BlueCare Won't Approve an ABA Assessment Until Less Intensive Care Falls Short

BlueCare's Medicaid guideline requires evidence that less intensive treatment wasn't enough, and a severity assessment from the last six months, before it approves 97151. BlueCross's commercial version has no such rule. All three TennCare plans share one rulebook for everything after.

BlueCross BlueShield of Tennessee reviewed its guideline Evaluation / Assessment for Applied Behavior Analysis – For BlueCare Use Only on June 18, 2026. It lists what “ALL” must be true before BlueCare, its TennCare plan, approves an ABA assessment. One criterion is easy to miss: “Less intensive behavior therapy or medical treatment has not been sufficient to reduce interfering behavior, to increase pro-social behavior or to maintain desired behaviors.”

The footnote makes it a gate for everything after it: “The assessment is required prior to receiving ABA Therapy.”

The turn: the Medicaid rule is stricter than the commercial one

BlueCross's commercial version of the same guideline, reviewed the same day, has no fail-first clause. It requires “severe challenging behavior(s)” instead, and caps the evaluation at 15 hours within 30 days. The BlueCare version is broader on diagnosis, covering autism, traumatic brain injury and intellectual disability. But it asks for a treatment history the commercial version doesn't.

Both versions require a “Severity assessment of symptoms has been performed within the last 6 months.” A diagnostic report older than that doesn't satisfy it on its own.

After the assessment: one rulebook for all three plans

TennCare, BlueCare, UnitedHealthcare Community Plan and Wellpoint publish one joint ABA Provider Requirements and Program Description, revised June 13, 2024. It applies across all three:

  • A treatment plan “dated within 30 days of start date” and reviewed every six months.
  • An “updated evaluation of functioning via standardized tools at least every two years.”
  • “Measurable parent/caregiver goals” and documented “commitment for engagement” from parents.
  • Services by or supervised by a BCBA licensed in Tennessee.
  • Not covered: billing “when members are sleeping,” provider travel time, and ABA “simultaneously with” OT or speech.
  • An “Annual ABA Provider Quality Assurance Attestation” and “collaborative Quality Reviews” on a random sample of providers.

The limits

The guideline doesn't say what counts as less intensive treatment or how much of it must have been tried. The joint document is from 2024. Neither is new, but both are in force, and the BlueCare guideline was re-reviewed three months ago. TennCare doesn't publish a statewide ABA fee schedule, so rates aren't covered here.

What you must know or do

  • Intake coordinators: add a prior-treatment history to every BlueCare assessment request. Name what was tried (speech, OT, behavioral therapy, medication) and why it wasn't enough.
  • Check the date on the severity measure. If it's older than six months, get a current one before submitting 97151.
  • Clinical directors: for every TennCare client, confirm three dates: the plan within 30 days of start, the last six-month review, and the last standardized re-evaluation (within two years).
  • Billers: check your schedules for ABA in the same time slot as OT or speech. All three plans list it as non-covered.