Date: January 28, 2022
Attention: Primary Care Providers, Developmental Pediatricians, and Neurologists
Effective Date: February 1, 2022Providers should monitor the Texas Children’s Health Plan (TCHP) Provider Portal regularly for alerts and updates associated to the COVID-19 event. TCHP reserves the right to update and/or change this information without prior notice due to the evolving nature of the COVID-19 event.
Call to action: Effective for dates of service on or after February 1, 2022, Autism Services, to include Applied Behavior Analysis (ABA) evaluation and treatment, will become a benefit of the Texas Health Steps-Comprehensive Care Program (THSteps-CCP). This new benefit will be available to Texas Children’s Health Plan (TCHP) STAR and STAR Kids Members. This is not a benefit for the CHIP program.
Resource:Texas Health & Human Services Medicaid Autism Services PolicyBenefit qualifications include the following:- This applies to Texas Medicaid recipients who are 20 years of age and younger and who meet the criteria outlined in the Autism Services benefit description.
- The new Medicaid Autism Services benefit includes coverage of medically necessary ABA services for individuals with Autism Spectrum Disorder (ASD) and provides for coordination of the service array in interdisciplinary team meetings.
Requirements for prior authorization for ABA evaluation and treatment- The CCP Prior Authorization Request Form is available at https://www.tmhp.com/sites/default/files/provider-forms/pa-forms/F00012_CCP_Prior_Authorization_Request_Form.pdf to enable requests for prior authorization of ABA services. Requests for prior authorization for new Autism Services benefits will be accepted on or after February 1, 2022.
- Adequate supporting clinical documentation
- Information on the prior authorization procedures and requirements can be found on TCHP’s Prior Authorization Requirements webpage available here.
- Providers should include the valid prior authorization number received for the provision of ABA services on the claim form.
How this impacts providers: The provider types for this new benefit are Licensed Behavior Analyst (LBA), licensed assistant Behavior Analysts (LaBAs) and Behavior Technicians (BTs) who may work under supervision of an LBA. LaBAs and BTs may not be a Medicaid Provider or bill for the service.
Please utilize this table for the ABA benefit procedural codes and descriptions, service limitations, modifiers and additional information. TCHP will adhere to the limits below; however, the limitations listed may be exceeded with evidence of medical necessity.
| PROCEDURE CODE | DESCRIPTION | PROVIDER SPECIALTY | REQUIRED BILLING MODIFIER | LIMITATIONS | ADDITIONAL INFORMATION |
| 97151 | ABA initial evaluation
| Licensed Behavior Analyst (LBA) | HO only | Limited to 6 hours (24 units) for initial evaluation | Authorized only for a 30-day period |
| 97151 | ABA re-evaluation
| Licensed Behavior Analyst (LBA) | HO only | Limited to 6 hours (24 units) | Authorized only for a 30-day period |
| 97153 | ABA individual treatment |
Licensed Behavior Analyst (LBA)
| HO only | Direct treatment for the child/youth is limited to a total of 8 hours per day, inclusive of procedure codes 97153, 97154, 97155, 97158. | n/a |
| 97154 | ABA group treatment |
Licensed Behavior Analyst (LBA)
| HO
| Direct treatment for the child/youth is limited to a total of 8 hours per day, inclusive of procedure codes 97153, 97154, 97155, 97158. | n/a |
| 97155 | ABA individual treatment |
Licensed Behavior Analyst (LBA)
Licensed Assistant Behavior Analyst (LaBA)
| HO or HN | Direct treatment for the child/youth is limited to a total of 8 hours per day, inclusive of procedure codes 97153, 97154, 97155, 97158. | n/a |
| PROCEDURE CODE | DESCRIPTION | PROVIDER SPECIALTY | REQUIRED BILLING MODIFIER | LIMITATIONS | ADDITIONAL INFORMATION |
| 97156 | ABA parent/caregiver/family education and training |
Licensed Behavior Analyst (LBA)
Licensed Assistant Behavior Analyst (LaBA)
| HO or HN | n/a | n/a |
| 97158 | ABA group treatment |
Licensed Behavior Analyst (LBA)
Licensed Assistant Behavior Analyst (LaBA)
| HO or HN | Direct treatment for the child/youth is limited to a total of 8 hours per day, inclusive of procedure codes 97153, 97154, 97155, 97158. | n/a |
| 99366 | Interdisciplinary team meeting | Not specified | No modifier required | Limited to diagnosis code F840-Autism and is contingent upon prior authorization of ABA evaluation, re-evaluation, or treatment team. | May be reimbursed for interdisciplinary team meetings attended by qualified non-physician healthcare providers |
Telehealth ABA Services:
TCHP supports the delivery of telehealth (non-physician-delivered) distant site services to its members. ABA evaluation and treatment services may only be delivered via telehealth using synchronous audio-visual technology or a similar technology. Procedure codes 97151, 97155, 97156, 97158 and 99366 may be delivered via telehealth and require Modifier 95 to designate remote delivery.
| DESCRIPTION | MODIFIER |
| Telehealth | 95 |
Providers may provide covered, medically necessary services in a synchronous audio-video format so long as the telehealth services are provided within the scope, practice and limitations of the practitioner’s license. Services must be provided in accordance with the Texas Medicaid Program benefit rules as stated in the Texas Medicaid Provider Procedures Manual (TMPPM).
Next steps for providers: Licensed Behavior Analyst Providers that are interested in this specialty should submit their Texas Medicaid Enrollment Applications. More information can be found at
https://www.tmhp.com/topics/provider-enrollment.
To enroll in Texas Medicaid, LBA providers must:
- Be licensed as a Licensed Behavior Analyst (LBA) by the Texas Department of Licensing and Regulation (TDLR) or the appropriate state board where services are rendered.
- Have a national provider identifier (NPI).
If you have any questions, please email Provider Network Management at: providerrelations@texaschildrens.org.For access to all provider alerts,log into:
www.thecheckup.org or
www.texaschildrenshealthplan.org/for-providers.
