CurrentOptumPolicy BH803

Applied Behavior Analysis (ABA) — New Mexico Medicaid

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State-specific clinical criteria for coverage, authorization, and delivery of ABA services for New Mexico Medicaid members, including eligibility, provider requirements, and stage-based evaluation and treatment processes.

Policy Summary

PayerOptum

PolicyApplied Behavior Analysis (ABA) — New Mexico Medicaid

Policy CodePolicy BH803

Change TypeNo material change

Effective DateJun 1, 2026

Last ReviewJun 1, 2026

Next Review DateJun 1, 2026

Key ActionObtain prior authorization for Stage 3 ABA services and reauthorize every 6 months with required documentation (CDE/ISP, treatment plan, model, hours, and supervision details).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 moStage 3 reauth interval

Up to 3 yrAuth period (< age 8)

Up to 6 yrAuth period (≥ age 8)

12–36 moAt-risk age window

30-40 hrs/wkComprehensive ABA intensity

5%Min BA supervision

Coverage Criteria and Medical Necessity

Initial eligibility (At-Risk or Diagnosed ASD)

ABA services are medically necessary when the member meets ONE of the two categories below and subsequent stage-specific requirements are met.

Eligibility categories

At-Risk for ASD: At-Risk requires Risk Evaluation via an approved AEP CDE; member age 12–36 months; meets at least one listed risk criterion: developmental differences/delays on standardized assessment, some ASD characteristics (impaired social communication or early indicators for restricted/repetitive behavior), or at least one genetic risk factor (e.g., older sibling with ASD, Fragile X).age 12–36 months
Services are time-limited when full DSM criteria are not met.
Diagnosed ASD: Documented medical diagnosis of ASD per the latest DSM or ICD from an AEP or Grace Exception Practitioner; confirmation via AEP CDE or use of a targeted evaluation when behaviors have changed since the last CDE; ABA is needed to ameliorate symptoms, build adaptive behaviors, or reduce maladaptive behaviors to enhance health, safety, functioning, or prevent deterioration.

Stage requirements and prior authorization

Stage-based criteria and required sequence

Stage sequence: Services must follow Stage 1 (AEP completes CDE/ISP and refers to an approved ABA provider agency), Stage 2 (AP agency completes behavior/functional analytic assessment, selects focused or comprehensive model, and develops the ABA treatment plan), then Stage 3 (implementation by BA/BCaBA/BT per the treatment plan).

BA is responsible for assessment, goal selection, measurement, and treatment documentation.

Stage 3 prior authorization and continuation: Within authorization periods (up to 3 years for age <8; up to 6 years for age ≥8), Stage 3 services must be reviewed and reauthorized at least every 6 months; prior authorization requests must include the CDE/ISP, ABA treatment plan, requested model and maximum hours/week, supervision and clinical management hours if exceeding specified thresholds, collaboration needs (including specialty care when identified), and documentation of other services in the ISP.

Family or AP may request ISP modifications prior to the six-month authorization point if immediate changes are warranted.

General medical necessity and delivery criteria

Covered when ALL of the following are met

Supervising BA qualifications and responsibilities: Functional analytic assessment and ABA treatment plan must be completed by BACB-qualified psychologists, BCBAs/BCBA-Ds, or mentored BCBAs/BCaBAs; the supervising BA is responsible for the assessment, selection and measurement of goals, and formulation and documentation of the treatment plan.

Treatment plan timing and content: The ABA Treatment Plan must be completed no later than two months after completion of 97151 and updated prior to the end of the recipient's Prior Authorization period; it must identify all target behaviors, include objective baseline data and standardized assessment scores as applicable, specify interventions and units allocated, service settings, family participation plan, signature of the responsible BA, time-limited goals tied to the authorization period, and measurable discharge criteria.2 months

Includes requirement to include objective baseline data and standardized assessment scores where applicable.

Stage 3 delivery and supervision: Stage 3 services require prior authorization, clinical management, and ongoing BA supervision meeting BACB standards, including a minimum of 5% of total service hours supervised; services may be delivered by RBTs, BCATs, or non-certified technicians under BA supervision.5%

Clinical management and case supervision requirements are detailed in the BH policy and billing manual.

Focused vs Comprehensive ABA criteria

Service model selection logic

Focused ABA appropriateness: Focused ABA is appropriate when the member needs development of a limited number of key functional skills or treatment of risky problem behavior; generally 10–25 hours per week of direct treatment (plus supervision and caregiver training), though severe cases may require more than 25 hours/week.10-25 hrs/week

Dosage determined by individualized factors including ISP and ASD level.

Comprehensive ABA appropriateness: Comprehensive ABA is appropriate when multiple targets across most or all developmental domains are affected; treatment often involves 30–40 hours per week of 1:1 direct treatment (not including caregiver training and supervision). For EPSDT-aged recipients, prior authorization is required if services average less than 20 hours/week.30-40 hrs/week

Dosage individualized; adult ranges vary by tier (10–40 hrs/week).

Excluded from coverage are activities that do not directly accomplish objectives specified in the member's ABA treatment plan or that are not based on the principles and application of Applied Behavior Analysis (ABA). Examples include interventions that are better characterized as other therapies (e.g., speech, occupational, physical therapy, counseling) even if provided by someone with ABA training, and activities that are essentially staff training, certification, licensure, or supervision requirements rather than clinical ABA casework. Services that occur in school settings and have the potential to supplant educational services are also excluded.

ABA services delivered in a school under an Individualized Education Program (IEP) or Individualized Family Service Plan (IFSP) do not, by themselves, preclude coverage of medically necessary ABA provided across natural settings. School-based IEP/IFSP services remain the mechanism to address educational goals and to ensure a student receives a Free and Appropriate Public Education; ABA in clinical or community settings should support the member’s ability to access those educational services rather than replace them. Services provided in school that risk supplanting educational instruction are non-covered.

Coding, Authorization Periods, and Key Intervals

Referenced ABA CPT/HCPCS codes and service codesmixed

97151	Behavioral analysis assessment
97152	Family/caregiver training (assessment related)
0362T	Targeted/Risk evaluation (as used collectively with 97151 for Stage 2)
T1026	Comprehensive Diagnostic Evaluation (CDE) / ISP references T1026 TG
T1026 TG	CDE (documented form)
T1026 TG/HI	Individual Service Plan (ISP) associated with CDE
T1026 HK	Targeted/Risk evaluation code referenced for adults
97156	Family training (Stage 3) - implemented in Treatment Plan
97157	Multiple-person family training / group

Prior authorization reauthorization interval — every 6 months

Reauthorization intervalPrior authorization for Stage 3 services must be secured and reauthorized every 6 months

Reviewer action at each intervalReviewer assesses progress with input from family and AP's BA and determines ISP or treatment plan changes if needed

Documentation required for reauthorizationEach prior authorization request must include the CDE/targeted evaluation, ISP, ABA treatment plan, requested model and hours, and supervision/clinical management hours if applicable

Authorization period by age — up to 3 years (<8) and up to 6 years (>=8)

Authorization period (age < 8)Up to 3 years

Authorization period (age ≥ 8)Up to 6 years

Review cadence within authorization periodContinued Stage 3 services must be reviewed and reauthorized at least every 6 months

At-risk age window — 12–36 months

At‑Risk age windowMembers aged 12 to 36 months (12–36 months) are eligible for time‑limited At‑Risk services

At‑Risk assessment pathwayA Risk Evaluation of ASD must occur through an approved Autism Evaluation Provider (AEP) via a Comprehensive Diagnostic Evaluation (CDE)

At‑Risk criteria examplesDevelopmental differences/delays on standardized assessments, some ASD characteristics, or at least one genetic risk factor

Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior authorization required for Stage 3; reauthorize every 6 months

Prior authorization is required for Stage 3 (ABA Treatment) services and must be obtained initially and every six (6) months within the state-defined authorization period.

Authorizations follow state timeframes: up to 3 years for members < age 8 and up to 6 years for members age 8 and older.
At each six-month authorization point the reviewer will assess need for ISP or treatment plan changes with input from the family and the AP's BA.

Prior Authorization

PA required for Stage 3 and certain Comprehensive ABA (EPSDT-aged)

Prior authorization is required for ABA Stage 3 services; for EPSDT-aged recipients, Comprehensive ABA delivered at less than 20 hours/week on average also requires prior authorization.

Prior auth requests must include evaluations, ISP, treatment plan, model, hours requested, and supervision/clinical management hours when exceeding thresholds.
Comprehensive ABA for EPSDT-aged recipients requires prior authorization if services average under 20 hours/week.

Step Therapy

Three-stage service progression (Stage 1 → Stage 2 → Stage 3)

Services follow a three-stage progression: Stage 1 (AEP completes CDE/ISP and refers to an AP), Stage 2 (AP agency completes behavior/functional analytic assessment and develops the ABA treatment plan), then Stage 3 (implementation of the treatment plan by BA/BCaBA/BT).

Stage 1: AEP develops Integrated Service Plan (ISP) and referral to approved ABA provider agency.
Stage 2: AP conducts assessment to select focused or comprehensive model and completes treatment plan.
Stage 3: Stage 3 practitioners implement the treatment plan under required supervision and authorization.

Note

Adult-specific access: Stage 2 available without CDE; CDE only if medically warranted

Adult recipients may access Stage 2 services without a CDE; a CDE is not required for adults unless medically warranted. Adults must complete a Targeted/Risk evaluation and ISP prior to the end of their first service authorization and must document ASD confirmation by a Grace Exception Practitioner within the last three years to access Stage 3.

If clinically warranted during authorization, adults may receive CDE or Targeted/Risk evaluation and a new ISP; medical necessity must be documented.
Adults transitioning from EPSDT at age 21 may continue Stage 1–3 services when an ABA Stage 3 Treatment Plan is approved.

Documentation Required

Documentation required to obtain initial and ongoing PA for Stage 3

To secure initial and ongoing prior authorization for Stage 3, the AP must submit the prior authorization request including the CDE or targeted evaluation and the ISP from the AEP, plus the ABA treatment plan and details about model, hours, supervision, clinical management, and other services.

Include the CDE or targeted evaluation and the ISP developed in Stage 1 along with the ABA treatment plan developed in Stage 2.
Specify requested treatment model (focused or comprehensive), maximum hours/week, hours of case supervision if >2 per 10 hours of intervention, hours of clinical management if >2 per 10 hours, and need for collaboration with an ABA specialty care provider.
Document hours allocated to other services in the ISP (e.g., early intervention, PT, speech) to determine feasibility of requested ABA intensity.

Billing Rule

CDE (T1026 TG) and ISP timing and deliverables

The CDE (T1026 TG) report must be issued within 60 calendar days of completion, and the individualized ISP (T1026 TG/HI) must be issued within 30 calendar days (no more than 45) after completion of the CDE; copies must be included in the recipient's record and provided to the family/PCP.

CDE must include direct observation, interviews, and relevant informants; the CDE record must be signed by the AEP.
ISP must include statements supporting that requested ABA services are expected to result in measurable improvement and must link to CDE findings.
ISP must be issued within required timelines and must indicate how other recommended services align with ABA.

Denial Risk

Denial risk: non‑covered activities and activities outside ABA scope

Services that are not designed to accomplish objectives in the ABA treatment plan, not based on ABA principles, that supplant school educational services, are better described as other therapies, or are staff training/certification activities are non‑covered.

Non-covered activities include interventions outside the ABA treatment plan, non-ABA modalities, school activities that supplant educational services, services better described as speech/OT/PT/counseling, and staff training or certification tasks.

Prior Authorization

Prior authorization note — Stage 3 and EPSDT Comprehensive ABA

Reminder: Prior authorization is required for Stage 3 services and Comprehensive ABA for EPSDT-aged recipients averaging less than 20 hours/week requires prior authorization from the MCO/TPA.

Stage 3 PA submissions must include treatment plan, CDE/ISP, model, hours requested, and supervision/clinical management details.
EPSDT-aged recipients receiving Comprehensive ABA under 20 hours/week on average need PA.

Service Settings and Level of Care

Outpatient ABA services (stage-based with possible specialty care)

Admission to ABA services: Member meets either At-Risk or Diagnosed ASD eligibility and has an ISP developed by an AEP; the AP agency completes Stage 2 assessment to select the treatment model and develop the ABA Treatment Plan prior to Stage 3 implementation.

Continued Stage 3 services: Ongoing medical necessity must be demonstrated at six-month reauthorization intervals with progress assessment, family and AP BA input, and documentation of progress toward discharge criteria; ISP modifications made as needed and specialty care referral when required.reauthorization every 6 months

If not responding, AP must attempt internal remedies and may request new evaluations before termination.

Discharge: Services may end when the member no longer meets service criteria, requires a higher level of care that precludes ABA, or the ISP/evaluations recommend cessation; discharge planning must begin at the start of Stage 3 services and include measurable discharge criteria.

Outpatient/Community-based ABA

Community and natural settings: Stage 3 ABA must be generalized across natural environments including home, school, clinics, childcare, alternative living arrangements, respite, day habilitation, vocational/educational settings, community-based locations, and workplace.

Coordinated with school resources and other therapies as specified in the ISP.

Adult tiered model for outpatient/community: Adult recipients may be assigned to Tier 1 (maintenance 10–15 hrs/week), Tier 2 (intervention 20–30 hrs/week), or Tier 3 (high-risk 30–40 hrs/week) based on clinical need; adult Stage 3 Treatment Plan must be prior authorized annually during the adult recipient’s six-year authorization.annual prior authorization for adult Stage 3

Service intensity determined by individualized assessment, functional needs, and risk level.

Stage Definitions, Assessments, and Treatment Planning

ABA Stage criteria

Clinical ABA coverage is organized into three stages (Evaluation, Assessment, Treatment) with specific provider roles and documentation/authorization requirements.

Stage 1 - Evaluation (AEP): AEP completes a Comprehensive Diagnostic Evaluation (CDE), Targeted Evaluation, or Targeted Risk Evaluation; develops the Integrated Service Plan (ISP) and refers to an approved ABA provider agency. For members with an existing ASD diagnosis, confirmation and ISP development remain required as indicated.

AEP must be an approved autism evaluation provider.

Stage 2 - Assessment (BA/BCBA/BCaBA): Supervising BA (BCBA/BCBA-D or qualified psychologist) or mentored BCBAs/BCaBAs complete a functional analytic assessment addressing skill acquisition and behavior reduction, select focused or comprehensive service model, and develop the individualized ABA Treatment Plan; BA is responsible for assessment, goal selection, measurement, and documentation including direct observation, standardized scales, interviews, and file review.

Family Set and stakeholders included in goal selection.

Stage 3 - Treatment (BA/BCaBA/BT): Implementation of the ABA Treatment Plan by BA, BCaBA under supervision, or Behavioral Technicians under BA supervision; prior authorization is required for Stage 3 services, with review and reauthorization at least every six months; specialty care referral available when complexity exceeds AP capacity.

AP must document hours, supervision, clinical management, and coordination with other services.

Stage 2 (Assessment and Goal Setting)

Stage 2 assessment and treatment plan requirements

Assessment components: Behavioral/functional analytic assessment must address both skill acquisition and behavior reduction and include direct observation and measurement in natural and structured contexts, file review, standardized behavior scales as appropriate, and interviews with the recipient, Family Set, and other professionals.

Data collected serve as the primary basis for baselines, discharge goals, and response evaluation.

Goal selection and measurement: Targets must be individualized and prioritized based on risk to safety, independence, and health; baselines must be measured; goals must be observable, measurable, and tied to objective methods of measurement with data graphed when possible to inform treatment modifications; stakeholder agreement is required for goals and discharge criteria.

Data represented graphically where possible to inform modifications.

Stage 3 (Implementation, Supervision, and Settings)

Stage 3 treatment plan and delivery requirements

Treatment plan elements: Stage 3 Treatment Plan must identify all target behaviors, specify interventions and units allocated, include objective baseline data and standardized assessment scores where applicable, specify service settings, include family training and participation strategies, be signed by the responsible BA/Mentored BA, be time-limited to the authorization period, and include measurable discharge criteria and planning beginning at service initiation.2 months for completion after 97151

Must be updated prior to each Prior Authorization period and include coordination with other therapies and community resources.

Service settings and generalization: Stage 3 treatment must be generalized across natural environments (home, school, clinic, childcare, alternative living, respite, day habilitation, vocational settings, community, workplace) and take into account school or community resources and IEP/IFSP coordination.

Family participation strategies (including telemedicine) required if family cannot attend in-person.

Supervision and provider types: Stage 3 services may be delivered by RBTs, BCATs, and non-certified technicians but require clinical management and ongoing supervision by BAs per BACB standards, including at least 5% supervision of total service hours; specialty care provider referral and prior authorization apply when case complexity exceeds AP capacity.5%

Supervision and clinical management details are provided in the BH policy and billing manual.

Treatment Modalities and Delivery Options

Applied Behavior Analysis (ABA)

ABA treatment purpose: Applied Behavior Analysis (ABA) is used to ameliorate symptoms, develop adaptive behaviors, and reduce maladaptive behaviors (e.g., self-injury, aggression, pica, elopement) to enhance functioning and prevent deterioration; ABA must be delivered according to accepted standards of care and scientific principles.

Telemedicine

Telemedicine use: Telemedicine is allowed and encouraged for delivery of ABA services to increase access, including for family participation when in-person attendance is not possible; New Mexico does not require an in-state telemedicine license for most ABA providers, but out-of-state MD/DO AEPs must obtain a NM telemedicine or full medical license.

BICC, BACB, and NM RLD psychologist board support telehealth for ABA.

Direct Treatment Intensity and Visit Ranges

Direct ABA treatment (ranges vary by Focused, Comprehensive, and adult tiers) — typical hours/week ranges

Focused ABA typical intensityGenerally 10–25 hours per week of direct treatment (may exceed 25 hrs/week for severe destructive behavior)

Comprehensive ABA typical intensityOften 30–40 hours per week of 1:1 direct treatment (not including caregiver training, supervision)

Adult tiered rangesAdult tiers range from 10–40 hours per week: Tier 1 (10–15 hrs), Tier 2 (20–30 hrs), Tier 3 (30–40 hrs)

Key Definitions

Applied Behavior Analysis (ABA) — definition of ABA

DefinitionApplied Behavior Analysis (ABA) is the science in which principles of behavior analysis are applied systematically to improve socially significant behavior; experimentation is used to identify variables responsible for behavior change.

PurposeABA treatments aim to ameliorate symptoms, develop adaptive behaviors, and reduce maladaptive behaviors to enhance functioning and prevent deterioration

Delivery standardABA services must be delivered in accordance with generally accepted standards of care and recognized best practices in behavioral health treatment

At-Risk for ASD — definition and criteria

Age range12–36 months

EligibilityMember meets At‑Risk criteria when full DSM criteria for ASD are not met but the member has developmental differences/delays on standardized assessment, some ASD characteristics, or at least one genetic risk factor

Assessment requirementA Risk Evaluation of ASD must occur through an approved AEP via a Comprehensive Diagnostic Evaluation (CDE)

Diagnosed ASD — definition and confirmation process

Diagnostic requirementDocumented medical diagnosis of ASD per DSM or ICD from an AEP or Grace Exception Practitioner

Confirmation pathwayConfirmation of ASD must occur through an AEP via a Comprehensive Diagnostic Evaluation (CDE); a targeted evaluation may be used when behaviors have changed since the last CDE

Clinical needABA services must be needed to ameliorate symptoms, build adaptive behaviors, or reduce maladaptive behaviors to enhance health, safety, or functioning

Focused ABA — definition and typical intensity

DefinitionFocused ABA addresses a limited number of key functional skills or prioritizes treatment of risky problem behavior

Typical intensityGenerally 10–25 hours per week of direct treatment (may exceed 25 hrs/week for severe cases)

Treatment featuresIncludes direct and indirect supervision and caregiver training; may use individual or small‑group formats when increasing socially appropriate behavior

Comprehensive ABA — definition and typical intensity

DefinitionComprehensive ABA is an intensive intervention targeting multiple domains with many treatment targets across cognitive, communicative, social, emotional, and adaptive functioning

Typical intensityOften involves 30–40 hours per week of 1:1 direct treatment (excluding caregiver training and supervision)

Authorization noteFor EPSDT‑aged recipients, prior authorization is required if services average less than 20 hours per week; adult comprehensive services may range from 10 to 40 hours depending on tier

Coding and Billing Notes

Referenced ABA CPT/HCPCS codes and service codesmixed

97151	Behavioral analysis assessment
97152	Family/caregiver training (assessment related)
0362T	Targeted/Risk evaluation (as used collectively with 97151 for Stage 2)
T1026	Comprehensive Diagnostic Evaluation (CDE) / ISP references T1026 TG
T1026 TG	CDE (documented form)
T1026 TG/HI	Individual Service Plan (ISP) associated with CDE
T1026 HK	Targeted/Risk evaluation code referenced for adults
97156	Family training (Stage 3) - implemented in Treatment Plan
97157	Multiple-person family training / group

Background and Clinical Context

Autism Spectrum Disorder (ASD) is a lifelong neurodevelopmental condition for which Applied Behavior Analysis (ABA) is an evidence-based set of techniques intended to increase adaptive skills and reduce maladaptive behaviors that impair health, safety, or functioning. ABA treatment is delivered through a staged process (evaluation, assessment, then treatment) and must be individualized, measurable, and documented in an ISP and ABA Treatment Plan. ABA supports may be provided across natural settings (home, clinic, community, and school) but will not be covered when they supplant required educational services or when activities fall outside ABA principles.

Policy Summary

PayerOptum

PolicyApplied Behavior Analysis (ABA) — New Mexico Medicaid

Policy CodePolicy BH803

Change TypeNo material change

Effective DateJun 1, 2026

Last ReviewJun 1, 2026

Next Review DateJun 1, 2026

Key ActionObtain prior authorization for Stage 3 ABA services and reauthorize every 6 months with required documentation (CDE/ISP, treatment plan, model, hours, and supervision details).

SourceLink

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CurrentOptumPolicy BH803

Applied Behavior Analysis (ABA) — New Mexico Medicaid

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Sign up for Optum Policy BH803 alerts

Get alerted when Policy BH803 changes without checking for updates manually.

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Policy Summary

PayerOptum

PolicyApplied Behavior Analysis (ABA) — New Mexico Medicaid

Policy CodePolicy BH803

Change TypeNo material change

Effective DateJun 1, 2026

Last ReviewJun 1, 2026

Next Review DateJun 1, 2026

Key ActionObtain prior authorization for Stage 3 ABA services and reauthorize every 6 months with required documentation (CDE/ISP, treatment plan, model, hours, and supervision details).

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

6 moStage 3 reauth interval

Up to 3 yrAuth period (< age 8)

Up to 6 yrAuth period (≥ age 8)

12–36 moAt-risk age window

30-40 hrs/wkComprehensive ABA intensity

5%Min BA supervision

Coverage Criteria and Medical Necessity

Initial eligibility (At-Risk or Diagnosed ASD)

ABA services are medically necessary when the member meets ONE of the two categories below and subsequent stage-specific requirements are met.

Eligibility categories

At-Risk for ASD: At-Risk requires Risk Evaluation via an approved AEP CDE; member age 12–36 months; meets at least one listed risk criterion: developmental differences/delays on standardized assessment, some ASD characteristics (impaired social communication or early indicators for restricted/repetitive behavior), or at least one genetic risk factor (e.g., older sibling with ASD, Fragile X).age 12–36 months
Services are time-limited when full DSM criteria are not met.
Diagnosed ASD: Documented medical diagnosis of ASD per the latest DSM or ICD from an AEP or Grace Exception Practitioner; confirmation via AEP CDE or use of a targeted evaluation when behaviors have changed since the last CDE; ABA is needed to ameliorate symptoms, build adaptive behaviors, or reduce maladaptive behaviors to enhance health, safety, functioning, or prevent deterioration.

Stage requirements and prior authorization

Stage-based criteria and required sequence

BA is responsible for assessment, goal selection, measurement, and treatment documentation.

Family or AP may request ISP modifications prior to the six-month authorization point if immediate changes are warranted.

General medical necessity and delivery criteria

Covered when ALL of the following are met

Includes requirement to include objective baseline data and standardized assessment scores where applicable.

Clinical management and case supervision requirements are detailed in the BH policy and billing manual.

Focused vs Comprehensive ABA criteria

Service model selection logic

Dosage determined by individualized factors including ISP and ASD level.

Dosage individualized; adult ranges vary by tier (10–40 hrs/week).

Coding, Authorization Periods, and Key Intervals

Referenced ABA CPT/HCPCS codes and service codesmixed

97151	Behavioral analysis assessment
97152	Family/caregiver training (assessment related)
0362T	Targeted/Risk evaluation (as used collectively with 97151 for Stage 2)
T1026	Comprehensive Diagnostic Evaluation (CDE) / ISP references T1026 TG
T1026 TG	CDE (documented form)
T1026 TG/HI	Individual Service Plan (ISP) associated with CDE
T1026 HK	Targeted/Risk evaluation code referenced for adults
97156	Family training (Stage 3) - implemented in Treatment Plan
97157	Multiple-person family training / group

Prior authorization reauthorization interval — every 6 months

Reauthorization intervalPrior authorization for Stage 3 services must be secured and reauthorized every 6 months

Reviewer action at each intervalReviewer assesses progress with input from family and AP's BA and determines ISP or treatment plan changes if needed

Authorization period by age — up to 3 years (<8) and up to 6 years (>=8)

Authorization period (age < 8)Up to 3 years

Authorization period (age ≥ 8)Up to 6 years

Review cadence within authorization periodContinued Stage 3 services must be reviewed and reauthorized at least every 6 months

At-risk age window — 12–36 months

At‑Risk age windowMembers aged 12 to 36 months (12–36 months) are eligible for time‑limited At‑Risk services

At‑Risk assessment pathwayA Risk Evaluation of ASD must occur through an approved Autism Evaluation Provider (AEP) via a Comprehensive Diagnostic Evaluation (CDE)

At‑Risk criteria examplesDevelopmental differences/delays on standardized assessments, some ASD characteristics, or at least one genetic risk factor

Authorization, Documentation, and Provider Requirements

Prior Authorization

Prior authorization required for Stage 3; reauthorize every 6 months

Prior authorization is required for Stage 3 (ABA Treatment) services and must be obtained initially and every six (6) months within the state-defined authorization period.

Authorizations follow state timeframes: up to 3 years for members < age 8 and up to 6 years for members age 8 and older.
At each six-month authorization point the reviewer will assess need for ISP or treatment plan changes with input from the family and the AP's BA.

Prior Authorization

PA required for Stage 3 and certain Comprehensive ABA (EPSDT-aged)

Prior authorization is required for ABA Stage 3 services; for EPSDT-aged recipients, Comprehensive ABA delivered at less than 20 hours/week on average also requires prior authorization.

Prior auth requests must include evaluations, ISP, treatment plan, model, hours requested, and supervision/clinical management hours when exceeding thresholds.
Comprehensive ABA for EPSDT-aged recipients requires prior authorization if services average under 20 hours/week.

Step Therapy

Three-stage service progression (Stage 1 → Stage 2 → Stage 3)

Stage 1: AEP develops Integrated Service Plan (ISP) and referral to approved ABA provider agency.
Stage 2: AP conducts assessment to select focused or comprehensive model and completes treatment plan.
Stage 3: Stage 3 practitioners implement the treatment plan under required supervision and authorization.

Note

Adult-specific access: Stage 2 available without CDE; CDE only if medically warranted

If clinically warranted during authorization, adults may receive CDE or Targeted/Risk evaluation and a new ISP; medical necessity must be documented.
Adults transitioning from EPSDT at age 21 may continue Stage 1–3 services when an ABA Stage 3 Treatment Plan is approved.

Documentation Required

Documentation required to obtain initial and ongoing PA for Stage 3

Include the CDE or targeted evaluation and the ISP developed in Stage 1 along with the ABA treatment plan developed in Stage 2.
Specify requested treatment model (focused or comprehensive), maximum hours/week, hours of case supervision if >2 per 10 hours of intervention, hours of clinical management if >2 per 10 hours, and need for collaboration with an ABA specialty care provider.
Document hours allocated to other services in the ISP (e.g., early intervention, PT, speech) to determine feasibility of requested ABA intensity.

Billing Rule

CDE (T1026 TG) and ISP timing and deliverables

CDE must include direct observation, interviews, and relevant informants; the CDE record must be signed by the AEP.
ISP must include statements supporting that requested ABA services are expected to result in measurable improvement and must link to CDE findings.
ISP must be issued within required timelines and must indicate how other recommended services align with ABA.

Denial Risk

Denial risk: non‑covered activities and activities outside ABA scope

Non-covered activities include interventions outside the ABA treatment plan, non-ABA modalities, school activities that supplant educational services, services better described as speech/OT/PT/counseling, and staff training or certification tasks.

Prior Authorization

Prior authorization note — Stage 3 and EPSDT Comprehensive ABA

Reminder: Prior authorization is required for Stage 3 services and Comprehensive ABA for EPSDT-aged recipients averaging less than 20 hours/week requires prior authorization from the MCO/TPA.

Stage 3 PA submissions must include treatment plan, CDE/ISP, model, hours requested, and supervision/clinical management details.
EPSDT-aged recipients receiving Comprehensive ABA under 20 hours/week on average need PA.

Service Settings and Level of Care

Outpatient ABA services (stage-based with possible specialty care)

If not responding, AP must attempt internal remedies and may request new evaluations before termination.

Outpatient/Community-based ABA

Coordinated with school resources and other therapies as specified in the ISP.

Service intensity determined by individualized assessment, functional needs, and risk level.

Stage Definitions, Assessments, and Treatment Planning

ABA Stage criteria

Clinical ABA coverage is organized into three stages (Evaluation, Assessment, Treatment) with specific provider roles and documentation/authorization requirements.

AEP must be an approved autism evaluation provider.

Family Set and stakeholders included in goal selection.

AP must document hours, supervision, clinical management, and coordination with other services.

Stage 2 (Assessment and Goal Setting)

Stage 2 assessment and treatment plan requirements

Data collected serve as the primary basis for baselines, discharge goals, and response evaluation.

Data represented graphically where possible to inform modifications.

Stage 3 (Implementation, Supervision, and Settings)

Stage 3 treatment plan and delivery requirements

Must be updated prior to each Prior Authorization period and include coordination with other therapies and community resources.

Family participation strategies (including telemedicine) required if family cannot attend in-person.

Supervision and clinical management details are provided in the BH policy and billing manual.

Treatment Modalities and Delivery Options

Applied Behavior Analysis (ABA)

Telemedicine

BICC, BACB, and NM RLD psychologist board support telehealth for ABA.

Direct Treatment Intensity and Visit Ranges

Direct ABA treatment (ranges vary by Focused, Comprehensive, and adult tiers) — typical hours/week ranges

Focused ABA typical intensityGenerally 10–25 hours per week of direct treatment (may exceed 25 hrs/week for severe destructive behavior)

Comprehensive ABA typical intensityOften 30–40 hours per week of 1:1 direct treatment (not including caregiver training, supervision)

Adult tiered rangesAdult tiers range from 10–40 hours per week: Tier 1 (10–15 hrs), Tier 2 (20–30 hrs), Tier 3 (30–40 hrs)

Key Definitions

Applied Behavior Analysis (ABA) — definition of ABA

PurposeABA treatments aim to ameliorate symptoms, develop adaptive behaviors, and reduce maladaptive behaviors to enhance functioning and prevent deterioration

Delivery standardABA services must be delivered in accordance with generally accepted standards of care and recognized best practices in behavioral health treatment

At-Risk for ASD — definition and criteria

Age range12–36 months

Assessment requirementA Risk Evaluation of ASD must occur through an approved AEP via a Comprehensive Diagnostic Evaluation (CDE)

Diagnosed ASD — definition and confirmation process

Diagnostic requirementDocumented medical diagnosis of ASD per DSM or ICD from an AEP or Grace Exception Practitioner

Confirmation pathwayConfirmation of ASD must occur through an AEP via a Comprehensive Diagnostic Evaluation (CDE); a targeted evaluation may be used when behaviors have changed since the last CDE

Clinical needABA services must be needed to ameliorate symptoms, build adaptive behaviors, or reduce maladaptive behaviors to enhance health, safety, or functioning

Focused ABA — definition and typical intensity

DefinitionFocused ABA addresses a limited number of key functional skills or prioritizes treatment of risky problem behavior

Typical intensityGenerally 10–25 hours per week of direct treatment (may exceed 25 hrs/week for severe cases)

Treatment featuresIncludes direct and indirect supervision and caregiver training; may use individual or small‑group formats when increasing socially appropriate behavior

Comprehensive ABA — definition and typical intensity

DefinitionComprehensive ABA is an intensive intervention targeting multiple domains with many treatment targets across cognitive, communicative, social, emotional, and adaptive functioning

Typical intensityOften involves 30–40 hours per week of 1:1 direct treatment (excluding caregiver training and supervision)

Coding and Billing Notes

Referenced ABA CPT/HCPCS codes and service codesmixed

97151	Behavioral analysis assessment
97152	Family/caregiver training (assessment related)
0362T	Targeted/Risk evaluation (as used collectively with 97151 for Stage 2)
T1026	Comprehensive Diagnostic Evaluation (CDE) / ISP references T1026 TG
T1026 TG	CDE (documented form)
T1026 TG/HI	Individual Service Plan (ISP) associated with CDE
T1026 HK	Targeted/Risk evaluation code referenced for adults
97156	Family training (Stage 3) - implemented in Treatment Plan
97157	Multiple-person family training / group

Background and Clinical Context

Policy Summary

PayerOptum

PolicyApplied Behavior Analysis (ABA) — New Mexico Medicaid

Policy CodePolicy BH803

Change TypeNo material change

Effective DateJun 1, 2026

Last ReviewJun 1, 2026

Next Review DateJun 1, 2026

Key ActionObtain prior authorization for Stage 3 ABA services and reauthorize every 6 months with required documentation (CDE/ISP, treatment plan, model, hours, and supervision details).

SourceLink

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