Texas Children's Health Plan (TCHP) — the Houston-anchored plan serving STAR, STAR Kids, and CHIP in the Harris, Jefferson, and Northeast service areas — is the rare Texas MCO that wrote its own ABA document: the ~30-page Autism Services Guideline #11281, version 3. Read it closely and it's the TMPPM in a different binder — the same diagnoser list, 3-year recency rule, LBA/LaBA/BT role definitions, and BT restrictions, transcribed nearly verbatim — with TCHP's own UM process bolted on. That's good news operationally: nothing clinically new to learn, and a clearly documented submission path.
TCHP's evaluation PA wants a referral that documents the child's age, the year of the initial ASD diagnosis, comorbidities and trauma history, and DSM symptom severity — with the diagnosis made or reconfirmed within the past 3 years, per the state rule. Requests go to the UM Department via the electronic authorization portal, fax, phone, or mail; electronic signatures are accepted, with the paper process running by fax. Treatment then follows the TMPPM cadence exactly, mapped in guideline sections 7.8.1 through 7.8.3: a 90-day initial course, a 90-day extension, then recertifications in up to 180-day increments. One continuity wrinkle the guideline adds: the LBA must have provided direct services within the previous 180 days for certain continuity requirements — worth tracking when supervision rotates.[1]
TCHP sells CHIP alongside its Medicaid lines, and the ABA benefit does not extend to CHIP — the exclusion is explicit in both the state benefit and TCHP's guideline. For intake, that means "we have Texas Children's" isn't enough: confirm the child is on STAR or STAR Kids, not CHIP, before quoting the ABA pathway. A CHIP family's options are commercial-style coverage rules, not THSteps-CCP.[1]
The questions that decide whether a family can start with Texas Children's Health Plan, 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.[2][1]
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.[2][1]
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).[2][1]
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.[2][1]
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. TCHP adds that the evaluation referral must document the child's age, the year of the initial ASD diagnosis, comorbidities and trauma history, and DSM symptom severity; electronic signatures are accepted.[1][2][4]
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.[2][1]
Texas Children's publishes its own turnaround table: "Routine 3 business days / Urgent 1 business day / Inpatient 1 business day / Life-threatening conditions Within one hour"; a request with no priority marked "will default to routine status." A standard decision may be extended "by up to 14 calendar days" if the member or provider asks, or if more information is needed and the extension is in the member's interest. Lead time: providers "are to request non-emergent services seven (7) days in advance of dates of service." The manual sets no ABA-specific recertification lead time; Texas law caps nonhospitalized decisions at 3 business days after receipt (Tex. Gov't Code § 540.0303), with the state's incomplete-request process in 1 TAC § 353.425.[5][6][7]
"Medicaid is secondary when coordinating benefits with all other insurance coverage, unless an exception applies under federal law." Providers "must submit claims to other health insurers for consideration prior to billing Texas Children's Health Plan," then file with "a copy of the Explanation of Payment (EOP) or rejection letter from the other insurance"; when the other payer denies or applies payment to the deductible, attach that denial or EOP too, or the claim will deny. The manual does not say whether Texas Children's own ABA prior authorization is still required when it pays second — confirm with TCHP utilization management before starting.[5][8]
Coverage decides whether Texas Children's Health Plan 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. TCHP adds a continuity rule of its own: the LBA must have provided direct services within the previous 180 days for certain continuity requirements.[1][2][3]
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.[2][1]
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.[2][1]
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.[2][1]
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.[2][1]
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.[2][1]
Yes — for STAR and STAR Kids members under the state Autism Services benefit, governed by TCHP's Guideline #11281 v3, which restates the TMPPM criteria. CHIP members are excluded.
No — it's a formatted restatement of TMPPM requirements (same diagnoser list, 3-year recency, credential roles) with TCHP's UM submission process added. Plan against the state baseline and TCHP's channels.
Online via the electronic authorization portal, or by fax, phone, or mail to the UM Department. Electronic signatures are accepted.
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.
Carelu collects all of this automatically.
Every ID, document, and detail this payer requires — gathered conversationally the moment a family reaches out, with insurance verified before your team touches the file.
Get a Demo