Note: Texas Medicaid managed care organizations (MCOs) must provide all medically necessary, Medicaid-covered services to eligible clients. Texas Medicaid managed care organizations (MCOs) must follow all aspects of the Medicaid Autism Services benefit language as outlined in the TMPPM. Providers should contact the client's specific MCO for details.
On April 1, 2023, the Texas Medicaid & Healthcare Partnership (TMHP) will update the Texas Medicaid Provider Procedures Manual, Children’s Services Handbook, section 2.3 “Autism Services,” to clarify benefit language. These changes include:
- Subheadings added for clarity.
- Language updated to clarify several requirements of the current benefit as well as edits for readability.
- New treatment note language for procedure code 97156.
- Updated language for performing providers in a group to align with current enrollment processes for consistency.
- Minor grammatical and formatting changes for consistency and accuracy.
Comprehensive Diagnostic Evaluation
The following language under the new subheading of Comprehensive Diagnostic Evaluation will be clarified as follows:
A comprehensive diagnostic evaluation is required to diagnose autism spectrum disorder (ASD). A comprehensive diagnostic evaluation is the entire process of gathering information to determine a diagnosis, which must include a reliable, valid, and standardized diagnostic assessment tool or tools. Each element must be conducted by appropriately trained, specialized, or certified providers. Diagnosis of ASD may be made by any one of the following providers or by using an interdisciplinary team approach:
- A developmental pediatrician
- A neurologist
- A psychiatrist
- A licensed psychologist
- An interdisciplinary diagnostic team
- Members of an interdisciplinary diagnostic team administer the elements required for the diagnosis of ASD. Each provider must be licensed to use a reliable, valid, and standardized diagnostic tool or combination of tools.
- An interdisciplinary diagnostic team may consist of a physician or allowed diagnosing provider who may coordinate with providers specializing in autism for a consultation as listed under the interdisciplinary team. Providers of the interdisciplinary diagnostic team must be qualified child specialists and have expertise in autism. The prescribing provider may use the documented results of a reliable, valid, and standardized diagnostic assessment tool or combination of tools from the following disciplines:
- Any provider listed above
- A licensed social worker
- A licensed professional counselor
- A licensed professional associate
- A licensed specialist in school psychology
- An occupational therapist (OT)
- A speech-language pathologist (SLP)
The comprehensive diagnostic evaluation must include all of the following to support a diagnosis of ASD:
- The diagnostic criteria and symptom severity level according to the most current edition of the Diagnostic and Statistical Manual of Mental Health Disorders (DSM).
- A reliable, valid, and standardized diagnostic assessment tool or combination of tools, using the most current editions or versions of the tools, as age and clinically appropriate, such as the Autism Diagnostic Observation Schedule, the Autism Diagnostic Interview-Revised (ADI-R), the Childhood Autism Rating Scale, or another validated diagnostic assessment tool, as clinically appropriate. The diagnostic assessment tool must be indicated for diagnostic purposes by the publisher.
- Screening tools such as the Screening Tool for Autism in Toddlers and Young Children (STAT) or the Modified Checklist for Autism in Toddlers (M-CHAT-R) may not replace the use of the validated diagnostic assessment tool.
The documentation of the diagnosis must include the following:
- Age of the child or youth
- Date of the initial ASD diagnosis
- Documentation of any known comorbid behavioral or physical health disorders
- Documentation of trauma history
To be eligible for applied behavior analysis (ABA) services outlined in this section, a diagnosis of ASD that includes the diagnostic criteria and symptom severity level from the current DSM must be made or reconfirmed within three years of initiation or recertification of the ABA services.
To be eligible for ABA services outlined in this section more than three years after the initial ASD comprehensive diagnosis, a comprehensive reevaluation of the ASD symptom severity level that meets the DSM criteria must be made by qualifying diagnostic providers.
A reevaluation must include the same components as an initial comprehensive diagnostic evaluation.
Behavior Technicians (BTs)
The following language under the Behavior Technicians (BTs) subheading will be clarified:
BTs may not use the term “therapist” or be referred to as a therapist in their job title when interacting with Medicaid-enrolled children or youth, families, or caregivers or with professionals who also serve the child or youth, such as school staff or physicians.
Documentation Required for Authorization of an ABA Initial Evaluation
The following language under the related subheading for the referral for ABA services will be clarified:
A diagnosis or reevaluation of ASD diagnosis must have been made within the past three years, including the diagnostic criteria and symptom severity level per DSM criteria. A reliable, valid, standardized diagnostic tool or combination of tools must have been a part of the initial evaluation or reevaluation.
A signed and dated referral may originate from the diagnosing provider, who is a physician or allowed practitioner.
Note: An allowed practitioner is an individual licensed in Texas as a physician assistant, a certified nurse practitioner, or a clinical nurse specialist.
Documentation Required for Authorization of Initiation of Treatment with ABA
The following language under the related subheading for required ABA assessment documentation will be clarified:
Document whether the child or youth has a previous history of ABA. When prior history exists, include how long the child or youth has been receiving ABA services (include any gaps in treatment) and their responses to previous interventions.
The following language related to individualized ABA treatment plan criteria will also be clarified:
The formal design of the treatment plan must be followed by all ABA service providers, including the supervised licensed assistant behavior analysts (LaBAs) and/or BTs.
Attendance Log and Progress Summary
The following language related to Attendance Log and Progress Summary will be clarified:
All attendance log documentation must be submitted to the child or youth’s health plan if they are in managed care or TMHP if they are in fee-for-service.
In cases where the child or youth or the parent or caregiver has not met the 85% attendance expectation, the ABA provider must submit justification to continue services at the previously approved frequency to the child or youth’s health plan for physician review.
Documentation Required for Recertification for Treatment of ABA
The following language related to documentation requirements for a request for recertification of ABA treatment will be clarified:
Documentation of the comprehensive ASD diagnosis within the three years prior to the date of the ABA reevaluation.
More specific language for documentation requirements for procedure code 97156 will be added.
For procedure code 97156 (parent or caregiver training and guidance, with or without the child or youth present), the following documentation in the treatment note must be kept on file by the treating provider and available on request:
- The child or youth’s name
- The date of service
- The start and stop time of each parent or caregiver education session
- The treatment plan goals addressed and progress noted, if applicable
- A summary of the parent or caregiver training covered during the session
- The rendering ABA providers must sign each entry with a full signature and credentials.
Change of Provider
The following language related to performing providers in a group will be updated:
When a child or youth transfers to a new performing provider within the same group, the new provider must use the same evaluation and plan of care.
The authorization period will not change when the provider changes in this situation.
ABA Initial Evaluation
Evaluation will replace assessment and reevaluation will replace reconfirmation in the following sentence:
Documentation of comprehensive diagnostic assessment or reconfirmation of diagnosis for ASD signed and dated by the diagnosing physician, dated within three years prior to the date that the prior authorization request for ABA initial evaluation is received.
Telehealth Service Delivery
A section header for telehealth service delivery will be added for readability, and the following sentence will be clarified: ABA evaluation and treatment services may only be delivered via telehealth using synchronous audio-visual technology.
The following note will be updated to refer to the Telecommunications Handbook:
Note: Refer to: The Telecommunication Services Handbook (Vol. 2, Provider Handbooks) for more information about telehealth documentation requirements including requirements for informed consent.
For more information, call the TMHP Contact Center at 800-925-9126.