ABA Clinic Revenue Cycle Flowchart: Intake to Cash

How to read this

Each phase below is a collapsible flowchart. Solid boxes are actions, amber boxes are decisions, green and red branches show the “good” and “problem” paths, and purple dashed boxes jump to another phase. Colored tags show who owns the step. Red boxes at the bottom of each phase are the Finance Director’s watch-outs. Unfamiliar acronym? See the glossary at the end.

Action Decision Start / end Good path Stop / exception INT Intake FIN Billing FD Finance Dir. OPS Ops Dir. CD BCBA Clinic Dir. BCBA BCBA RBT RBT FAM Family

The whole journey at a glance

↺ Feedback loop: every denial, rejection and write-off is coded to a root cause (Phase 13) and sent back to Intake, Authorization, Documentation or Scrub (Phases 1 to 10) so the same error is not repeated.

Time-sensitive: ABA CPT code set changes on January 1, 2027

Dates of service on or after 1/1/2027 use a revised code set. Dates of service in 2026 still bill under the current codes, even if the claim is sent in 2027. See the 2027 transition checklist below before building authorizations that run past December 31.

Audit system for the Finance Director

How to use this audit system

Part 1 is the repeating audit cycle, what to do with a serious finding, and the weekly to annual questions to ask Operations.
Part 2 has eleven operations audits (A1 to A11) that follow a client from intake to cash. Part 3 has nine business-structure audits (S1 to S9): governance, controls, contracts, workforce, compliance, systems, vendors, insurance and policies.
Open a module, follow its flow, then work the question cards. Each card says whom to ask, what evidence to request and what the red flag looks like. Mark Pass, Fail or N/A and add a note.
The scoreboard and findings log below update as you mark cards, with a suggested severity and response time for each failed item. Marks stay in this browser only; use Copy summary to keep a record. No client information should be typed into notes.
In the PDF every card prints with empty boxes so it can be used as a paper checklist.

Thresholds, sample sizes and response times are suggested starting points. Have health care counsel confirm anything involving overpayments, self-disclosure or record retention. This is a process-design aid, not legal advice.

Scoreboard

Findings log (built from your Fail marks)

Confirm reset

Payer playbook (five lanes)

Item	Texas Medicaid	TRICARE West	CHAMPVA	Aetna	BCBS Texas
Who qualifies	Members 20 and younger with autism who meet Texas Medicaid Autism Services criteria (THSteps-CCP benefit, effective 2/1/2022). Most members are in an MCO such as Community First.	Eligible beneficiaries with a definitive ASD diagnosis, enrolled in the Autism Care Demonstration (ACD)	Spouse or child of a veteran who is permanently and totally disabled from a service-connected condition, or a survivor of one. Not for anyone eligible for TRICARE.	Depends on plan. Fully insured Texas plans fall under the state autism mandate; self-funded plans can differ.	Same as Aetna. If the member is on a BCBSTX Medicaid plan, use the Texas Medicaid column.
Entry paperwork	Diagnostic report and an MCO authorization request with a treatment plan	Referral with ASD diagnosis, severity level and DSM-5 checklist; renewed every 2 years	Autism diagnosis, treatment plan and medical-necessity documentation	Diagnostic report and the Aetna ABA treatment request form with clinical records	Diagnostic report, order if the plan requires one, treatment plan
Authorization	Required from the MCO before services, for both evaluation and treatment	Required through TriWest (Availity); review quoted at about 5 business days	Treatment needs pre-authorization; the evaluation does not. Waived when other insurance already authorized it.	Precertification required for the ABA codes, initial and ongoing, through Availity	Check per code and plan; some codes were exempted from PA in 2022 unless the plan requires it
Provider setup	Each LBA enrolled with TMHP, then credentialed with each MCO	TriWest ACD certification (about 10 business days after a complete application) and annual education	Confirm provider requirements and claims route with the VA CHAMPVA office	Participation contract and credentialing for the group and each BCBA	BCBSTX network contract and credentialing
Special billing rule	The supervising LBA is the rendering provider on claims for all ABA services, including technician-delivered. MCOs set daily unit caps (Community First: 32 units or less per day). Telehealth modifier 95 applies to certain codes.	TriWest publishes billing guidance for concurrent care and overlapping session times	Generally pays after other coverage, so bill the other insurer first	Use benefit and service-type codes in Availity to read the ABA benefit before quoting	Confirm commercial versus Medicaid product on the member card
Claims route	837P to the member’s MCO (confirm payer ID and portal for each MCO)	837P through Availity	Confirm the current route with the VA CHAMPVA office; TriWest does not process CHAMPVA	837P through Availity	837P through Availity or the BCBSTX portal
Patient cost-share	None. Never balance-bill a Medicaid member.	Plan copay or cost-share (separate from ECHO)	Primary: $50 individual or $100 family deductible, then 25%. Secondary: usually nothing.	Deductible, copay, coinsurance per plan	Deductible, copay, coinsurance per plan
Timely filing (typical, confirm)	95 days from date of service for most MCOs	1 year from date of service	Typically 1 year from date of service	Per contract; commonly 90 to 180 days	Often 180 days
Setup note for STXBI	Community First has been a slow payer rather than a denial problem. Track days-to-pay by MCO.	TriWest has been a slow payer rather than a denial problem.	Set up days-to-pay tracking from the first claim	Set up days-to-pay tracking from the first claim	Low volume

ABA CPT code reference (2026 dates of service)

CPT	Service	Typical rendering provider	Unit	Finance note
`97151`	Behavior identification assessment (includes face-to-face and non-face-to-face analysis and report writing)	BCBA / QHP	15 min	Initial assessment and reassessment. Needs its own authorization. Report-writing time counts here.
`97152`	Supporting assessment, administered by technician under direction	RBT	15 min	Only where payer allows technician assessment support.
`97153`	Treatment by protocol, one-to-one	RBT	15 min	The volume code. Most revenue and most auth units.
`97154`	Group treatment by protocol	RBT	15 min	Group sizes and payer coverage vary.
`97155`	Treatment with protocol modification (through 2026, may include directing a technician)	BCBA / QHP	15 min	Common denial when billed for routine supervision with no protocol change. Narrows in 2027.
`97156`	Family / caregiver guidance, with or without the client	BCBA / QHP	15 min	Note must name who attended and what was taught.
`97157`	Multiple-family group guidance	BCBA / QHP	15 min	Low volume.
`97158`	Group treatment with protocol modification	BCBA / QHP	15 min	Low volume.
`0362T` / `0373T`	Severe-behavior supporting assessment / treatment (Category III)	Technicians, BCBA on site	30 min	Deleted effective 1/1/2027. Needs a specially set-up environment and two or more technicians.

Modifiers, place-of-service and technician-level modifiers differ by payer. Confirm against each payer’s current provider manual and fee schedule before loading CentralReach.

2027 code transition checklist (for dates of service on or after 1/1/2027)

Situation	Through 12/31/2026	From 1/1/2027
RBT delivers 1:1 treatment	`97153`	`97153` (unchanged)
BCBA directs the RBT during a session	`97155`	`97155` (descriptor narrowed to direction of technician with analysis)
BCBA treats the client directly	`97155`	`97173` (new)
Initial assessment	`97151`	`97151` (wording revised)
Caregiver guidance	`97156`	`97156` (wording revised)
Harmful-behavior assessment	`0362T`	`97148` + add-on `97149`
Harmful-behavior treatment	`0373T`	`97159` + add-on `97160`
Professional work away from the client	Bundled into treatment codes	New code `97180` (confirm payer coverage)

Action list for the Finance Director (suggested deadlines)

By Nov 30: Ask each payer (your Texas Medicaid MCOs such as Community First, TriWest, CHAMPVA, Aetna, BCBSTX) in writing which 2027 codes they will accept, the effective date they will adopt, and the rate for 97173, 97155 and any new code. Payers often lag the AMA schedule.
By Dec 15: Pull every active authorization that lists 97155, 0362T or 0373T and decide whether a modification request is needed so BCBA direct treatment can bill as 97173.
By Dec 20: Add 2027 service codes, fee schedules and unit rules to CentralReach with an effective date of 1/1/2027. Do not overwrite 2026 codes, because 2026 dates of service will still be billed in 2027.
By Dec 31: Train BCBAs to document “directing a technician” and “treating the client directly” as separate time blocks, because they will bill under different codes.
Jan 2027: Hold and review the first week of 2027 claims before release (extra scrub step) to catch code and modifier mismatches.

Who owns what

Function	Intake	Billing	RBT	BCBA	Clinic Dir.	Ops Dir.	Finance Dir.
Referral and paperwork packet	R	C		I	A	I
Eligibility and benefits	C	R					A
Assessment and treatment plan		I		R	A
Authorization request and tracking		R		C	C	I	A
Scheduling and sessions			R	R	C	A	I
Session notes and QA		C	R	R	A		I
Charge capture, scrub, claims		R					A
Payment posting and reconciliation		R					A
Denials and appeals		R		C	C	I	A
Patient balances		R					A
Month-end close and KPIs		C			I	C	R / A

R = does the work, A = accountable, C = consulted, I = informed. Adjust to your actual org chart.

Glossary: acronyms and terms

Programs, payers and agencies

Term	Stands for	What it means here
ACD	Autism Care Demonstration	TRICARE program that covers ABA for eligible beneficiaries with autism. Requires a referral, diagnosis and DSM-5 checklist.
ASN	Autism Services Navigator	Care coordinator assigned to a TRICARE family in the ACD.
BCBSTX	Blue Cross and Blue Shield of Texas	Commercial payer, and also administers Texas Medicaid plans. Check which product the member has.
CHAMPVA	Civilian Health and Medical Program of the Department of Veterans Affairs	VA health program for spouses and children of certain disabled or deceased veterans. Not for anyone eligible for TRICARE.
CMS	Centers for Medicare & Medicaid Services	Federal agency that sets the 8-minute rounding convention many payers copy and runs the CMS-1500 claim form standard.
DEERS	Defense Enrollment Eligibility Reporting System	Database that confirms TRICARE eligibility.
DoD	Department of Defense	Sponsor of TRICARE. The DoD benefit number identifies the beneficiary.
ECHO	Extended Care Health Option	TRICARE benefit for beneficiaries with qualifying conditions. ABA cost-share under the ACD is separate from ECHO.
ERISA	Employee Retirement Income Security Act	Federal law that governs self-funded employer plans. These plans may not follow state autism mandates.
HHSC	Texas Health and Human Services Commission	State agency that runs Texas Medicaid and publishes the Medicaid autism services policy.
MCO	Managed care organization	Health plan that administers Medicaid for a member (for example, Community First Health Plans). Medicaid ABA authorization and claims go through it.
OIG	Office of Inspector General (HHS)	Publishes the exclusion list used to screen staff.
PCM	Primary care manager	The TRICARE Prime member’s assigned primary care provider, who issues the referral.
THSteps-CCP	Texas Health Steps Comprehensive Care Program	Texas Medicaid program for members 20 and younger. ABA became a covered benefit under it on 2/1/2022.
TMHP	Texas Medicaid & Healthcare Partnership	State contractor that handles Texas Medicaid provider enrollment and publishes the Medicaid manuals.
TriWest	TriWest Healthcare Alliance	The TRICARE West Region contractor. Handles authorizations and claims for TRICARE West.
VA	Department of Veterans Affairs	Administers CHAMPVA.

Clinical and credentials

Term	Stands for	What it means here
ABA	Applied Behavior Analysis	The therapy being billed.
ASD	Autism spectrum disorder	The qualifying diagnosis for ABA coverage.
ARD	Admission, Review and Dismissal	Texas school committee that decides special-education services. Its documents can support the assessment.
BACB	Behavior Analyst Certification Board	Certifies BCBAs and RBTs and sets the RBT supervision minimum (about 5% of monthly hours).
BCaBA	Board Certified Assistant Behavior Analyst	Assistant-level certification, supervised by a BCBA.
BCBA	Board Certified Behavior Analyst	Graduate-level clinician who assesses, writes treatment plans and supervises RBTs.
BHEC	Texas Behavioral Health Executive Council	Texas board that licenses LBAs.
DSM-5	Diagnostic and Statistical Manual of Mental Disorders, 5th edition	Source of the ASD diagnostic criteria. TRICARE requires a DSM-5 checklist with the referral.
IEP	Individualized Education Program	School plan for a student with a disability. Supports the assessment.
LBA	Licensed Behavior Analyst	Texas license for behavior analysts. Texas Medicaid requires the supervising LBA to be enrolled and to serve as the rendering provider.
QHP	Qualified health care professional	Term in CPT descriptors for the BCBA-level rendering provider.
RBT	Registered Behavior Technician	Technician who delivers direct 1:1 treatment (97153) under BCBA supervision.

Billing and revenue cycle

Term	Stands for	What it means here
AR	Accounts receivable	Money owed to the clinic by payers and families. Aged in buckets (0–30, 31–60, 61–90, 91–120, 120+ days).
CAQH	Council for Affordable Quality Healthcare	Online profile that many payers use for credentialing. Keep it current.
CARC	Claim Adjustment Reason Code	Code on a remittance that explains why a payer adjusted or denied a line (for example CO-197).
CO	Contractual obligation	Adjustment group code. The clinic cannot bill the patient for it (for example CO-45).
COB	Coordination of benefits	The order in which multiple coverages pay.
CPB	Clinical Policy Bulletin	Aetna’s medical policy document. CPB 648 covers autism and ABA.
CPT	Current Procedural Terminology	The AMA procedure codes used on ABA claims (97151 to 97158 and others).
DOS	Date of service	The day the session happened. It drives which code set, rate and authorization apply.
EFT	Electronic funds transfer	The payment itself, matched to the ERA by trace number.
ERA	Electronic remittance advice	The electronic explanation of payment (the 835).
ICD-10	International Classification of Diseases, 10th revision	Diagnosis code set. F84.0 is the common ASD code.
KPI	Key performance indicator	A tracked metric, such as days in AR or clean claim rate.
LEIE	List of Excluded Individuals/Entities	OIG exclusion list. Screen all staff monthly.
NPI	National Provider Identifier	10-digit provider ID. Type 1 is an individual, Type 2 is an organization.
NPPES	National Plan and Provider Enumeration System	Registry where NPIs are issued and updated.
PA	Prior authorization	Payer approval before services. Aetna calls it precertification.
PI	Payer initiated	Adjustment group code for reductions the payer decides on its own.
PR	Patient responsibility	Adjustment group code for amounts the family owes: PR-1 deductible, PR-2 coinsurance, PR-3 copay.
RARC	Remittance Advice Remark Code	Supplemental code that gives more detail than the CARC.
SLA	Service level agreement	In this guide, an internal target turnaround time for a step.
TIN	Taxpayer Identification Number	Federal tax ID of the billing entity.

Billing terms in plain language

Term	Stands for	What it means here
8-minute (midpoint) rule		Rounds minutes to 15-minute units: 8 to 22 minutes is 1 unit, 23 to 37 is 2, and so on. Some payers bill only full 15-minute units.
Billing provider vs rendering provider		Billing provider is the entity paid (the clinic). Rendering provider is the clinician credited with the service. Texas Medicaid requires the LBA as rendering provider.
Clean claim		A claim with no errors that is accepted and paid without rework.
Contractual adjustment		The difference between the clinic’s charge and the payer’s contracted rate. Written off by contract, not collected.
Corrected (replacement) claim		A fixed claim sent with frequency code 7 and the original claim number. Code 8 voids a claim.
Denial vs rejection		A rejection never enters payer processing (data error) and has no appeal. A denial is a processed decision that can be appealed.
Modifier		Two-character add-on to a CPT code, for example 95 for synchronous telemedicine or a technician-level modifier some payers require.
Peer-to-peer		Phone review between the BCBA and the payer’s clinical reviewer to contest a denied or reduced authorization.
Precertification		Aetna’s term for prior authorization.
Recoupment		Payer takes back money previously paid, usually by reducing a later payment.
Retro-authorization		Authorization requested after services began. Allowed by only some payers and only within a short window.
Scrub		Automated check of a claim for errors before it is sent.
Timely filing		The deadline to submit a claim after the date of service. Late claims are denied (CO-29).
Unapplied cash		Money received but not yet matched to a claim.
Write-off		Balance removed from AR as uncollectible. Needs a root cause and approval.

Electronic transactions (EDI)

Term	Stands for	What it means here
270 / 271		Eligibility inquiry and response.
276 / 277		Claim status inquiry and response.
277CA		Claim acknowledgement from the payer. Shows accepted or rejected and is your proof of timely filing.
835		Electronic remittance advice (ERA).
837P		Electronic professional claim, the electronic version of the CMS-1500.
999		Acknowledgement that the clearinghouse or payer received the file.
CMS-1500		Standard professional claim form (paper layout used as the basis for the 837P).

Staff tags used in the flowcharts

Term	Stands for	What it means here
INT	Intake Coordinator
FIN	Billing staff
FD	Finance Director
OPS	Operations Director
CD	BCBA Clinic Director
BCBA	Board Certified Behavior Analyst
RBT	Registered Behavior Technician
FAM	Family or guardian

Place-of-service codes

Term	Stands for	What it means here
POS 02	Telehealth, patient not at home	Telehealth delivered when the patient is somewhere other than home.
POS 03	School
POS 10	Telehealth, patient at home
POS 11	Office	Clinic-based sessions.
POS 12	Home	In-home sessions.
POS 99	Other place of service