Wellpoint Tennessee — the Elevance plan formerly branded Amerigroup — administers the TennCare ABA benefit under the shared tri-MCO program description it helped build (Wellpoint hosts the unified program documents). Clinically it's the TennCare baseline; the Wellpoint-specific layer is workflow: the Availity Interactive Care Reviewer submission path, its fax lines, an MD-order emphasis on assessment requests, and named regional ABA contacts.
Submissions go through Availity — Wellpoint's stated preferred workflow is to complete the universal tri-MCO ABA request form and attach it as the clinical documentation in the Interactive Care Reviewer; fax fallback is (866) 920-6006 (the form also lists (888) 881-6309). The assessment request needs an MD order or a licensed treating provider's recommendation. Treatment authorizations run in the standard 26-week periods, and continuation requests must report the percentage of authorized units used — under 90% on direct-treatment code 97153 requires a written explanation — plus the 97156 parent-training volume delivered.[2][1]
Wellpoint publishes named regional ABA contacts (West, Middle, and East Tennessee plus a statewide UM manager and behavioral-health liaison) with direct phones and emails in its tri-MCO update materials; provider services runs at (833) 731-2154. For an intake team, a saved contact sheet per region turns authorization questions from portal tickets into phone calls.[3]
The questions that decide whether a family can start with Wellpoint Tennessee (formerly Amerigroup), and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the TennCare rule: EPSDT covers “children from birth through age 20 who have TennCare,” and the shared tri-MCO program description Wellpoint hosts sets no age floor or ceiling of its own. Wellpoint publishes no deviating age rule.[5][1]
Follows the TennCare rule: no recency limit on the ASD diagnosis, with updated evaluation of functioning via standardized tools expected “at least every two years.” The universal form Wellpoint hosts asks for the date the diagnosis was initially rendered and whether a standard assessment was used in it. Authorizations then run in 26-week periods.[1][2]
Follows the TennCare rule — the diagnosis must be issued by “a qualified health professional, practicing within their scope, with training in assessment of individuals with ASD and/or other neurodevelopmental concerns,” and a TN-licensed clinician must document medical necessity. Wellpoint names no additional credential; its emphasis falls on the ordering provider instead (see referral).[1][2]
Follows the TennCare rule — no named instrument. The diagnosis must be validated by a documented comprehensive assessment against DSM-5-TR criteria, and the ABA assessment must include direct observation, file review, informant interviews and standardized assessments across cognition, communication, social, adaptive and behavioral domains. At continuation the universal form asks providers to “list Standardized Assessments used to validate progress and include scores,” with page references.[1][2]
Required, with Wellpoint’s own emphasis: the assessment request needs an MD order or a licensed treating provider’s recommendation, landing on the universal form’s “Doctor’s Order Attached” checkbox alongside the diagnostic report. Wellpoint’s stated preferred workflow is to complete the universal tri-MCO form and attach it as the clinical documentation in Availity’s Interactive Care Reviewer; fax fallback is (866) 920-6006, with (888) 881-6309 also listed on the form. No validity window is published for the order.[2][1]
Follows the TennCare rule: telehealth is requested and authorized per code via the “Indicate if Hours are telehealth” checkbox that appears on every ABA code row of the universal form Wellpoint hosts, with Telehealth also listed among the places of service. No Wellpoint-Tennessee-specific ABA telehealth policy was located, so the shared program description’s cautions — clinical appropriateness protocols by model, HIPAA-compliant technology, demonstrated provider competence — are the operative standard.[2][1]
Wellpoint's TennCare manual: "The decision regarding an authorization request for service must be made within 14 calendar days (seven calendar days as of 1/1/26) for standard request or 72 hours for expedited." The TennCare contract counts the 7 days from receipt of the request. It allows up to 14 more calendar days if the family or provider asks, or if the MCO justifies needing more information. ABA is requested on the shared tri-MCO form in 26-week authorization periods. Wellpoint publishes no reauthorization lead time.[6][7][8]
Wellpoint and its providers agree "the Medicaid program will be the payer of last resort." Providers "should bill the third party prior to billing Wellpoint." Wellpoint's secondary payment is the lesser of the primary's allowed amount and its own. A secondary claim "without the primary carrier's EOP will be denied stating the member has other insurance." Two exceptions matter for ABA. First, Wellpoint does not enter its own authorization when other insurance is primary: "If Member has Other Health Insurance (OHI) ... no authorization should be entered for a review as the member's OHI insurance is primary and responsible for payment." Second, Wellpoint pays and pursues "When the services are rendered to a child under the age of 21 who does not have Medicare, including preventive, EPSDT and pediatric care." For a child, Wellpoint pays and then recovers from the other plan. 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."[6][7][9][10]
Coverage decides whether Wellpoint Tennessee (formerly Amerigroup) 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 TennCare rule: direct ABA must be provided by or supervised by a TN Licensed Behavior Analyst (or a health professional permissible under TN law); unlicensed persons deliver “under the extended authority and direction of a TN LBA” and may not represent themselves as behavior analysts; and RBTs with their supervising BCBAs must comply with all current BACB supervision requirements, which sets the floor at 5% of monthly service hours and two face-to-face contacts. Wellpoint publishes no ratio of its own. Non-client-specific administrative supervision and technician training remain non-covered.[1]
No per-day ceiling, no annual limit and no fixed weekly cap — units are requested per week and per 26-week authorization period in 15-minute increments and justified against the severity/unit guide. The back-end constraint is Wellpoint’s signature rule: continuation must report units utilized divided by units approved times 100, and “if under 90% utilized, please explain,” measured on 97153 direct care. The form also asks for the volume of parent training (97156) delivered per week or per month.[2][1]
Follows the TennCare rule: Clinic, Home, Community, School, Telehealth and Other are all on the universal form’s place-of-service grid, and medically necessary school-based behavioral health services “are not required to be included in a child’s Individualized educational plan (IEP) in order to be reimbursable.” Non-covered regardless of setting: IEP services and functioning as an educational aide, provider travel time, transport in lieu of a caregiver, live-in help, billing while the member sleeps, and accompanying the member to outside activities not in the treatment plan.[2][1]
Follows the TennCare rule — the claim rides on the Group NPI (or the Servicing Provider NPI for a solo practitioner) captured on the universal form, with the supervisor’s name and credentials recorded alongside and a TN Medicaid ID required if out of network. Practitioner level is expressed as a modifier: HO for analyst-delivered codes, HM for technician-delivered, 97153 split between them. Rates sit in the Wellpoint participating-provider agreement, since TennCare publishes no ABA fee schedule.[2]
Not answered for 97153 with 97155 — the program description Wellpoint hosts bars only two overlaps (more than one licensed analyst serving the member during a specific time interval, and ABA delivered simultaneously with OT, speech, PT or psychotherapy), and the universal form lets both codes be requested in one authorization without an overlap rule.[1][2]
Ask the plan: Wellpoint TN provider services (833) 731-2154 or the named regional ABA contacts published in the tri-MCO update materials; Wellpoint’s own reimbursement policies on provider.wellpoint.com.
No session-note signature rule is published. The universal form Wellpoint hosts requires a provider signature — “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” — with an attestation that all the information is in the member’s medical record. That is a request-level rule; the program description otherwise relies on BACB documentation standards.[2][1]
Blocked on: Wellpoint TN provider services (833) 731-2154 and the Wellpoint Tennessee provider manual’s medical-record documentation standards.
Yes — Wellpoint (formerly Amerigroup) administers the TennCare ABA benefit under the shared tri-MCO program description: EPSDT members under 21, PA on assessment and treatment, TN LBA licensure.
Complete the universal tri-MCO ABA request form and attach it as clinical documentation in Availity's Interactive Care Reviewer; fax fallback (866) 920-6006. The assessment request needs an MD order or treating-provider recommendation.
Clinically, no — it's the shared TennCare baseline. The plan-specific layer is workflow: Availity ICR, fax lines, the MD-order emphasis, and the sub-90% unit-utilization explanation rule at continuation.
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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