Wellpoint — the Elevance plan formerly branded Amerigroup Texas, serving STAR, STAR Kids, and STAR+PLUS — administers the ABA benefit as a faithful restatement of TMPPM policy: its Texas behavioral-health provider document carries the state's modifier table (HO=LBA, HN=LaBA, HM=BT, 95=telehealth), unit caps, ages 0–20 scope, and the telehealth ban on BT/LaBA-delivered direct treatment, essentially unchanged. The January 2024 Amerigroup-to-Wellpoint rebrand changed no PA or claims processes. The plan's one genuine convenience: it accepts either its own ASD form or the state's.
The assessment PA needs a completed treatment-request form — Wellpoint accepts either its own "Treatment Plan Request Form for Autism Spectrum Disorders" or the state CCP Prior Authorization Request Form — plus a current, signed physician ABA referral and the clinical documentation the TMPPM requires. If your practice standardizes on the state CCP form across payers, Wellpoint doesn't force a conversion step: one less template to maintain. Submissions run through Availity Essentials (or phone/fax), with appeals via Availity or 833-731-2162, and treatment follows the state's 90/90/180 cadence.[1]
Wellpoint's provider doc spells out the billing edges that mirror the TMPPM: 97151 is capped at 24 units (6 hours) per evaluation; direct treatment caps at 8 hours per day; the credential-modifier table governs claims; LaBAs and BTs may not deliver via telehealth; and — explicitly — no separate reimbursement for treatment planning or report writing outside 97151, and no partial units. Practices that bill documentation time separately elsewhere should scrub that habit out of Wellpoint claims before it generates denials.[1]
The questions that decide whether a family can start with Wellpoint (formerly Amerigroup Texas), 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.[3][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.[3][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).[3][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.[3][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.[3][1][5]
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.[3][1]
Wellpoint's decision table: Medicaid routine/non-urgent "3 business days"; CHIP routine "2 business days (approval) / 3 business days (adverse determination)"; Medicaid and CHIP urgent/expedited "3 calendar days"; concurrent "1 business day"; post-service "30 calendar days," with written notice "no later than the next business day following a prior authorization request determination." A request is not expedited when "The date of service is greater than one week from the request date." Incomplete requests are paused while Wellpoint asks for the missing documentation; if it does not arrive "within the designated time frame, the medical director will make a determination based on the information previously received." Lead times: initial requests "a minimum of three business days prior to the start of care"; recertifications may be submitted "at least 60 calendar days prior to the expiration of the current authorization" (the 30-day exception list names only PT/OT/speech therapy, private duty nursing and PPECC — not ABA).[6][7][8]
"Federal and state laws require Medicaid — including the STAR, STAR Kids, and STAR+PLUS programs — to be the payer of last resort." Submit to the other insurer first and attach its "EOB/EOP or rejection letter"; if Wellpoint already knows of other coverage it "will deny the claim and redirect the provider to bill the appropriate insurance carrier." Filing deadline with other insurance: "within 95 days of receiving a response from the third-party payer" (after a primary adjustment, the 95 days run from the most recent EOB). Wellpoint pays first and recovers later only for "Preventive pediatric care" and services tied to a child support enforcement action; the TMPPM's matching option is limited to THSteps medical and dental checkup providers, so bill the other coverage first for ABA. The manual does not say whether Wellpoint's PA is still needed when it is secondary — request it.[6][9][10]
Coverage decides whether Wellpoint (formerly Amerigroup Texas) 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.[3][1][4]
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.[3][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. Wellpoint restates the same caps in its own behavioral-health provider document and adds that partial units are not payable.[1][3]
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.[3][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.[3][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. Wellpoint carries the same HO/HN/HM modifier table and states there is no separate reimbursement for treatment planning or report writing outside 97151.[1][3]
Yes — the Texas Medicaid Autism Services benefit on TMPPM criteria, restated in its behavioral-health provider document: PA on evaluation and treatment, ages 0–20, credential modifiers, 8-hour daily cap.
No — Wellpoint accepts either its Treatment Plan Request Form for Autism Spectrum Disorders or the state CCP Prior Authorization Request Form, plus the signed physician referral.
No — the January 2024 rebrand changed no PA or claims processes. Documents and portals under the Amerigroup name remain valid references.
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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