABA?:** Yes — through age 21, via EPSDT
- **Annual limit:** No annual benefit limit; no fixed hour caps (hours justified by severity)
- **Prior auth:** Required — one universal ABA request form across all three MCOs
- **Licensure:** Direct ABA requires a TN Licensed Behavior Analyst (LBA)
- **Administered by:** BlueCare, UnitedHealthcare Community Plan, Wellpoint (all MCO)
- **Rates:** Not published — negotiated in each MCO's provider contracts
- **Staff screening:** BACB checks for RBTs; LTSS/Katie Beckett staff: criminal check within 30 days pre-start + 6 registries, monthly SAM/LEIE/TTPL

## Coverage & benefit

Children on TennCare receive services through EPSDT, which requires coverage of medically necessary services — including ABA — for members under 21. There is no annual benefit limit on ABA under TennCare, and the unified MCO program sets no fixed weekly-hour cap either: requested hours are justified clinically using a severity/unit guide (levels 1–3 per domain), in 15-minute units. Covered ABA includes assessment, direct therapy, and parent/caregiver training.

## One program, three MCOs

TennCare and its three MCOs jointly issued a single "ABA Provider Requirements and Program Description" (2024) and a universal "Request for Applied Behavior Analysis" form carrying all three MCOs' logos, fax numbers, and portals (current version January 2026). The shared baseline: an ASD or other qualifying DSM-5-TR diagnosis by a qualified professional with the diagnostic report and a doctor's order; direct ABA delivered by a Tennessee Licensed Behavior Analyst (LBA), with RBTs working under LBA authority; a treatment plan within 30 days of starting, reviewed every 6 months; and telehealth allowed per-code (flagged on the form) but treated cautiously. [2][3][4]

The operational tripwire intake should know from day one: continuation requests must report the percentage of authorized units actually used — utilization under 90% (on direct-treatment code 97153) requires a written explanation. Families whose real availability can't support the requested hours become a reauthorization problem six months later, so capture honest availability at intake. [2][3][4]

## Authorization & provider requirements

A licensed provider must prescribe the service, and coverage is always subject to medical necessity, with prior authorization required for both the assessment and treatment. Authorizations run in 6-month (26-week) periods; continuation requires documented progress against goals, current severity levels, requested hours per code, and parent-training (97156) volume. Tennessee requires that a BCBA or other qualified licensed clinician delivering direct ABA be licensed as a Licensed Behavior Analyst (LBA) through the Tennessee Applied Behavior Analyst Licensing Board. Because TennCare is entirely MCO-administered, capture which plan the family is on — it decides the portal, fax, forms, and timelines (see the per-MCO guides). [3]

## Rates: negotiated, not published

Unlike most state Medicaid programs, TennCare publishes no ABA fee schedule — each "at-risk" MCO negotiates its own provider contracts and maintains its own rates. A February 2026 multistate comparison of Medicaid ABA reimbursement leaves every Tennessee cell blank for exactly this reason. For practices modeling TennCare revenue, the only source of truth is your own MCO contracts — and rate negotiation is a per-plan conversation, not a state lookup. [5]

## Staffing & credentialing: who you can hire, and what they must clear

Tennessee does not license or register behavior technicians — the tri-MCO program description is the binding document, and it requires that RBTs and their supervising BCBAs "comply with ALL of the current BACB requirements for credentialing, ethics, competency, supervision, and maintenance of the RBT credential." Unlicensed staff deliver ABA under the extended authority and direction of a TN LBA and may not represent themselves as behavior analysts. So the BACB floor is the operative technician standard: 18+, high-school education, the 40-hour training and initial competency assessment (updated curriculum from January 2026), and — within 180 days of paying for the RBT application — a criminal background check plus an abuse-registry check "comparable to those required of home health aides, child care professionals, and teachers," attested by the RBT supervisor or employer. Tennessee sets no numeric supervision ratio of its own, so the BACB minimum governs: 5% of monthly service hours supervised, with two face-to-face contacts per month, at least one individual. [2][6][7][8][9]

State-mandated screening enters through TennCare's Aligned Background Check Protocol (effective July 1, 2024), and its scope matters: it formally binds LTSS providers — 1915(c) waiver, Katie Beckett, ECF CHOICES, and CHOICES. For those programs, every employee, subcontractor, or volunteer with direct member contact needs a Title 52-compliant criminal check (TBI fingerprint check, or a state-licensed private investigation company as an alternative; nationwide check if the hire has lived in TN a year or less) completed within 30 days before their first day of direct contact, plus six registry clearances: the TN Elderly/Vulnerable Abuse Registry, National Sex Offender Registry, SAM, OIG LEIE, the TennCare Terminated Provider List, and TN FOIL. A hit on the first five is automatically disqualifying; convictions and FOIL hits require a documented individualized assessment — blanket no-felony policies are prohibited. SAM, LEIE, and TTPL must then be rechecked monthly, and TennCare can recoup payments for services rendered by staff whose checks weren't compliant. An ABA agency serving only standard EPSDT members inherits employee screening chiefly through the BACB requirement and its MCO contract terms — but any agency serving Katie Beckett children falls squarely under the protocol, so most practices should simply run it for everyone. [2][6][7][8][9]

At the supervisor level, direct ABA requires a Tennessee Licensed Behavior Analyst (LBA) — a BCBA or BCBA-D credential is the qualification basis — through the Applied Behavior Analyst Licensing Committee. Application mechanics under the May 2025-revised Rules 1180-05: minimum age 21, a vendor-submitted criminal background check sent directly to the Committee, two good-moral-character letters, and fees of $50 (application), $40 (license), and $150 biennial renewal, which also requires proof of current BACB certification plus 3 CE hours on cultural diversity. Assistant-level LABAs (BCaBA-based) may practice only under LBA supervision, and practicing without a license draws $500–$1,000 civil penalties. One carve-out worth knowing: a licensed mental health clinician who can attest to BACB and MCO standards may provide direct ABA without an LBA license if practicing within a provider group, not independently. Each MCO also independently verifies BCBA credentials at network enrollment, requires an annual ABA quality-assurance attestation — and does not separately reimburse non-client-specific administrative supervision or technician training. The rules and program description publish no TB-test, CPR, or crisis-training mandate for ABA staff (only a crisis plan per BACB best practices); confirm any extra health-screening requirements with your MCO contract. [2][6][7][8][9]

## Intake gates

The questions that decide whether a family can start with TennCare (Tennessee Medicaid), and what they have to bring.

- **Age limit**: Birth through age 20. ABA rides on EPSDT, and TennCare defines that benefit as “a full program of checkups and health care services for children from birth through age 20 who have TennCare.” The shared tri-MCO program description sets no age floor and no age ceiling of its own — so the EPSDT boundary is the operative one, there is no minimum age, and the 21st birthday is the coverage cliff to diary at intake. [10][2]
- **Diagnosis recency**: No recency rule on the ASD diagnosis itself. The program description requires only that the diagnosis be “(a) issued by a qualified health professional, practicing within their scope, with training in assessment of individuals with ASD and/or other neurodevelopmental concerns, (b) based on current DSM-5-TR criteria if applicable, and (c) include history, observation, and if/when clinically appropriate formal assessment of developmental skills.” What does carry a clock is functional re-evaluation: the initial pre-certification review expects providers to describe outcomes “including updated evaluation of functioning via standardized tools at least every two years.” The universal form asks for the date the diagnosis was initially rendered and whether a standard assessment was used — so an older report is a documentation question, not a disqualifier. [2][3]
- **Who may diagnose**: “ASD or other identified diagnosis necessitating ABA intervention should be… issued by a qualified health professional, practicing within their scope, with training in assessment of individuals with ASD and/or other neurodevelopmental concerns” — the program names no specific license. Initial pre-certification separately requires “documentation by a TN licensed clinician supporting medical necessity for ABA.” The universal form captures the diagnosing facility/group plus the provider name and credentials. Note Tennessee is not autism-only: another qualifying DSM-5-TR diagnosis “for which ABA is proven to be an effective appropriate intervention” also opens the door, and the form asks about it explicitly. [2][3]
- **Diagnostic tools required**: No single instrument is mandated. The diagnosis “must be validated by a documented comprehensive assessment demonstrating the presence of” the DSM-5-TR ASD criteria, and the evaluation should include “formal assessment of developmental skills (e.g. cognitive, adaptive, ASD assessment tools).” The ABA assessment itself “should be comprehensive and include direct observation (ideally a minimum of one in-person contact), file review, interviews with one or more informants, and standardized assessments to evaluate cognition, communication, social skills, adaptive skills, and behavioral domains,” plus a Functional Behavioral Assessment. The program points to AAP/AAN/AACAP-recommended instruments generically rather than publishing a required list; the form asks only “Was Standard Assessment used: In diagnosis of ASD?” and, at continuation, “List Standardized Assessments used to validate progress and include scores.” [2][3]
- **Referral required?**: Yes — a doctor's order, attached to the request. The universal ABA request form’s assessment section carries a hard “Doctor’s Order Attached: Yes/No” checkbox alongside “Diagnostic Report Attached,” and the review requires documentation by a TN-licensed clinician supporting medical necessity. No validity window is published for the order, so submit the most current one. The three MCOs sharpen this differently — UnitedHealthcare requires a physician order or script at initiation and Wellpoint asks for an MD order or treating-provider recommendation — see the per-MCO guides. [3][2]
- **Telehealth**: Available per code, not blanket-approved. Every code row on the universal request form — 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158 — carries an “Indicate if Hours are telehealth” checkbox, and “Telehealth” is one of the place-of-service options alongside Clinic, Home, Community and School, so telehealth hours are requested and authorized code by code. The program description adds no prohibition but frames it cautiously: providers must weigh the CDC-derived limitations, “identify protocols for clinical appropriateness of telehealth models (i.e., direct service, clinical direction, caregiver consultation),” use HIPAA-compliant technology and ensure provider competence. [3][2]
- **Prior-auth decision time**: Every TennCare ABA request is decided by the member's MCO, and the statewide MCO contract sets the clock. For a standard (non-urgent) request, the decision is due "within seven (7) calendar days of the request's receipt." This took effect January 1, 2026; before that it was 14 days. The MCO may add "up to fourteen (14) additional calendar days" if the family or provider asks, or if it shows TennCare it needs more information. An expedited decision is due "no later than seventy-two (72) hours after receipt of the request for service." Expedited applies when the standard clock "could seriously jeopardize the enrollee's life or health or ability to attain, maintain, or regain maximum function." These match the federal managed-care cap in 42 CFR 438.210(d). The shared tri-MCO ABA form sets 26-week authorization periods but publishes no lead time for filing a continuation. Put the end date in the calendar and file before it. [11][12][3]
- **Other insurance (who pays first)**: TennCare pays last. The MCO contract makes TennCare "the payer of last resort for all covered services." Provider agreements must require providers "to seek such third party liability payment before submitting claims" to the MCO. So a child on a parent's commercial plan is billed there first, and the primary EOB goes with the TennCare claim. Get the commercial plan's prior authorization too. The MCO "shall deny payment on a claim that has been denied by a third party payer when the reason for denial is the provider or enrollee's failure to follow prescribed procedures, including but not limited to, failure to obtain prior authorization." The contract does let certain claims be paid first and recovered later (the State Medicaid Manual 3904.4 services). Each MCO publishes its own list: Wellpoint pays and pursues for any child under 21 without Medicare, BlueCare/TennCareSelect list "TennCare Kids," and UnitedHealthcare's manual lists none. See the MCO guides. TRICARE by statute pays only after other coverage "except in the case of a plan administered under title XIX" (Medicaid), so TRICARE goes before TennCare. CHAMPVA is the reverse: "If you are eligible under Medicaid, CHAMPVA will pay first." [11][13][14][15][16]

## Delivery and billing rules

Coverage decides whether TennCare (Tennessee Medicaid) 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**: Tennessee sets no numeric ratio of its own — the BACB floor governs by incorporation. The program description requires that “RBT’s and their supervising BCBA providers, must comply with ALL of the current Behavior Analyst Certification Board (BACB) requirements for credentialing, ethics, competency, supervision, and maintenance of the RBT credential,” which puts the operative standard at 5% of monthly service hours supervised with two face-to-face contacts per month. Direct ABA “must be provided by or supervised by a Board-Certified Behavior Analyst (BCBA) licensed in TN (LBA) or a health professional permissible under TN state law”; “unlicensed persons may deliver applied behavior analysis (ABA) services under the extended authority and direction of a TN LBA” and “shall not represent themselves as professional behavior analysts.” One carve-out: a licensed mental health clinician who can attest to BACB and MCO standards may deliver direct ABA without an LBA license if practicing within a provider group, not independently. The supervision overhead itself is not payable — “non-client specific administrative Supervision/training of behavior technician/paraprofessionals” is an explicit non-covered service. [2][7]
- **Daily limits / MUEs**: No per-day unit ceiling, no annual benefit limit and no fixed weekly-hour cap. The universal form asks for units “per week” and “per authorization period” in 15-minute increments, justified against a severity/unit guide that scores communication, social, behavior and adaptive domains at levels 1–3. The only published quantitative ceiling is group size: “group size should be no larger than six to eight participants as a best practice.” Utilization is policed at the back end instead of the front — continuation requests must compute units utilized divided by units approved times 100, and “if under 90% utilized, please explain,” with the form noting “these figures are in reference to 97153/direct care, per authorization.” UnitedHealthcare separately applies extra scrutiny above 20 hours per week. [2][3]
- **Place of service**: Home, clinic, community and school are all payable — the universal request form’s place-of-service grid lists Clinic, Home, Community, School, Telehealth and Other, and the program description states that “school based behavioral health services that are medically necessary are not required to be included in a child’s Individualized educational plan (IEP) in order to be reimbursable.” That makes Tennessee materially friendlier than New York, which bars school-setting ABA outright. The line is drawn around function, not building: “providing services that are part of an individualized education program (IEP) or functioning as an educational aide in the school setting” is non-covered, as are provider travel time, transporting the member in lieu of a caregiver, a provider residing in the member’s home as live-in help, billing while the member is sleeping, and accompanying the member to outside activities not in the documented treatment plan. [2][3]
- **Bill as provider**: The claim goes out under the enrolled group or servicing provider, with practitioner level riding as a modifier rather than a separate NPI. The universal form collects Group Name, Group TIN and Group NPI and — “if practicing as a solo provider” — the Servicing Provider NPI, plus the supervisor’s name, credentials and phone, and a TN Medicaid ID for out-of-network providers. Level is expressed through modifiers on the form’s code grid: HO on the analyst-delivered codes (97151, 97155, 97156, 97157, 97158) and HM on the technician-delivered ones (97152, 97154), with 97153 split “97153 BA or RBT — indicate with modifier.” Because TennCare publishes no fee schedule, the rate behind each modifier lives in your MCO contract, not a state lookup. [3]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not answered for 97153 with 97155. The program description’s non-covered list bars “more than one appropriately trained, licensed psychologist/LABA delivering services to a member during a specific time interval” and “services provided simultaneously with other medical services such as occupational therapy, speech and language therapy, physical therapy, and psychotherapy” — both about two distinct services on the same clock, neither about an analyst modifying protocol while a technician runs it. The AMA descriptor for 97155 already contemplates simultaneous direction of a technician, and the universal form lets a provider request 97153 and 97155 units in the same authorization without addressing overlap. [2][3]
  - Ask the plan: The member’s MCO and its claim-edit policy — BlueCare behavioral (BHABA@bcbst.com, (423) 535-5717 option 2), Wellpoint provider services (833) 731-2154, or UnitedHealthcare’s TN ABA line (800) 690-1606. TennCare publishes no ABA fee schedule or edit table, so the answer lives in each MCO contract.
- **Session-note signature** _(ask the plan)_: The program description sets no session-note co-signature rule. What it does require is BACB-standard documentation control — behavior analysts “comply with all applicable requirements (e.g., BACB rules, laws, regulations, contracts, funder, and organization requirements) for storing, transporting, retaining, and destroying” records, and “when a behavior analyst leaves an organization, these responsibilities remain with the organization” — plus individualized treatment plans within 30 days of admission, reviewed every 6 months. The one signature rule that is published belongs to the authorization request, not the note: “this may be the signature of the person completing the form; however, it should note that is on behalf of the current treating provider. Or the actual recommending current treating provider may sign,” attesting that everything submitted sits in the member’s medical record. [2][3]
  - Ask the plan: The member’s MCO provider manual (BlueCare’s Provider Administration Manual, Wellpoint’s TN provider manual, UHC’s TN Community Plan manual) and the record-documentation terms of your MCO participation agreement.

## What intake should collect for TennCare (Tennessee Medicaid)

- **TennCare MCO:** BlueCare, UnitedHealthcare, or Wellpoint — clinically identical program, but the portal, fax, and mechanics differ per plan.
- **ASD diagnosis + report:** Diagnosis, diagnosing provider and credentials, date, and the diagnostic report — required with the universal request form.
- **Doctor's order:** The physician order or licensed treating provider's recommendation for ABA — required for the assessment PA.
- **LBA licensure:** Confirm the supervising/rendering analyst holds a Tennessee LBA license.
- **Realistic availability:** Continuations must explain utilization under 90% of authorized units — request hours the family can actually attend.

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

## Verification of benefits (VOB) data

How TennCare (Tennessee Medicaid) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00185
- **Supports 270/271 eligibility:** Yes
- **Real-time eligibility:** Yes
- **Behavioral health administrator:** none — ABA benefit administration is 100% delegated to the member's assigned MCO; TennCare's own state-level system (TCMIS) handles base Medicaid eligibility only (see the BlueCare / UHC Community Plan / Wellpoint guides for each MCO's own carve-out status)
- **BH administrator payer ID:** N/A
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required — Universal Request for ABA form (assessment + treatment) | No fixed numeric cap published — "Units Per Week"/"Units per Authorization period" are blank fields on the Universal Request form, justified via the severity/unit guide (levels 1-3 across communication, social, behavior, and adaptive domains) per 26 weeks (6 months) per authorization period | clinic, home, community, school, telehealth (checkbox on the Universal Request form — no CMS POS number given) | Allowed as a modality (flagged per code via a checkbox on the Universal Request form) but treated cautiously per the Program Description's telehealth-appropriateness guidance (interstate licensure, safety, technology limits); no CPT-code-specific POS number or modifier (GT/95) is published in the tri-MCO documents. | HO |
| 97152 | Yes | Required — Universal Request for ABA form (assessment + treatment) | No fixed numeric cap published — "Units Per Week"/"Units per Authorization period" are blank fields on the Universal Request form, justified via the severity/unit guide (levels 1-3 across communication, social, behavior, and adaptive domains) per 26 weeks (6 months) per authorization period | clinic, home, community, school, telehealth (checkbox on the Universal Request form — no CMS POS number given) | Allowed as a modality (flagged per code via a checkbox on the Universal Request form) but treated cautiously per the Program Description's telehealth-appropriateness guidance (interstate licensure, safety, technology limits); no CPT-code-specific POS number or modifier (GT/95) is published in the tri-MCO documents. | HM |
| 97153 | Yes | Required — Universal Request for ABA form (assessment + treatment) | No fixed numeric cap published — "Units Per Week"/"Units per Authorization period" are blank fields on the Universal Request form, justified via the severity/unit guide (levels 1-3 across communication, social, behavior, and adaptive domains) per 26 weeks (6 months) per authorization period | clinic, home, community, school, telehealth (checkbox on the Universal Request form — no CMS POS number given) | Allowed as a modality (flagged per code via a checkbox on the Universal Request form) but treated cautiously per the Program Description's telehealth-appropriateness guidance (interstate licensure, safety, technology limits); no CPT-code-specific POS number or modifier (GT/95) is published in the tri-MCO documents. | HO (BCBA/LBA-delivered — billed "97153HO" per BlueCare's Provider Administration Manual, eff. DOS 9/1/2019+), HM (RBT/technician-delivered) |
| 97154 | Yes | Required — Universal Request for ABA form (assessment + treatment) | No fixed numeric cap published — "Units Per Week"/"Units per Authorization period" are blank fields on the Universal Request form, justified via the severity/unit guide (levels 1-3 across communication, social, behavior, and adaptive domains) per 26 weeks (6 months) per authorization period | clinic, home, community, school, telehealth (checkbox on the Universal Request form — no CMS POS number given) | Allowed as a modality (flagged per code via a checkbox on the Universal Request form) but treated cautiously per the Program Description's telehealth-appropriateness guidance (interstate licensure, safety, technology limits); no CPT-code-specific POS number or modifier (GT/95) is published in the tri-MCO documents. | HM |
| 97155 | Yes | Required — Universal Request for ABA form (assessment + treatment) | No fixed numeric cap published — "Units Per Week"/"Units per Authorization period" are blank fields on the Universal Request form, justified via the severity/unit guide (levels 1-3 across communication, social, behavior, and adaptive domains) per 26 weeks (6 months) per authorization period | clinic, home, community, school, telehealth (checkbox on the Universal Request form — no CMS POS number given) | Allowed as a modality (flagged per code via a checkbox on the Universal Request form) but treated cautiously per the Program Description's telehealth-appropriateness guidance (interstate licensure, safety, technology limits); no CPT-code-specific POS number or modifier (GT/95) is published in the tri-MCO documents. | HO |
| 97156 | Yes | Required — Universal Request for ABA form (assessment + treatment) | No fixed numeric cap published — "Units Per Week"/"Units per Authorization period" are blank fields on the Universal Request form, justified via the severity/unit guide (levels 1-3 across communication, social, behavior, and adaptive domains) per 26 weeks (6 months) per authorization period | clinic, home, community, school, telehealth (checkbox on the Universal Request form — no CMS POS number given) | Allowed as a modality (flagged per code via a checkbox on the Universal Request form) but treated cautiously per the Program Description's telehealth-appropriateness guidance (interstate licensure, safety, technology limits); no CPT-code-specific POS number or modifier (GT/95) is published in the tri-MCO documents. | HO |
| 97157 | Yes | Required — Universal Request for ABA form (assessment + treatment) | No fixed numeric cap published — "Units Per Week"/"Units per Authorization period" are blank fields on the Universal Request form, justified via the severity/unit guide (levels 1-3 across communication, social, behavior, and adaptive domains) per 26 weeks (6 months) per authorization period | clinic, home, community, school, telehealth (checkbox on the Universal Request form — no CMS POS number given) | Allowed as a modality (flagged per code via a checkbox on the Universal Request form) but treated cautiously per the Program Description's telehealth-appropriateness guidance (interstate licensure, safety, technology limits); no CPT-code-specific POS number or modifier (GT/95) is published in the tri-MCO documents. | HO |
| 97158 | Yes | Required — Universal Request for ABA form (assessment + treatment) | No fixed numeric cap published — "Units Per Week"/"Units per Authorization period" are blank fields on the Universal Request form, justified via the severity/unit guide (levels 1-3 across communication, social, behavior, and adaptive domains) per 26 weeks (6 months) per authorization period | clinic, home, community, school, telehealth (checkbox on the Universal Request form — no CMS POS number given) | Allowed as a modality (flagged per code via a checkbox on the Universal Request form) but treated cautiously per the Program Description's telehealth-appropriateness guidance (interstate licensure, safety, technology limits); no CPT-code-specific POS number or modifier (GT/95) is published in the tri-MCO documents. | HO |
| 0362T | Mixed by MCO — BlueCare Tennessee's own Provider Administration Manual lists 0362T with a full CPT description; the shared tri-MCO Program Description and Universal Request form (which the UnitedHealthcare Community Plan and Wellpoint guides rely on) omit it entirely. Confirm per the member's specific MCO — see the BlueCare / UHC Community Plan / Wellpoint guides. | — | — | — | — | — |
| 0373T | Mixed by MCO — BlueCare Tennessee's own Provider Administration Manual lists 0373T with a full CPT description; the shared tri-MCO Program Description and Universal Request form (which the UnitedHealthcare Community Plan and Wellpoint guides rely on) omit it entirely. Confirm per the member's specific MCO — see the BlueCare / UHC Community Plan / Wellpoint guides. | — | — | — | — | — |

Code notes:

- **97153:** Continuation requests must report % of authorized units used on this code — under 90% requires a written explanation (formula on the Universal Request form).
- **97156:** Parent-training volume delivered is tracked separately at continuation, per week/month, on the Universal Request form.
- **0362T, 0373T:** Verify via: this MCO's provider services, or the Universal Request form's blank "Other" code line — the shared tri-MCO documents' own printed code lists stop at 97158.

### Contacts

- **Provider services phone:** (800) 852-2683 — TennCare Provider Services, per the state's own EDI Front Matter (that line is stated there specifically for PDMS registration/portal-access questions; ABA benefit administration itself is 100% delegated to the member's MCO — use the BlueCare / UnitedHealthcare Community Plan / Wellpoint guide's own number for benefit or PA questions)

Questions to ask on a verification call:

- Which of the three TennCare MCOs — BlueCare, UnitedHealthcare Community Plan, or Wellpoint — is this member currently enrolled with for ABA services?
- Does this member's specific MCO cover 0362T and 0373T, or only the shared tri-MCO code set (97151-97158)?
- What is the negotiated per-unit rate for 97151-97158 (and 0362T/0373T where covered) under this member's MCO provider contract, since TennCare publishes no statewide ABA fee schedule?
- Can you confirm which loop/segment carries this member's MCO enrollment on the 271 response, or should we route this eligibility question to the assigned MCO directly?

### VOB data sources

- https://www.tn.gov/content/dam/tn/tenncare/documents/HCFATennCareEDIFrontMatter.pdf (accessed 2026-07-23)
- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.provider.wellpoint.com/docs/gpp/TN_WLP_CAID_BH_ABARequirements.pdf (accessed 2026-07-23)
- https://www.provider.wellpoint.com/docs/gpp/TN_WLP_CAID_BH_RequestABA.pdf (accessed 2026-07-23)
- https://content.bcbst.com/api/public/content/prov-bct-pam.pdf (accessed 2026-07-23)

## Common questions

### Does TennCare cover ABA therapy?

Yes — for members up to age 21 through the EPSDT benefit, with no annual benefit limit and no fixed hour cap (hours are justified clinically). Coverage requires prior authorization and medical necessity, through the member's MCO.

### Who can provide ABA under TennCare?

Direct ABA must be delivered by a BCBA or qualified licensed clinician who holds a Tennessee Licensed Behavior Analyst (LBA) license, with RBTs working under LBA authority.

### Are TennCare's ABA rules different per MCO?

The clinical rules are deliberately unified — one shared program description and one universal request form across BlueCare, UnitedHealthcare, and Wellpoint. What differs is submission mechanics (portal, fax, forms, timelines) and UnitedHealthcare's additional Level of Care guidelines — see each MCO's guide.

### What does TennCare pay for ABA?

TennCare publishes no ABA fee schedule — each MCO negotiates rates in its provider contracts. Your contract is the only source of truth on reimbursement.

## Primary sources

1. [TennCare — official program site](https://www.tn.gov/tenncare.html)
2. [ABA Provider Requirements & Program Description — TennCare MCOs](https://www.provider.wellpoint.com/docs/gpp/TN_WLP_CAID_BH_ABARequirements.pdf)
3. [Universal Request for ABA form (all 3 MCOs, Jan 2026)](https://www.provider.wellpoint.com/docs/gpp/TN_WLP_CAID_BH_RequestABA.pdf)
4. [Tri-MCO ABA Overview of Updates (Sept 2024)](https://www.provider.wellpoint.com/docs/gpp/TN_WLP_CAID_BH_ABAOverviewofUpdates.pdf)
5. [CSG South — Medicaid ABA reimbursement comparison (Feb 2026)](https://csgsouth.org/wp-content/uploads/HSPS-Converted-IR__Comparison-of-Medicaid-Reimbursement-for-ABA-Individual-Services.pdf)
6. [TennCare Aligned Background Check Protocol (eff. July 1, 2024)](https://www.tn.gov/content/dam/tn/tenncare/documents/AlignedBackgroundCheckProtocol.pdf)
7. [Rules of the TN Applied Behavior Analyst Licensing Committee, Ch. 1180-05 (rev. May 2025)](https://publications.tnsosfiles.com/rules/1180/1180-05.20250507.pdf)
8. [BACB — Meeting RBT Requirements During the 2026 Transition (updated 08/2025)](https://www.bacb.com/wp-content/uploads/2025/07/RBT-2026-Requirements_250723-a.pdf)
9. [BACB RBT Handbook](https://assets.bacb.com/wp-content/uploads/2022/01/RBTHandbook_230622-a.pdf)
10. [TennCare Kids (EPSDT) — birth through age 20](https://www.tn.gov/tenncare/tenncare-kids.html)
11. [TennCare Statewide MCO Contract (Amendment 25, July 1, 2026) — A.2.19.3 and A.2.21.4](https://www.tn.gov/content/dam/tn/tenncare/documents/MCOStatewideContract.pdf)
12. [42 CFR 438.210(d) — MCO authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/section-438.210)
13. [42 CFR 433.139 — Medicaid third-party liability, payment of claims (eCFR)](https://www.ecfr.gov/current/title-42/section-433.139)
14. [42 U.S.C. 1396a(a)(25) — Medicaid third-party liability](https://www.govinfo.gov/content/pkg/USCODE-2023-title42/html/USCODE-2023-title42-chap7-subchapXIX-sec1396a.htm)
15. [10 U.S.C. 1079(i)(1) — TRICARE pays after other coverage, Medicaid excepted](https://www.govinfo.gov/content/pkg/USCODE-2023-title10/html/USCODE-2023-title10-subtitleA-partII-chap55-sec1079.htm)
16. [CHAMPVA Guidebook (updated Jan. 1, 2025) — Other Health Insurance](https://www.va.gov/COMMUNITYCARE/docs/pubfiles/programguides/CHAMPVA-Guide.pdf)

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.