Texas Medicaid: Autism Services (State‑Specific Supplemental Clinical Criteria)
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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.
No material clinical or coverage changes in this revision.
Coverage Criteria for Autism (ABA) Services
Medical necessity for ABA services
Covered when ALL of the following are met
Diagnosis may be made by qualified providers or interdisciplinary diagnostic team using validated diagnostic assessment tools
Screening tools (e.g., M-CHAT-R, STAT) may not replace diagnostic tools
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
Supported by initial evaluation and referral requirements
Goals must be objectively measurable and time-limited
LaBAs and BTs may not enroll in Medicaid; LBA collaboration required for out-of-scope elements
Requests exceeding guideline levels are sent for physician review
Recertification and re-evaluation criteria
Criteria for extension, recertification, and re-evaluation
Progress summary must be billed as 97155 and signed by LBA
Recertifications may be approved in up to 180-day increments; late submissions may require new re-evaluation
97151 re-evaluations are reviewed for authorization upon submission; 97151 authorized up to 24 units
Discharge criteria
Discharge conditions — discontinue authorization when ANY of the following apply
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
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
| 97151 | Initial ABA evaluation / re-evaluation |
| 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 |
| 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 |
| 95 | Telehealth modifier (synchronous audiovisual) |
| HO | Licensed behavior analyst modifier |
| HN | Licensed assistant behavior analyst modifier |
| HM | Behavior technician modifier |
Provider Responsibilities, Authorization, and Documentation
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.
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
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
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
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
Team members may attend remotely with telehealth modifier as appropriate
Attendance and documented progress drive continued authorization
Outpatient / Community-based ABA
Documentation must show the specified criteria
Recertification requires re-evaluation within 60 days of authorization end
Outpatient / ABA services
Direct treatment is limited to 8 hours per day across 97153/97154/97155/97158
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
Requests signed after evaluation date will have prior dates denied
Late submissions beyond specified windows require additional documentation or re-evaluation
Requests submitted after current authorization end date are denied for prior dates
ABA clinical expectations
ABA-specific clinical expectations
Parent training (97156) is a separate component and the child need not be present
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
All services are subject to retrospective review; documentation must be retained though not always submitted with PA
Treatment Modalities and Service Types
ABA / IBI
Collaboration with other disciplines is encouraged or required in some circumstances
Family/Caregiver Training
Participation by parent/caregiver is expected and influences continued authorization; attendance for caregiver sessions is included in attendance calculations
Telehealth
LBA must ensure telehealth is clinically appropriate and within scope of practice; reimbursable telehealth services require synchronous audiovisual interaction
Visit Limits and Authorization Periods
Background and Context
Autism Spectrum Disorder (ASD) is characterized by deficits in social communication and interaction and by restricted, repetitive patterns of behavior with onset in early childhood. Texas Medicaid covers medically necessary, evidence-based services for children and youth up to 20 years of age; Applied Behavior Analysis (ABA) is an evidence-based discipline intended to produce durable, generalized improvements in socially significant behaviors across everyday settings. ABA is delivered by licensed behavior analysts and supervised teams to target functional goals tied to health, safety, or independence and does not replace other medically necessary therapies.
Definitions and Key Terms
Policy Revision History
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
Health Plan and Optum approved revisions to Timelines and Required Items and ABA 90-Day Treatment Extension sections
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
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
Optum approval recorded December 17, 2024 related to the January 21, 2025 health plan approval process
Policy updated (Version 3) on June 11, 2024
Policy updated (Version 2) on June 13, 2023
Policy revised with TMHP updates on February 22, 2022 (Version 1-Revised)
Initial policy version published February 1, 2022 (Version 1)
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