BCBS in Texas, Illinois and Oklahoma Pays One BCBA per Day and Moved ABA to MCG

HCSC retired its own ABA medical policy on December 31 and switched to MCG criteria. Its revised ABA billing policy, in effect since March 20, adds a same-day limit on analysts and keeps an eight-hour assessment ceiling.

Health Care Service Corporation, which runs Blue Cross and Blue Shield in Texas, Illinois, Oklahoma and New Mexico, made two changes to ABA this year. It retired its own ABA medical policy, PSY301.021, on December 31, 2025. From January 1, 2026, medical necessity is “moving to MCG Criteria,” under medical policy ADM1001.036. And its revised ABA billing policy, CPCP011 version 1.0, took effect on March 20, 2026, in all four states.

The turn: one new sentence that can deny a claim

Most of CPCP011 carries over from the 2024 version. Compared line by line, three things changed:

  • New: ABA is “not reimbursable for more than one Board Certified Behavior Analyst (BCBA) or qualified healthcare professional providing same/similar services on the same dates of service.” Technicians working alongside the BCBA aren't counted.
  • New: 97156 is “not to be used for training staff of another facility.”
  • Removed: the old line that 97151 “cannot be reported concurrently with other codes.”

The first one catches ordinary operations: a clinical director and a case BCBA who both bill 97155 for one client on one day, or a handoff day between two analysts.

What carried over

  • Assessments over eight hours (32 units of 97151) “may not be eligible for reimbursement.”
  • Parent training: 26 hours per typical 26-week authorization. More than one hour a week needs supporting documentation.
  • Direct supervision: at least one hour a week when fewer than 10 direct hours are authorized. Indirect supervision is never separately paid.
  • Exactly one modifier, HM, HN or HO, on every 97153.
  • Any place of service other than 10, 11 or 12 needs a documented rationale.
  • A parent or caregiver signature for every session, with code, rendering provider and credentials, place of service, date, and start and end times.

The limits

MCG criteria are licensed, so HCSC's new medical-necessity standard isn't public the way PSY301.021 was. CPCP011 says plan documents and provider contracts govern where they conflict with it. We covered HCSC's prior-authorization call process in August. This is a separate policy.

What you must know or do

  • Billers: query BCBS claims since March 20 for any date where two different BCBAs billed 97151, 97155 or 97156 for the same member. Check those against your denials.
  • Billers: confirm every 97153 line carries exactly one of HM, HN or HO.
  • Clinical directors: if two analysts must see a client the same day, document why the services differ, or schedule so they don't overlap.
  • Operations: audit ten recent BCBS session notes for the caregiver signature and the six fields above.
  • When a BCBS request is denied, ask which MCG guideline was applied. You'll need it to appeal.