---
title: Wellpoint Tennessee ABA coverage (TennCare MCO).
url: "https://carelu.com/payers/wellpoint-tennessee"
markdown_url: "https://carelu.com/payers/wellpoint-tennessee.md"
state: TN (Tennessee)
payer: Wellpoint Tennessee (formerly Amerigroup)
kind: Medicaid managed care plan (MCO)
parent_program: TennCare
description: "How Wellpoint Tennessee (formerly Amerigroup) administers TennCare ABA — the shared tri-MCO program description, universal request form workflow in Availity, the MD-order requirement, and the sub-90% utilization explanation rule."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Wellpoint Tennessee ABA coverage (TennCare MCO).

_Payer Guide · Wellpoint (TN) · Last updated September 2026 · 5 primary sources_

> Shared TennCare program via Availity ICR; MD-order emphasis, <90% utilization rule.

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.

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

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — universal form with MD order / treating-provider recommendation, via Availity or fax (866) 920-6006 [2][1]
- **Prior auth for treatment**: Required — 26-week periods; continuation reports unit utilization (<90% on 97153 needs explanation) [2][1]
- **Autism diagnosis required?**: ASD or another qualifying DSM-5-TR diagnosis — not strictly autism-only [1][2]

## At a glance

- **Plan type:** TennCare MCO (Wellpoint / Elevance, formerly Amerigroup)
- **Clinical rules:** Shared tri-MCO ABA program description (TennCare baseline)
- **Prior auth:** Required — universal form attached as "clinical" in Availity ICR
- **Assessment PA:** MD order / licensed treating provider recommendation required
- **Utilization rule:** Continuation must explain <90% use of authorized 97153 units
- **Rates:** Negotiated per contract — no published ABA fee schedule

## How Wellpoint administers the benefit

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]

## Contacts worth having on file

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]

## Intake gates

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

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

## Delivery and billing rules

Coverage decides whether Wellpoint Tennessee (formerly Amerigroup) 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 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]
- **Daily limits / MUEs**: 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]
- **Place of service**: 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]
- **Bill as provider**: 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]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: 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.

## What intake should collect for Wellpoint Tennessee (formerly Amerigroup)

- **MD order / provider recommendation:** Required on the assessment request — collect it with the diagnostic report.
- **Diagnosis + severity levels:** DSM-5-TR diagnosis with the severity/unit guide levels the universal form requests.
- **Realistic availability:** The <90% utilization explanation rule makes honest scheduling a reauthorization safeguard.
- **Parent-training capacity:** 97156 volume is reported at continuation — set caregiver expectations at intake.

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

## Verification of benefits (VOB) data

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

### EDI routing

- **Payer ID (Availity):** WLPNT

### 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 | Not confirmed in the shared tri-MCO code set — absent from both the Program Description's own "ABA Codes" appendix and the Universal Request form's CPT table (97151-97158 only). BlueCare Tennessee's own Provider Administration Manual DOES list 0362T (see bluecare-tennessee) — confirm directly with this MCO's provider services before assuming coverage. | — | — | — | — | — |
| 0373T | Not confirmed in the shared tri-MCO code set — absent from both the Program Description's own "ABA Codes" appendix and the Universal Request form's CPT table (97151-97158 only). BlueCare Tennessee's own Provider Administration Manual DOES list 0373T (see bluecare-tennessee) — confirm directly with this MCO's provider services before assuming coverage. | — | — | — | — | — |

Code notes:

- **97151, 97152:** Assessment request needs an MD order or a licensed treating provider's recommendation attached (per the Universal Request form and Wellpoint's own workflow emphasis).
- **97153:** Continuation requests must report % of authorized units used on this code — under 90% requires a written explanation.
- **97156:** Parent-training volume delivered is tracked separately at continuation.
- **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:** (833) 731-2154 — Wellpoint Tennessee Provider Services (Medicaid line), confirmed on both Wellpoint's own ABA provider page and the Universal Request form's MCO contact table
- **Portal:** [Availity (Interactive Care Reviewer)](https://www.availity.com)
- **Fax:** (866) 920-6006 or (888) 881-6309

Questions to ask on a verification call:

- Is ABA administered directly by Wellpoint, or delegated to an outside behavioral health vendor?
- Does this member's plan cover 0362T and 0373T in addition to the shared tri-MCO 97151-97158 code set?
- Can eligibility for this member be checked in real time through Availity, or does it require a batch request?

### 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; source document older than 18 months)
- https://www.provider.wellpoint.com/tennessee-provider/claims/electronic-data-interchange (accessed 2026-07-23)
- https://www.provider.wellpoint.com/docs/gpp/TN_WLP_CAID_BH_RequestABA.pdf (accessed 2026-07-23)
- https://www.provider.wellpoint.com/docs/gpp/TN_WLP_CAID_BH_ABAOverviewofUpdates.pdf (accessed 2026-07-23)
- https://www.tn.gov/content/dam/tn/tenncare/documents/HCFATennCareEDIFrontMatter.pdf (accessed 2026-07-23)
- https://www.provider.wellpoint.com/docs/gpp/TN_WLP_CAID_BH_ABARequirements.pdf (accessed 2026-07-23)

## Common questions

### Does Wellpoint Tennessee cover ABA therapy?

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.

### How do I submit an ABA authorization to Wellpoint TN?

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.

### Is Wellpoint's ABA policy different from TennCare's?

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.

## Primary sources

1. [ABA Provider Requirements & Program Description (Wellpoint copy, rev. 06/2024)](https://www.provider.wellpoint.com/docs/gpp/TN_WLP_CAID_BH_ABARequirements.pdf)
2. [Universal Request for ABA form (Jan 2026)](https://www.provider.wellpoint.com/docs/gpp/TN_WLP_CAID_BH_RequestABA.pdf)
3. [Tri-MCO ABA Overview of Updates (Sept 2024)](https://www.provider.wellpoint.com/docs/gpp/TN_WLP_CAID_BH_ABAOverviewofUpdates.pdf)
4. [Wellpoint TN — ABA provider page](https://www.provider.wellpoint.com/tennessee-provider/patient-care/behavioral-health/applied-behavior-analysis)
5. [TennCare Kids (EPSDT) — birth through age 20](https://www.tn.gov/tenncare/tenncare-kids.html)
6. [Wellpoint Tennessee Provider Manual (TNWP-CD-PM-086546-25-B, Dec 2025)](https://www.provider.wellpoint.com/docs/gpp/TN_WLP_CAID_ProviderManual.pdf)
7. [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)
8. [42 CFR 438.210(d) — MCO authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/section-438.210)
9. [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)
10. [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.