Autism Billing Services — 2026 Complete Playbook
Autism billing requires expertise across 3 payer worlds: TRICARE (military autism benefit), commercial ABA benefit (state mandate), and Medicaid EPSDT autism coverage. Each has different codes, PA rules, and reimbursement rates.
Payer-by-Payer Autism Coverage 2026
TRICARE
- Autism Care Demonstration (ACD) provides ABA to TRICARE beneficiaries
- ACD-approved providers only; separate credentialing from standard TRICARE network
- Rates: 97153/97155 higher than commercial (Health Net Federal Services admin)
Commercial (mandated 50 states)
- All 50 states + DC mandate commercial autism ABA coverage
- State-specific age limits + spending caps vary (mostly age 21, no cap)
- Prior auth required on 97153/97155; supervision-hour docs required
Medicaid EPSDT
- Federal EPSDT mandate covers ABA for Medicaid children under 21
- State-by-state implementation via CDR (Comprehensive Diagnostic Report) or independent eval
- Waiver programs (e.g., NC Innovations, TX STAR Kids) add complexity
Case Study
Free 30-day autism billing audit · Pricing 4-8%
– KD, Revenant Care