---
title: Wellpoint Texas ABA coverage (Texas Medicaid MCO).
url: "https://carelu.com/payers/wellpoint-texas"
markdown_url: "https://carelu.com/payers/wellpoint-texas.md"
state: TX (Texas)
payer: Wellpoint (formerly Amerigroup Texas)
kind: Medicaid managed care plan (MCO)
parent_program: Texas Medicaid (THSteps-CCP)
description: "How Wellpoint (formerly Amerigroup Texas) administers Texas Medicaid ABA — TMPPM rules restated in its behavioral-health provider doc, the two-form choice, Availity submission, and billing rules worth knowing."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Wellpoint Texas ABA coverage (Texas Medicaid MCO).

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

> TMPPM restated; accepts its own ASD form OR the state CCP PA form; Availity submission.

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.

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 — its ASD Treatment Plan Request Form OR the state CCP PA form, plus a current signed physician ABA referral [1]
- **Prior auth for treatment**: Required — TMPPM cadence; submit via Availity Essentials, phone, or fax; appeals via Availity or 833-731-2162 [1][3]
- **Autism diagnosis required?**: Yes — ASD, ages 0–20, per TMPPM (restated in Wellpoint's provider doc) [1][3]

## At a glance

- **Plan type:** Texas Medicaid MCO (Elevance, ex-Amerigroup) — STAR, STAR Kids, STAR+PLUS
- **Clinical rules:** TMPPM Autism Services policy, restated in the plan's BH provider doc
- **Forms:** Its ASD Treatment Plan Request Form OR the state CCP PA form — either works
- **Submission:** Availity Essentials, phone, or fax; appeals via Availity or 833-731-2162
- **Caps:** 97151 max 24 units / 6 hrs; 8 hrs/day direct treatment (state baseline)
- **Rates:** Paid per contract; no separate pay for report writing outside 97151

## How Wellpoint runs authorization

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]

## Billing rules that bite

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]

## Intake gates

The questions that decide whether a family can start with Wellpoint (formerly Amerigroup Texas), 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. [3][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. [3][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). [3][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. [3][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. [3][1][5]
- **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. [3][1]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: "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]

## Delivery and billing rules

Coverage decides whether Wellpoint (formerly Amerigroup Texas) 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. [3][1][4]
- **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. [3][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. Wellpoint restates the same caps in its own behavioral-health provider document and adds that partial units are not payable. [1][3]
- **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. [3][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. [3][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. 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]

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

- **Physician ABA referral:** A current, signed referral attaches to the PA — collect it with the diagnosis report.
- **Form choice:** State CCP PA form or Wellpoint's ASD form — pick one and standardize.
- **ASD dx + recency:** TMPPM rules: qualified diagnoser, DSM severity, within 3 years.
- **Clean unit math:** No partial units, no separate documentation-time billing — align billing staff early.

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

## Verification of benefits (VOB) data

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

### EDI routing

- **Payer ID (pVerify):** 06067
- **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:** Wellpoint accepts its own ASD Treatment Plan Request Form OR the state CCP PA form; submit via Availity Essentials, phone, or fax.
- **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:** 1-833-731-2162
- **Portal:** [Availity Essentials](https://apps.availity.com/)
- **Fax:** 1-800-964-3627

Questions to ask on a verification call:

- Which Availity payer ID routes Wellpoint Texas Medicaid eligibility — one of the legacy Amerigroup regional codes (26374 Houston, 26375 Ft. Worth, 26378 Multiple States, 27518 generic), and if so which one?
- Does Wellpoint support real-time (vs. batch) 270/271 eligibility for payer ID 06067?
- 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 Wellpoint'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://provider.amerigroup.com/docs/gpp/TX_CAID_TexasBehavioralHealth.pdf?v=202207071852 (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.wellpoint.com/tx/provider/state-federal/contact-us (accessed 2026-07-23)

## Common questions

### Does Wellpoint Texas cover ABA?

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.

### Do I have to use Wellpoint's own PA form?

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.

### Did the Amerigroup-to-Wellpoint rebrand change anything?

No — the January 2024 rebrand changed no PA or claims processes. Documents and portals under the Amerigroup name remain valid references.

## Primary sources

1. [Wellpoint/Amerigroup — Texas Behavioral Health provider document (PDF)](https://provider.amerigroup.com/docs/gpp/TX_CAID_TexasBehavioralHealth.pdf?v=202207071852)
2. [Wellpoint TX — Prior Authorization Requirements](https://www.wellpoint.com/tx/provider/state-federal/resources/prior-authorization-requirements)
3. [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)
4. [BACB RBT Handbook (updated 06/2026)](https://www.bacb.com/rbt-handbook)
5. [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)
6. [Wellpoint Texas — Provider Manual, STAR/STAR Kids/STAR+PLUS/CHIP (January 2026) (PDF)](https://provider.wellpoint.com/content/dam/digital/wellpoint/documents/provider/texas/government/general/TX_WLP_CAID_ProviderManual.pdf)
7. [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)
8. [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)
9. [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)
10. [42 CFR § 433.139 — Medicaid payment of claims involving third party liability](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)

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.