DraftOptumPolicy BH803TX082025

Texas Medicaid: Autism Services (State‑Specific Supplemental Clinical Criteria)

State-specific supplemental clinical criteria governing Medicaid-covered autism services, including Applied Behavior Analysis (ABA), for Texas children and youth (age ≤20) and requirements for prior authorization and documentation.

Policy Summary

PayerOptum

PolicyTexas Medicaid: Autism Services (ABA)

Policy CodePolicy BH803TX082025

Change TypeNo material changes

Effective DateAug 19, 2025

Next Review DateN/A

Key ActionSubmit completed CCP Prior Authorization Request form with required documentation and obtain prior authorization for ABA treatment or re-evaluation as specified.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

20Max eligible age

90 daysInitial auth period

180 daysRecert increment

85%Attendance threshold

2497151 max units

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Medical necessity for ABA services

Covered when ALL of the following are met

Age: Member is a child or youth 20 years old or younger<= 20 years

Diagnosis of ASD documented with DSM criteria and symptom severity level

Diagnosis may be made by qualified providers or interdisciplinary diagnostic team using validated diagnostic assessment tools

Diagnostic assessment tool: Use of a reliable, valid, standardized diagnostic assessment tool (e.g., ADOS, ADI-R, CARS) appropriate to age and indication

Screening tools (e.g., M-CHAT-R, STAT) may not replace diagnostic tools

Medical necessity: ABA services must be medically necessary to treat, correct, or ameliorate the individual's condition; diagnosis alone is insufficient

Documentation must align with an individualized, person-centered treatment plan

Medical necessity criteria for ABA initiation and intensity

Covered when ALL of the following are met

Diagnosis and referral: Child or youth must have ASD diagnosis; referral signed and dated by a prescribing provider; diagnosis or re-evaluation within past 3 years with standardized diagnostic tool(s)diagnosis within 3 years

Supported by initial evaluation and referral requirements

Comprehensive assessment elements: ABA evaluation must include developmental history, co-morbidities, observations (including natural settings), caregiver interviews, family history, validated cognitive/adaptive assessments, and a functional behavior assessment (FBA) if indicated; baseline data for targeted behaviors requiredN/A

Individualized treatment plan: Treatment plan must identify specific functional behaviors/skills, measurable goals tied to DSM core ASD symptoms, baseline data, planned frequency and duration, parent/caregiver training goals, Behavior Support Plan (BSP) if appropriate, discharge criteria and transition plan

Recertification and re-evaluation criteria

Criteria for extension, recertification, and re-evaluation

90-day extension: Extension requires submission of attendance logs (child and parent/caregiver) with percent of authorized sessions completed and a progress summary signed by the LBAAttendance logs submitted after first 90 days

Progress summary must be billed as 97155 and signed by LBA

180-day recertification: Recertification requires ABA re-evaluation and treatment plan signed by LBA, attendance logs with percent completed for child and parent/caregiver, documentation of ASD diagnosis within prior 3 years, and a CCP Prior Authorization Request signed by a prescribing provider within 60 days prior to recertification start dateRe-evaluation within 60 days of current authorization end for recertification

Recertifications may be approved in up to 180-day increments; late submissions may require new re-evaluation

Re-evaluation currency:

Discharge criteria

Discharge conditions — discontinue authorization when ANY of the following apply

Discharge criteria: Met treatment goals; lack of clinically significant progress after successive reviews and modifications; gains not generalizable or durable; inability to participate due to medical, family, or other factors; parent or caregiver elects to discontinue; attendance falls below 85% of authorized sessions without documentation supporting continued medical necessity; or providers fail to collect/track/review progress or make appropriate treatment modificationsAttendance <85%

When attendance is <85%, provider must submit justification for physician review to continue prior levels of service

Covered ABA service codes and use

Covered ABA services and intended use

ABA service definitions: 97151 for LBA initial evaluations, re-evaluations, and treatment plans (authorized up to 24 units/6 hours); 97153 for direct one-on-one ABA delivered by behavior technician (BT); 97155 for LBA (or delegated LaBA) protocol development, modification, and direct supervision; 97154 for direct group ABA by BT; 97158 for LBA (or delegated LaBA) group protocol modification; 97156 for parent/caregiver training by LBA or delegated LaBA

Providers may request total hours of direct individual or group treatment for the authorization period using the appropriate codes; 97151 must be used within 30 days of first date of service for that code

Physical restraint is not appropriate during any ABA service except in emergency instances where there is an imminent threat of physical harm to the child or others. Restraint may only be implemented by staff trained in the specific type of restraint, must be limited to the reasonable force necessary to address the emergency, and must be discontinued once the emergency has resolved. Restraint must protect the health and safety of the child and others and must not deprive the child of basic human necessities. Documentation must be maintained of up-to-date staff training and of each incident that resulted in restraint.

Goals that are broadly framed as general activities of daily living (ADL) skill acquisition are excluded from coverage. While ABA may target specific ADL-related deficits when they are functional, measurable, and directly tied to the child’s health, safety, or independence, general ADL goal statements without that functional linkage do not meet the policy’s coverage criteria.

ABA services that are solely focused on academic objectives or on performative social norms that do not materially affect the child’s health, safety, or independence are excluded. Treatment plans must target functional behaviors in real-world contexts; goals limited to academic performance or to socially normative behaviors without clear clinical necessity are not a covered benefit.

Licensed Behavior Analysts (LBAs) and their supervised staff must coordinate with other licensed professionals for conditions outside the scope of ABA. LBAs are not permitted to treat underlying medical conditions as the sole provider, may not serve as the sole provider for feeding treatment plans, and must collaborate with medical, nutritional, or therapy specialists (e.g., physicians, dietitians, OT, SLP) when those conditions or goals are present. LBAs must not dictate or require discontinuation of other medically necessary treatments as a condition of ABA services.

Services that do not meet accepted standards of practice for effective ASD treatment or that are not expected to produce functional improvement are not medically necessary. This includes interventions that are experimental or investigational, services that do not require LBA-level judgment and supervision, BT-delivered ‘‘shadow’’ or general support in school settings, and services provided by or directly by a child’s responsible adult or by agencies owned by that adult. Equipment and supplies used during ABA are considered part of the service and are not separately reimbursable.

Coding and Billing Guidelines

Covered CPT Codes for ABA servicesCPTCovered

97151	ABA evaluation (re-evaluation)
97153	Adaptive behavior treatment by protocol
97154	Group adaptive behavior treatment by protocol
97155	Adaptive behavior treatment with protocol modification
97156	Family adaptive behavior treatment
97158	Group adaptive behavior treatment with protocol modification

Evaluation/Re-evaluation CPT CodesCPTCovered

97151

Initial ABA evaluation / re-evaluation

ABA treatment CPT CodesCPTCovered

97153	Adaptive behavior treatment by protocol — one-on-one
97154	Group adaptive behavior treatment by protocol
97155	Adaptive behavior treatment with protocol modification, each 15 minutes (includes direct supervision billing)
97156	Family adaptive behavior treatment guidance, per 15 minutes
97158	Group adaptive behavior treatment with protocol modification, each 15 minutes

Covered CPT Codes (ABA-related)CPTCovered

97151	Initial/re-evaluation and treatment plan (LBA)
97153	Direct one-on-one ABA treatment (BT)
97155	Individual treatment with protocol modification (LBA/LaBA)
97154	Direct group ABA treatment (BT)
97158	Group treatment with protocol modification (LBA/LaBA)
97156	Parent or caregiver training and guidance
99366	Interdisciplinary team meeting by qualified non-physician providers

Modifiers for telehealthModifier

95	Telehealth modifier (synchronous audiovisual)

Provider role modifiersModifier

HO	Licensed behavior analyst modifier
HN	Licensed assistant behavior analyst modifier
HM	Behavior technician modifier

Evaluation currency window

Evaluation currency windowEvaluation or re-evaluation is considered current when performed within 60 days prior to the start of care date or within 60 days before the end of the current authorization period.

Authorization validity for initial evaluationAuthorization for the initial ABA evaluation (97151) is valid for 60 days from the requested evaluation date.

Timing for re-evaluation submissionsA re-evaluation may occur as early as 60 days prior to the end of the current authorization period and is current if performed within 60 days before that end date.

Attendance threshold

Attendance threshold for continued authorization>= 85% attendance required for the child or youth and for parent/caregiver participation (attendance logs must include calculation of percent attended).

Documentation when attendance below thresholdIf attendance falls below 85% without supporting documentation, continuation at previously approved frequency requires physician review and may be denied.

Use in extensions/recertificationAttendance logs with percentage attended are required for 90-day extensions and 180-day recertifications.

15-minute billing rounding

15-minute billing rounding ruleConvert total daily billable minutes to units by dividing by 15; partial units of 7 minutes or fewer = 0 units; partial units >7 minutes round up to 1 unit.

Daily aggregation methodCount total billable minutes for the calendar day for the client, then divide by 15 to compute billable units of service.

Example providedExample: 68 total billable minutes/15 = 4 units + 8 minutes; 8 minutes >7 so converted to 1 unit; total = 5 units of service.

97151 authorization limit

97151 authorization limitProcedure code 97151 will be authorized for up to 24 units (six hours) for initial evaluations and for re-evaluations on subsequent authorizations.

Timeframe for use97151 must be used within 30 calendar days of the first date of service for that code and is not reimbursable unless the evaluation was submitted for authorization.

Re-evaluation frequency97151 is intended for initial evaluations and re-evaluations by the LBA once every 180 days (and authorized up to 24 units each authorization).

Daily direct treatment cap

Daily direct treatment capDirect treatment for the child or youth is limited to a total of 8 hours per day, inclusive of procedure codes 97153, 97154, 97155, and 97158.

Applies to individual and group codesThe 8-hour per day cap applies across direct individual (97153, 97155) and group (97154, 97158) ABA treatment codes.

Exceptions for clinical needFor clients 20 years old and younger, limitations may be exceeded with evidence of medical necessity.

Provider Responsibilities, Authorization, and Documentation

Prior Authorization

Prior Authorization Required

Prior authorization is required for an ABA initial evaluation (procedure code 97151), an initial course of ABA treatment, and subsequent recertifications for treatment (procedure codes 97153, 97154, 97155, 97156, 97158). Re-evaluations (97151) for recertification require authorization. Requests may be submitted via mail, fax, or electronic portal; electronic signatures must comply with applicable federal and state statutes and include an electronic date on the same page as the signature. All authorization requests must include the completed CCP Prior Authorization Request form and submitter certification.

Affected codes: 97151, 97153, 97154, 97155, 97156, 97158
Submission channels: TMHP Prior Authorization Department via mail, fax, or electronic portal
Electronic signature requirements: date on same page; certification of compliance

Denial Risk

Late Signature Denies Prior Dates

When the CCP Prior Authorization Request Form (or other required authorization documentation) is signed and dated after the requested evaluation date, dates of service prior to the prescribing provider's signature date will be denied. Similarly, when a PA request is submitted after the requested evaluation date, dates of service prior to the received date may be denied.

Prescribing provider signature must be within 60 days prior to or on the anticipated evaluation date for initial evaluation PA requests
Authorization for initial ABA evaluation (97151) is valid for 60 days from the requested evaluation date

Denial Risk

Late Recertification Denial Risk

Recertification requests submitted after the current authorization end date are denied for all dates of service prior to the date the request is received (for 90-day extensions and for 180-day recertification requests). A 90-day recertification is timely when submitted within 30 days prior to the end of the current authorization period; a 180-day recertification request must be received no earlier than 60 days before the current authorization period expires. Gaps in service of 180 days or more require submission as an initial request with full initial documentation.

90-day recertification: submit within 30 days before current authorization end date
180-day recertification: complete request no earlier than 60 days before expiration
Requests after authorization end date are denied for prior dates; gaps >=180 days treated as initial requests

Documentation Required

Required Documentation for Initial Authorization

Initial authorization requests must include comprehensive diagnostic documentation and specific referral elements. For an ABA initial evaluation authorization, submit a completed CCP Prior Authorization Request Form signed and dated by a prescribing provider within 60 days prior to or on the anticipated evaluation date, and documentation of a comprehensive diagnostic assessment or reconfirmation of ASD diagnosis signed and dated by the diagnosing physician dated within 3 years prior to the PA request receipt.

Referral must include age and year of initial ASD diagnosis, co-morbid conditions, DSM symptom severity, and standardized diagnostic assessment documentation within 3 years
CCP Prior Authorization Request Form must be signed by the prescribing provider within 60 days prior to or on the requested evaluation date
Initial 97151 authorization valid for 60 days from requested evaluation date

Documentation Required

Re-evaluation and Recertification Documentation

Re-evaluation and recertification requests must include a current ABA re-evaluation and updated treatment plan (signed and dated by the LBA), baseline/current/interim data across settings, attendance logs and progress summaries as applicable, and a completed CCP Prior Authorization Request Form signed by the prescribing provider within required timeframes. Re-evaluations are considered current when performed within 60 days prior to the end of the authorization period; re-evaluation documentation will be reviewed upon submission for authorization.

ABA re-evaluation components: updated BSP if applicable; baseline, current, and interim data demonstrating progress across at least two settings; standardized assessment results; discharge/fading plan
Attendance logs must calculate % of authorized sessions attended by child and by parent/caregiver; attendance <85% requires additional justification
Progress summary (97155) must be submitted after first 90 days and signed by LBA; recertification requests submitted >60 and <=180 days after evaluation require progress summary; >180 days require a new re-evaluation

Service Setting and Level-of-Care Criteria

Applied Behavior Analysis (ABA) services / outpatient

Interdisciplinary team meeting participation: Interdisciplinary team meetings are encouraged; the LBA is required to participate; to bill 99366, each participating licensed provider must have provided direct services to the child or youth within the prior 180 days and the meeting must include at least two other licensed professionals plus the parent/caregiverProviders must have provided direct services within prior 180 days

Team members may attend remotely with telehealth modifier as appropriate

Continued stay criteria: Continued authorization requires attendance logs showing percentage of authorized sessions attended and progress summaries signed by LBA and parent/caregiver; gaps of 180 days or more require initial request documentation

Attendance and documented progress drive continued authorization

Outpatient / Community-based ABA

High frequency admission: High frequency (IBI) admission may be considered when two or more criteria are met, such as age ≤6, Autism Severity Level 2 or 3, goals related to severe elopement/aggression/self-injury, or within first 2 years initiating ABA>20 hrs/week

Documentation must show the specified criteria

Continued stay: Continued authorization depends on documented progress, attendance ≥85% (or justification for lower attendance), updated re-evaluations and progress summaries, and physician review if attendance criteria not met>=85% attendance expected

Recertification requires re-evaluation within 60 days of authorization end

Outpatient / ABA services

Authorization for services: 97151 must be submitted and authorized for evaluation and initial plan prior to reimbursement; 97151 is authorized up to 24 units (6 hours) for initial and re-evaluations and must be used within 30 calendar days of first date of service for that code24 units (6 hours)

Direct treatment is limited to 8 hours per day across 97153/97154/97155/97158

Ongoing authorization and limits: Providers may request total hours of direct individual or group treatment for the authorization period using 97153/97155 (individual) or 97154/97158 (group); direct treatment limited to 8 hours per day; re-evaluations via 97151 authorized up to 24 units every authorization8 hours/day

Requests exceeding guideline frequency/duration sent for physician review

ABA Authorization and Clinical Expectations

ABA authorization criteria

Authorization and timing requirements for ABA evaluation, initiation, and recertification

Initial evaluation authorization: Submit comprehensive diagnostic assessment (signed and dated by prescribing/diagnosing provider within 3 years where required) and a completed CCP Prior Authorization Request form signed by the prescribing provider within 60 days prior to the requested evaluation or start datePA valid for 60 days from requested evaluation date

Requests signed after evaluation date will have prior dates denied

Initial 90-day treatment authorization: Submit completed ABA evaluation and treatment plan signed by LBA and CCP Prior Authorization Request signed by the prescribing provider within 60 days prior to start date; providers may be authorized for up to 90 days for 97153/97154/97155/97156/97158; providers must obtain authorization within 3 business days of start of care if not prior authorizedUp to 90 days

Late submissions beyond specified windows require additional documentation or re-evaluation

90-day extension and 180-day recertification: For 90-day extension submit attendance logs and progress summary signed by LBA; for 180-day recertification submit attendance logs and current ABA re-evaluation within 60 days before prior authorization end date and CCP form signed by prescribing provider within 60 days prior to recertification start dateExtensions up to 90 days; recertification up to 180 days

Requests submitted after current authorization end date are denied for prior dates

ABA clinical expectations

ABA-specific clinical expectations

Parent/caregiver involvement: Active parent or caregiver participation is expected; participation must be documented and influences continued authorization; exceptions considered case-by-caseN/A

Parent training (97156) is a separate component and the child need not be present

Treatment planning and scope: LBA must collaborate with prescribing provider for elements outside LBA scope; treatment goals must be functional, measurable, tied to DSM core symptoms, include baseline data, BSP if appropriate, and must not include aversive interventionsN/A

Goals relating to ADLs that are generic are excluded; plans must include discharge criteria and generalization plans

ABA clinical and documentation criteria

Operational and clinical expectations for ABA delivery

Documentation and supervision: LBAs must maintain documented treatment plans with measurable functional goals, use standardized assessment tools, document baseline/current/interim data across settings, record direct observation data each session, sign entries, and ensure access to sufficient staff to deliver authorized frequency/duration/places of service; LaBAs and RBTs may not deliver telehealth; LBAs may delegate tasks but must provide appropriate supervision

All services are subject to retrospective review; documentation must be retained though not always submitted with PA

Visit Limits and Authorization Periods

ABA procedure codes authorization period limits

Authorization period limits (codes 97153/97154/97155/97156/97158)Providers may be authorized for units of these procedure codes for up to 90 days for initial requests and up to 180 days for recertification periods, per the authorization request.

Initial authorizationInitial requests for ABA direct service codes may be authorized for up to 90 days from the requested start date.

Recertification authorizationRecertification requests for these codes may be authorized in increments up to 180 days following initial authorization periods.

Documentation requirements tied to periodExtensions and recertifications require attendance logs, progress summaries, and current re-evaluations as specified by the policy.

ABA direct services vary by intensity category

Intensity-based authorizationUnits for direct ABA services (97153, 97154, 97155) vary by intensity category (Maintenance, Targeted, Moderate, High) with frequency/duration determined by age, DSM severity, target behaviors, and time since initiating ABA.

High intensity (IBI)High frequency (greater than 20 hours/week) may be considered when documentation shows two or more specified criteria (e.g., age <=6, Severity Level 2 or 3, severe elopement/aggression/self-injury, within first 2 years of initiating ABA).

Moderate/Targeted/MaintenanceModerate (6–20 hrs/week), Targeted (up to 5 hrs/week or 20 hrs/month), and Maintenance (2–4 hrs/week or less) categories have specified eligibility criteria and documentation expectations.

Direct ABA treatment daily cap

Daily cap for direct ABA treatment codesDirect ABA treatment codes (97153, 97154, 97155, 97158) are limited to a maximum of 8 hours per calendar day in total.

Counting and billing considerationsWhen billing timed procedure codes, aggregate daily billable minutes and convert to 15-minute units using the policy rounding rules; the 8-hour cap applies to billed units across codes.

Medical necessity exceptionsLimitations may be exceeded with documented evidence of medical necessity for clients 20 years old and younger.

97151 authorization details

97151 units per authorizationProcedure code 97151 is authorized for up to 24 units (six hours) per authorization for initial evaluations and for re-evaluations on subsequent authorizations.

Use timing requirement97151 must be used within 30 calendar days of the first date of service for that code and is reimbursable only if the evaluation was submitted for authorization of payment.

Authorized for report and plan developmentThe 24-unit authorization includes time to complete initial ABA evaluation, develop the treatment plan, data analysis, and report writing as specified by the policy.

Definitions and Key Terms

Applied Behavior Analysis (ABA) definition and LBA role

Applied Behavior Analysis (ABA)The application of evidence-based behavior-analytic principles by a trained provider (e.g., Licensed Behavior Analyst) to produce meaningful, durable, generalized changes in socially significant behaviors; Intensive Behavioral Intervention (IBI) denotes high-intensity ABA.

Licensed Behavior Analyst (LBA) roleLBAs conduct initial evaluations and re-evaluations (97151), develop treatment plans, may delegate parent training to licensed assistant behavior analysts (LaBAs), and must ensure supervision and documentation standards are met.

Scope and intentABA focuses on treating behavior difficulties and shaping behavior patterns through environmental adaptations and consistent reinforcement across settings to achieve durable, generalized outcomes.

Eligibility age

Eligibility age for autism servicesAutism services under the Texas Health Steps-Comprehensive Care Program are a benefit for Medicaid children and youth 20 years old and younger (age <= 20 years).

Age referenced in intensity criteriaIntensity categories reference age thresholds (e.g., high frequency often considered for age <=6; moderate for <=12), but overall eligibility remains <=20 years.

Exceptions for medical necessityFor clients 20 years old and younger, limitations may be exceeded with evidence of medical necessity.

Intensity categories

Intensity categories definedHigh (IBI) >20 hrs/week; Moderate 6–20 hrs/week; Targeted/focused up to 5 hrs/week or 20 hrs/month; Maintenance/consultative 2–4 hrs/week or less.

Eligibility criteria per categoryEach category requires documentation showing specified criteria (age, DSM severity level, target behaviors severity, time since initiating ABA) to justify the requested intensity.

Review of requests exceeding guidelinesTreatment plans requesting frequency above these guidelines are sent for physician review to determine medical necessity.

Key procedure code summaries

97151 (LBA evaluation/re-evaluation and treatment plan)Used for initial evaluations, re-evaluations, and treatment plan development; authorized up to 24 units (6 hours) per authorization and intended once every 180 days for re-evaluation.

97153 (Direct one-on-one ABA by BT)Direct individual ABA treatment delivered by a behavior technician as defined by the ABA treatment plan; may be used to request total individual treatment hours for authorization period.

97155 (Adaptive behavior treatment with protocol modification)Used by LBA (or delegated LaBA) for direct one-on-one time to develop/modify protocol and to directly supervise BT/LaBA; may be billed for supervision and protocol changes.

97154 and 97158 (Group ABA services)97154: BT-delivered direct group ABA; 97158: LBA (or delegated LaBA) group protocol development/modification; groups include 2–8 children and either code may be used to request total group hours for authorization.

97156 (Parent/caregiver training)Used by LBA (or delegated LaBA) to guide parents or caregivers to implement ABA protocols; considered a separate component of the treatment plan and does not always require the child to be present.

Policy Revision History

2025-08-19Policy effective date / annual reviewLatest

Policy effective date set to August 19, 2025; annual review completed with minor language updates to align with the Texas Medicaid Provider Services Manual and no changes to clinical coverage criteria

2025-05-20Revision

Health Plan and Optum approved revisions to Timelines and Required Items and ABA 90-Day Treatment Extension sections

2025-03-18Revision

Health Plan and Optum approved revision per Texas Medicaid Provider Services Manual removing CCP form requirement for ABA 90-day treatment extension effective April 1, 2025

2025-01-21Revision

Health plan approved revisions per Texas Medicaid Provider Services Manual with minor language updates to align with TX provider manual; no changes to coverage criteria

2024-12-17Optum approval

Optum approval recorded December 17, 2024 related to the January 21, 2025 health plan approval process

2024-06-11Revision

Policy updated (Version 3) on June 11, 2024

2023-06-13Revision

Policy updated (Version 2) on June 13, 2023

2022-02-22Revision

Policy revised with TMHP updates on February 22, 2022 (Version 1-Revised)

2022-02-01Revision

Initial policy version published February 1, 2022 (Version 1)

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