---
title: "Texas Children's Health Plan ABA coverage (Texas Medicaid MCO)."
url: "https://carelu.com/payers/texas-childrens-health-plan"
markdown_url: "https://carelu.com/payers/texas-childrens-health-plan.md"
state: TX (Texas)
payer: "Texas Children's Health Plan"
kind: Medicaid managed care plan (MCO)
parent_program: Texas Medicaid (THSteps-CCP)
description: "How Texas Children's Health Plan administers Texas Medicaid ABA — its Autism Services Guideline #11281 v3 (a TMPPM restatement), UM submission channels, the 90/90/180 cadence, and the CHIP exclusion."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Texas Children's Health Plan ABA coverage (Texas Medicaid MCO).

_Payer Guide · Texas Children's Health Plan · Last updated September 2026 · 4 primary sources_

> Own 30-page guideline (#11281 v3) that restates TMPPM; PA via portal, fax, phone, or mail.

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.

This plan administers the **Texas Medicaid (THSteps-CCP)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Texas Medicaid (THSteps-CCP) guide](https://carelu.com/payers/texas-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — referral must document age, year of initial ASD dx, comorbidities, DSM severity; dx within 3 years [1][2]
- **Prior auth for treatment**: Required — 90-day initial → 90-day extension → 180-day recerts (guideline §§ 7.8.1–7.8.3); e-signature accepted [1]
- **Autism diagnosis required?**: Yes — ASD per TMPPM criteria (restated in TCHP's guideline) [1][2]

## At a glance

- **Plan type:** Texas Medicaid MCO — STAR, STAR Kids, CHIP (Harris / Jefferson / Northeast SDAs)
- **Clinical rules:** Autism Services Guideline #11281 v3 — a formatted restatement of TMPPM criteria
- **Prior auth:** Required — online portal, fax, phone, or mail to the UM Department
- **Auth cadence:** 90-day initial → 90-day extension → 180-day recertifications (§§ 7.8.1–7.8.3)
- **CHIP:** Explicitly excluded from the ABA benefit — Medicaid lines only
- **Rates:** References the Texas Medicaid fee schedule (no plan-specific rates published)

## What the guideline asks for

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]

## The CHIP boundary

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]

## Intake gates

The questions that decide whether a family can start with Texas Children's Health Plan, and what they have to bring.

- **Age limit**: 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]
- **Diagnosis recency**: 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]
- **Who may diagnose**: 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]
- **Diagnostic tools required**: 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]
- **Referral required?**: 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]
- **Telehealth**: 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]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: "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]

## Delivery and billing rules

Coverage decides whether Texas Children's Health Plan 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**: 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]
- **Concurrent billing (97153 + 97155)**: 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]
- **Daily limits / MUEs**: 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]
- **Session-note signature**: 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]
- **Place of service**: 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]
- **Bill as provider**: 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]

## What intake should collect for Texas Children's Health Plan

- **STAR / STAR Kids vs. CHIP:** CHIP is excluded from ABA — confirm the Medicaid line before promising the benefit.
- **Referral details:** Age, year of initial dx, comorbidities/trauma history, DSM severity — TCHP's evaluation PA asks for all of it.
- **Dx recency:** Within 3 years, or a reconfirmation is needed first.
- **Supervising LBA continuity:** The guideline's 180-day direct-service continuity rule makes supervisor tracking a compliance item.

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

## Verification of benefits (VOB) data

How Texas Children's Health Plan ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00275
- **Payer ID (Availity):** TXCSM — Availity separately lists "TEXAS CHILDRENS HEALTH PLAN COMM" (76048/TXCHLDCOMM) as a distinct commercial product — TXCSM ("TEXAS CHILDRENS HEALTH PLAN STAR") is the Medicaid-line code used here; do not conflate the two when routing.
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** none
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### How the 271 reports ABA benefits

- **ABA benefit bucket (service type code):** MH
- **Deductible applies to ABA:** no
- **Cost-share type:** plan-dependent
- **271 response quality for ABA:** high

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes — ABA Initial Evaluation / Re-evaluation, by the LBA | Required — CCP PA form + signed prescriber referral; not reimbursable unless the evaluation was submitted for authorization of payment; must be billed within 30 calendar days of the first date of service | 24 units (6 hours) per evaluation or re-evaluation event per per evaluation event; re-evaluations authorized no more than once every 180 days | office, home, clinic, community | Yes — 95 modifier, synchronous audio-visual only, delivered by the LBA (LaBAs and BTs/RBTs may not deliver any service remotely) | HO (required — LBA only) |
| 97152 | Not confirmed (see code notes) | — | — | — | — | — |
| 97153 | Yes — direct 1:1 ABA treatment (BT-complexity level), delivered per treatment-plan protocol | Required — covered under the treatment authorization (90-day initial + 90-day extension, then 180-day recertifications; no prescriber signature on the 90-day extension since 4/1/2025) | Shares the 8-hour (32-unit) combined daily direct-treatment cap, shared with 97153, 97154, 97155, and 97158 (TMPPM §2.3.12). per day | office, home, clinic, community | No — 1:1 direct treatment must be delivered in person | No modifier required (HO/HN/HM may be reported for information only) |
| 97154 | Yes — direct group ABA treatment (BT-complexity level; group is 2–8 children/youth) | Required — covered under the treatment authorization (90-day initial + 90-day extension, then 180-day recertifications) | Shares the 8-hour (32-unit) combined daily direct-treatment cap, shared with 97153, 97154, 97155, and 97158 (TMPPM §2.3.12). per day | office, home, clinic, community | No — group direct treatment must be delivered in person | No modifier required (HO/HN/HM may be reported for information only) |
| 97155 | Yes — protocol modification / direct 1:1 time by the LBA (or delegated LaBA) | Required — covered under the treatment authorization (90-day initial + 90-day extension, then 180-day recertifications) | Shares the 8-hour (32-unit) combined daily direct-treatment cap, shared with 97153, 97154, 97155, and 97158 (TMPPM §2.3.12). per day | office, home, clinic, community | Yes — 95 modifier, synchronous audio-visual, delivered by the LBA only | HO or HN (one required) |
| 97156 | Yes — parent/caregiver education & training, by the LBA (or delegated LaBA) | Required — covered under the treatment authorization | — | office, home, clinic, community | Yes — 95 modifier, synchronous audio-visual, delivered by the LBA (LaBAs may not deliver this — or any — service via telehealth, even by delegation) | HO or HN (one required) |
| 97157 | Not confirmed (see code notes) | — | — | — | — | — |
| 97158 | Yes — group protocol modification, by the LBA (or delegated LaBA) | Required — covered under the treatment authorization | Shares the 8-hour (32-unit) combined daily direct-treatment cap, shared with 97153, 97154, 97155, and 97158 (TMPPM §2.3.12). per day | office, home, clinic, community | Yes — 95 modifier, synchronous audio-visual, delivered by the LBA only | HO or HN (one required) |
| 99366 | Yes — interdisciplinary team meeting, attended by qualified nonphysician health-care providers | Not separately authorized — reimbursable when a PA for ABA evaluation, re-evaluation, or treatment is already on file; reimbursement limited to primary diagnosis F84 | — | office, home, clinic, community, remote participation for team members (95 modifier) | Yes — 95 modifier for remote participation by team members | No modifier required (95 for remote participation) |
| 0362T | Not confirmed (see code notes) | — | — | — | — | — |
| 0373T | Not confirmed (see code notes) | — | — | — | — | — |

Code notes:

- **97151:** TCHP's Guideline #11281 v3 restates this requirement nearly verbatim; submit to the UM Department via the electronic authorization portal, fax, phone, or mail.
- **97152:** 97152 does not appear anywhere in the TMPPM Children's Services Handbook §2.3 Autism Services or in TMHP's "AUTISM SERVICES" static fee schedule (PRCR615C) — cross-checked against both independently. Texas's actual THSteps-CCP Autism Services billable code set appears to be limited to 97151, 97153, 97154, 97155, 97156, 97158, and 99366. Verify via: TMHP provider relations / Online Fee Lookup — confirm whether this code is billable under Texas Medicaid THSteps-CCP Autism Services at all, under a different program, or not covered.
- **97153:** Either 97153 or 97155 may be billed for direct individual treatment hours — bill the code matching who delivered the session.
- **97154:** Either 97154 or 97158 may be billed for direct group treatment hours.
- **97155:** Also the code used to bill the required progress summary submitted after the first 90 days of treatment. Only DIRECT supervision (LBA observing the LaBA/BT with the client) is reimbursable under this code — indirect supervision (caseload review, data discussion) is not billable.
- **97156:** Continued treatment authorization considers caregiver attendance at ≥85% of planned sessions.
- **97157:** 97157 does not appear anywhere in the TMPPM Children's Services Handbook §2.3 Autism Services or in TMHP's "AUTISM SERVICES" static fee schedule (PRCR615C) — cross-checked against both independently. Texas's actual THSteps-CCP Autism Services billable code set appears to be limited to 97151, 97153, 97154, 97155, 97156, 97158, and 99366. Verify via: TMHP provider relations / Online Fee Lookup — confirm whether this code is billable under Texas Medicaid THSteps-CCP Autism Services at all, under a different program, or not covered.
- **99366:** School-district personnel may participate and count toward the 3-participant licensed-professional minimum but are not separately reimbursable.
- **0362T:** 0362T does not appear anywhere in the TMPPM Children's Services Handbook §2.3 Autism Services or in TMHP's "AUTISM SERVICES" static fee schedule (PRCR615C) — cross-checked against both independently. Texas's actual THSteps-CCP Autism Services billable code set appears to be limited to 97151, 97153, 97154, 97155, 97156, 97158, and 99366. Verify via: TMHP provider relations / Online Fee Lookup — confirm whether this code is billable under Texas Medicaid THSteps-CCP Autism Services at all, under a different program, or not covered.
- **0373T:** 0373T does not appear anywhere in the TMPPM Children's Services Handbook §2.3 Autism Services or in TMHP's "AUTISM SERVICES" static fee schedule (PRCR615C) — cross-checked against both independently. Texas's actual THSteps-CCP Autism Services billable code set appears to be limited to 97151, 97153, 97154, 97155, 97156, 97158, and 99366. Verify via: TMHP provider relations / Online Fee Lookup — confirm whether this code is billable under Texas Medicaid THSteps-CCP Autism Services at all, under a different program, or not covered.

### Contacts

- **Provider services phone:** 832-828-1004 (toll-free 1-877-213-5508)
- **Phone menu path:** Telephone TouCHPoint automated system (832-828-1007) offers 24/7 automated eligibility, benefits, and claims-status lookup without a live rep; its own fax is 832-825-8777.
- **Hours:** 8 a.m.–5 p.m. Central Time, Monday–Friday; after-hours/weekend/holiday calls route to an answering service with next-business-day callback
- **Portal:** [Texas Children's Link (EpicCare Link)](https://epiccarelink.texaschildrens.org)
- **Fax:** 832-825-8750

Questions to ask on a verification call:

- Does TCHP support real-time (vs. batch) 270/271 eligibility for payer ID 00275?
- Confirm TXCSM is the correct Availity code for TCHP's STAR Medicaid line, distinct from the separately listed TXCHLDCOMM commercial product (76048).
- Is the ABA copay or coinsurance charged per visit or per day, and does the plan's out-of-pocket maximum apply?
- Are CPT codes 97152, 97157, 0362T, and 0373T billable under TCHP's Autism Services benefit?
- Is there a daily/weekly unit cap for 97156 (parent/caregiver training) or 99366 (team meeting)?

### VOB data sources

- 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)
- https://www.texaschildrenshealthplan.org/sites/default/files/2025-02/Autism%20Services%20Guideline.pdf (accessed 2026-07-23)
- https://www.tmhp.com/sites/default/files/file-library/edi/D00026_270_271_Medicaid_CHIP_Eligibility_Companion_Guide.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.tmhp.com/sites/default/files/microsites/provider-manuals/tmppm/html/TMPPM/2_04_Childrens_Services/2_04_Childrens_Services.htm (accessed 2026-07-23)
- https://public.tmhp.com/FeeSchedules/StaticFeeSchedule/FeeSchedules.aspx?fn=%5C%5Ctmhp.net%5CFeeSchedule%5CPROD%5CStatic%5CTexas_Medicaid_Fee_Schedule_PRCR615C.pdf (accessed 2026-07-23)
- https://www.texaschildrenshealthplan.org/providers/provider-resources/quick-reference-guide (accessed 2026-07-23)
- https://www.texaschildrenshealthplan.org/contact-us (accessed 2026-07-23)

## Common questions

### Does Texas Children's Health Plan cover ABA?

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.

### Is TCHP's ABA guideline stricter than the state's?

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.

### How do I submit an ABA PA to TCHP?

Online via the electronic authorization portal, or by fax, phone, or mail to the UM Department. Electronic signatures are accepted.

## Primary sources

1. [TCHP — Autism Services Guideline #11281 v3 (PDF)](https://www.texaschildrenshealthplan.org/sites/default/files/2025-02/Autism%20Services%20Guideline.pdf)
2. [TMPPM Children's Services Handbook, § 2.3 Autism Services](https://www.tmhp.com/sites/default/files/microsites/provider-manuals/tmppm/html/TMPPM/2_04_Childrens_Services/2_04_Childrens_Services.htm)
3. [BACB RBT Handbook (updated 06/2026)](https://www.bacb.com/rbt-handbook)
4. [TMHP — Update to a PA Requirement for Autism Services (eff. 4/1/2025)](https://www.tmhp.com/news/2025-02-14-update-prior-authorization-requirement-autism-services-effective-april-1-2025)
5. [Texas Children's Health Plan — Provider Manual, CHIP and STAR/Medicaid (Sept. 1, 2026) (PDF)](https://www.texaschildrenshealthplan.org/sites/default/files/2026-08/FY26%20PR-2105-045%20STAR_CHIP%20Provider_Manual.pdf)
6. [Tex. Gov't Code § 540.0303 — MCO PA determinations for nonhospitalized recipients (eff. 4/1/2025)](https://texas.public.law/statutes/tex._gov't_code_section_540.0303)
7. [1 Tex. Admin. Code § 353.425 — MCO processing of incomplete PA requests](https://www.law.cornell.edu/regulations/texas/1-Tex-Admin-Code-SS-353-425)
8. [TMPPM Vol. 1, Section 8: Third Party Liability (TPL)](https://www.tmhp.com/sites/default/files/microsites/provider-manuals/tmppm/html/TMPPM/1_08_Third_Party_Liability/1_08_Third_Party_Liability.htm)

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.