Operations · Stage 4 · Benefits + intakePrintable checklist

Eligibility and benefits checklist

What to confirm before a family's first session, and again whenever their plan changes. This sheet has no spaces for names or member IDs on purpose: record answers in your EHR or another secure system.

Checked November 2, 2026 · Billing4ABA · Billing built only for ABA.

Use it as the script for the verification call. Tick each line once you have the answer and a reference number.

The rhythm we set up

  • 7 days before the first session: run eligibility and benefits.Our process target. It leaves time to request authorization at least 3 days ahead.
  • At least 3 days before the session: authorization requested, or confirmed in writing as not required.
  • Re-check at every plan-year change, and whenever a family mentions a new job, plan or address.

Member and policy

  • Subscriber and member details match the card exactly.
  • Member's relationship to the subscriber.
  • Group number and the plan name printed on the card.
  • Front and back of the card saved in your secure system.

Active coverage on the date of service

  • Coverage is active on the planned session dates, not only today.
  • Any termination date on file.
  • When the plan year starts, so you know when deductibles reset.

Exact plan, network and who administers ABA

  • Exact plan and product (for example HMO, PPO, Medicaid managed care plan, TRICARE).
  • Your network status for that exact product, not just the payer name.
  • Who administers ABA benefits.Some plans use a separate behavioral health company. Verify with them, not the medical line.
  • Texas Medicaid: which managed care plan the member is in, and that you are contracted with it.

Texas commercial plan questions

  • Is it an employer group plan or an individual plan? Fully insured or self-funded?The Texas mandate is written for fully insured group plans. Self-funded employer plans are not bound by state mandates.
  • Was the autism diagnosis made before the child's 10th birthday?For fully insured group plans, Tex. Ins. Code §1355.015 applies then. Those plans may limit ABA to $36,000 a year for enrollees age 10 and older.

Authorization requirements

  • Is prior authorization required for the assessment, and separately for treatment?
  • Who submits it, how (portal or fax), what documents, and the usual turnaround.
  • Any yearly limits on hours, units or visits.
  • Texas Medicaid: prior authorization for all ABA services, requested within 3 business days of the start-of-care date.

Cost share

  • Deductible: amount and how much is met.
  • Copay or coinsurance, and whether it applies per day, per session or per code.
  • Out-of-pocket maximum and how much is met.
  • Family told their estimated share in writing before the first session.

Coordination of benefits

  • Any other coverage? Ask the payer which plan is primary. Do not assume.
  • If Medicaid is one of the plans, confirm the order of payment with both payers.

Write it down

  • Reference number, representative's name, date and time of the call.
  • Who checked, and the date they checked.

Sources

  1. [1]Tex. Ins. Code §1355.015
  2. [2]TMHP news, Feb 2025: prior authorization update for autism services (effective Apr 1, 2025)
  3. [3]TMPPM Children's Services Handbook, §2.3 (TMHP)

Checked November 2, 2026. Payer rules change; confirm with the payer and the cited source before acting.

Billing4ABA is a billing service, not legal counsel. Payer rules change; confirm with the payer before acting.

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