---
title: UnitedHealthcare Community Plan of Arizona ABA coverage (AHCCCS plan).
url: "https://carelu.com/payers/unitedhealthcare-community-plan-arizona"
markdown_url: "https://carelu.com/payers/unitedhealthcare-community-plan-arizona.md"
state: AZ (Arizona)
payer: UnitedHealthcare Community Plan of Arizona
kind: Medicaid managed care plan (MCO)
parent_program: AHCCCS (Arizona Medicaid)
description: "How UnitedHealthcare Community Plan administers Arizona AHCCCS ABA through Optum — no PA on 97151/97152, the AZ Treatment Request Form documentation regime, the ACC + DDD dual membership, and AHCCCS registration mechanics."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# UnitedHealthcare Community Plan of Arizona ABA coverage (AHCCCS plan).

_Payer Guide · UHC Community Plan (AZ) · Last updated September 2026 · 4 primary sources_

> Optum-run; PA on everything except 97151/97152; explicit "no ASD dx required" rule.

UnitedHealthcare Community Plan of Arizona runs its ABA benefit through Optum, with a dedicated AZ AHCCCS ABA Program on Provider Express — an Arizona-specific orientation, treatment request form, and quick reference guide, staffed by a dedicated Arizona autism clinical team. Like Mercy Care, it covers both Arizona funnels: it is an ACC plan and one of the two statewide DDD Health Plans ("DD by UHCCP"), plus an ALTCS contractor. The clinical posture matches the state baseline — no PA on assessment, no autism diagnosis required — but the paperwork is Optum-national in flavor, with Arizona-specific forms and a demanding treatment-request documentation list.

This plan administers the **AHCCCS (Arizona Medicaid)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [AHCCCS (Arizona Medicaid) guide](https://carelu.com/payers/arizona-ahcccs).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Not required — "All ABA services require prior authorization except 97151 and 97152" (Optum AZ orientation) [1]
- **Prior auth for treatment**: Required for all treatment codes — Provider Express online ABA Treatment Form or fax 1-888-541-6691 [1]
- **Autism diagnosis required?**: No — "ASD diagnosis is not required for ABA services for Arizona Medicaid members" (Optum AZ orientation, verbatim) [1]

## At a glance

- **Plan type:** ACC plan + statewide DDD Health Plan ("DD by UHCCP") + ALTCS; BH run by Optum
- **Assessment PA:** None — all ABA codes require PA except 97151 and 97152
- **Treatment PA:** Required — Provider Express ABA Treatment Form or fax 1-888-541-6691
- **Diagnosis:** ASD diagnosis explicitly NOT required for Arizona Medicaid members
- **Portals:** providerexpress.com (auth) + UHCprovider.com (claims); payer ID 03432
- **Claims deadline:** 90 days from date of service

## The Optum layer: forms, documentation, concurrent review

Assessments (97151/97152) start without authorization; every other ABA code requires PA, submitted through the online ABA Treatment Form on Provider Express or by fax to 1-888-541-6691. The treatment request is where Optum's rigor lives — it must include baseline and mastery criteria, a transition plan, discharge criteria, a behavior-reduction/crisis plan, parent goals, and supervision hours, and goals must not be educational or academic in nature. Concurrent reviews weigh progress and medical necessity under Optum's Autism/ABA clinical policy, run by a dedicated Arizona autism team of licensed clinicians and BCBAs. The plan's fee schedule mirrors the AHCCCS structure — 9715x plus 0362T/0373T in 15-minute units with credential modifiers — though dollar amounts aren't published in the orientation. Note the operational split: authorizations live on Provider Express, claims on UHCprovider.com (payer ID 03432), with a 90-day filing deadline. [1]

## Both funnels, and the registration mechanics

The orientation is explicit that UHC Community Plan is "the selected managed care administrator for Arizona AHCCCS Complete Care and AZ DD membership" — DD member cards say "DDD Health Plan by UHCCP" and carry Group AZDDD, versus AZHCCCS for ACC members. Same forms and rules, but confirm which book the member is in, since the DDD path comes with a different eligibility gate and bundled HCBS services. Registration mechanics that block claims if missed: the agency must be enrolled as AHCCCS provider type 77, BCBAs must be individually AHCCCS-registered, and the rendering provider's NPI (the BCBA or licensed clinician) goes in box 24J. And the diagnosis rule worth quoting in any dx-gate dispute: "ASD diagnosis is not required for ABA services for Arizona Medicaid members." Like the other big plans, UHC terminated Action Behavior Centers in the March 2026 network purge — expect displaced families. [1][4]

## Intake gates

The questions that decide whether a family can start with UnitedHealthcare Community Plan of Arizona, and what they have to bring.

- **Age limit**: Optum's Arizona eligibility list is membership-based, not age-based: the member must be covered under AHCCCS (Arizona Complete Care or the Developmentally Disabled program) and "diagnosed with a condition for which ABA-based therapy services are recognized as therapeutically appropriate, including autism spectrum disorder, by a qualified health care professional." No upper or lower age bound is published, and AMPM 320-S sets none either. [1][3]
- **Diagnosis recency**: None published. Neither Optum's Arizona orientation nor AMPM 320-S puts a clock on the diagnostic evaluation; each clinical review instead asks for "confirmation member has an appropriate DSM-5 diagnosis that can benefit from ABA," current medications, concurrent services and school hours. [1][3]
- **Who may diagnose**: "Diagnosed with a condition for which ABA-based therapy services are recognized as therapeutically appropriate, including autism spectrum disorder, by a qualified health care professional. ASD diagnosis is not required for ABA services for Arizona Medicaid members." That last sentence is the one to quote in any diagnosis-gate dispute. [1]
- **Diagnostic tools required**: Optum's Arizona orientation names no required instrument — it asks each review to confirm an appropriate DSM-5 diagnosis. The instrument standard is the state's: AMPM 320-S requires assessments using standardized and/or non-standardized instruments through both direct and indirect methods, naming the PDDBI, the Brigance Inventory of Early Development and the Vineland Adaptive Behavior Scales as standardized examples. [1][3]
- **Referral required?**: No physician referral is required; the gate is authorization. "All ABA services require prior authorization except 97151 and 97152" — assessment requests go through the online ABA Treatment Form on Provider Express, treatment requests through the same form or fax 1-888-541-6691. The treatment request must carry baseline and mastery criteria, a transition plan, discharge criteria, a behavior-reduction/crisis plan, parent goals, supervision and treatment-planning hours, relevant psychological information and coordination of care, and goals "must not be educational or academic in nature." [1]
- **Prior-auth decision time**: UHC Community Plan of Arizona’s 2026 manual: "A decision and notification is made no later than 14 calendar days following the receipt of the request. This time frame may be extended up to 7 days" on request; expedited no later than 72 hours (extendable up to 14 days). Optum administers ABA — all ABA codes except 97151 and 97152 need PA, with the same clinical packet at each concurrent review — and publishes no ABA clock or reauth lead time. AHCCCS’s own CY2025 prior-authorization metrics report (March 2026) says that "Beginning January 1, 2026" the CMS rule requires Medicaid managed care plans to decide within "7 calendar days for standard requests (non-urgent)" and "72 hours for expedited requests (urgent)"; the federal regulation ties the 7-day ceiling to rating periods starting on or after January 1, 2026. Confirm with UHC which clock it runs. [5][1][6][7]
- **Other insurance (who pays first)**: UHC is payer of last resort and "will reimburse as secondary payer without prior authorization when the claim is submitted with an EOB showing primary allowed. If an authorization is denied by the Primary Insurer, providers are to submit the request" to UHC with clinical documentation. Secondary claims "must be received within 6 months (180 days) from the date of service, even if the primary carrier has not made payment." Payment is the difference up to the contracted rate. The manual lists no pay-and-chase services of its own; AHCCCS policy (ACOM 434), which it follows, requires pay-and-recover for preventive pediatric/EPSDT services and bars a secondary PA when the other insurer approved the service. Under federal rules TRICARE pays before Medicaid, and CHAMPVA pays first when the child is also Medicaid-eligible. [5][8][9][10]

## Delivery and billing rules

Coverage decides whether UnitedHealthcare Community Plan of Arizona pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: Credentialing conditions rather than a ratio. For ABA/IBT groups Optum requires that "Behavior Technicians receive appropriate training and supervision by BCBAs or licensed clinician," that a "BCBA or licensed clinician on staff [provides] program oversight," and that a "BCBA or licensed clinician performs skills assessments and provides direct supervision of behavior technicians in joint sessions with client and family." Supervision hours must be itemised in the treatment request. No percentage or caseload cap is published, and AMPM 320-S sets none — so the BACB floor governs RBT-credentialed staff. [1][3]
- **Bill as provider**: The supervisor carries the claim. "The rendering provider's 10-digit NPI is required in box 24J and must be an active AHCCCS registered provider (The rendering provider is the BCBA/Licensed Clinician)," and "Field 31 must have a rendering provider name. Rendering supervisor (BCBA/Licensed Clinician) will bill for all services by them or the BCaBAs/RBTs under the supervisory protocol." The agency must hold an AHCCCS registration number as provider type 77, BCBAs must be individually AHCCCS-registered, claims go on a Form 1500 to payer ID 03432, and when a provider is contracted as a group the payment is made to the group, not the individual. [1]
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: Optum provider services / the Arizona autism clinical team, and the CMS NCCI edits Optum says it follows. [1]
- **Daily limits / MUEs** _(ask the plan)_: No per-day unit ceiling is published for the Arizona Medicaid program; Optum points to CMS Correct Coding Initiative standards and enforces the authorization instead — "units exceed authorization" is one of the named coding reasons claims get denied, alongside missing unit counts. [1]
  - Ask the plan: Optum provider services; confirm authorized units per code before scheduling.

## What intake should collect for UnitedHealthcare Community Plan of Arizona

- **ACC vs. DD membership:** Check the card — Group AZDDD ("DDD Health Plan by UHCCP") vs. AZHCCCS routes the eligibility conversation.
- **Diagnosis (any qualifying):** No ASD dx required — capture whatever diagnosis and assessment supports medical necessity.
- **Treatment-request inputs:** Baseline/mastery criteria, transition + discharge plans, crisis plan, parent goals, supervision hours — collect early; goals can't be academic.
- **AHCCCS registration status:** Agency as provider type 77, BCBA individually registered, rendering NPI for box 24J — verify before the first claim.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How UnitedHealthcare Community Plan of Arizona ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00205
- **Payer ID (Availity):** 03432
- **Payer ID (Change Healthcare / Optum):** 03432 — Optum RTE = 03432 "Arizona Physicians IPA - Community and State" (Loop 2100B must contain the NPI); Optum AZ ABA orientation confirms claims Payer ID 03432. pVerify 00205 = "Arizona Physician's IPA - UHC Community Plan"; Availity 3432/F03432 "ARIZONA PHYSICIANS IPA".
- **Supports 270/271 eligibility:** Yes
- **Real-time eligibility:** Yes
- **Behavioral health administrator:** Optum Behavioral Health (network administrator; integrated)
- **BH administrator payer ID:** 03432
- **ABA rides on:** medical benefit — Optum administers the BH network but claims route to 03432 (integrated) — no two-hop.
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Not required — assessment codes 97151/97152 are explicitly PA-exempt. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |
| 97152 | Yes | Not required — assessment codes 97151/97152 are explicitly PA-exempt. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |
| 97153 | Yes | Required — treatment codes require PA on the plan's ABA form/portal. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |
| 97154 | Yes | Required — treatment codes require PA on the plan's ABA form/portal. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |
| 97155 | Yes | Required — treatment codes require PA on the plan's ABA form/portal. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |
| 97156 | Yes | Required — treatment codes require PA on the plan's ABA form/portal. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |
| 97157 | Yes | Required — treatment codes require PA on the plan's ABA form/portal. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |
| 97158 | Yes | Required — treatment codes require PA on the plan's ABA form/portal. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |
| 0362T | Yes | Required — treatment codes require PA on the plan's ABA form/portal. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |
| 0373T | Yes | Required — treatment codes require PA on the plan's ABA form/portal. | — | office/clinic, home (POS 12 — pays a ~10–11.5% premium on the AHCCCS schedule), school, community, telehealth (modality allowed under AMPM 320-S; ABA-specific POS/modifier not itemized) | — | HM (below bachelor's / BT-RBT), HN (bachelor's / BCaBA), HO (master's / BCBA), HP (doctoral / BCBA-D) |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** Optum-run; treatment via the Provider Express ABA Treatment Form or fax 1-888-541-6691; 90-day filing deadline. AMPM 320-S covers ASD "and/or other diagnoses as justified by medical necessity" — no strict autism-dx requirement. Per-code daily unit caps are not published (AzCH uses hour bands, not caps).

### Medicaid rates

Source: Not separately published by UnitedHealthcare Community Plan of Arizona. AHCCCS ACC/DDD plans are capitated, but ABA tracks the AHCCCS physician fee schedule (see arizona-ahcccs rates) as the public benchmark — UnitedHealthcare Community Plan of Arizona's actual contracted rate is not published (and is NOT a statutory floor, unlike New Mexico). Effective 2023-11-01 (AHCCCS benchmark).

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | Benchmark: $30.06 (HN) / $35.78 (HO) / $44.73 (HP) office — see arizona-ahcccs | 15min | — |
| 97152 | Benchmark: $21.49 (HM) / $25.58 (HN) / $28.43 (HO/HP) office — see arizona-ahcccs | 15min | — |
| 97153 | Benchmark: $17.91 (HM) / $21.32 (HN) / $23.69 (HO/HP) office — see arizona-ahcccs | 15min | — |
| 97154 | Benchmark: $4.48 (HM) / $5.33 (HN) / $5.92 (HO/HP) office — see arizona-ahcccs | 15min | — |
| 97155 | Benchmark: $25.05 (HN) / $29.82 (HO) / $37.28 (HP) office — see arizona-ahcccs | 15min | — |
| 97158 | Benchmark: $6.26 (HN) / $7.46 (HO) / $9.32 (HP) office — see arizona-ahcccs | 15min | — |

### Contacts

- **Provider services phone:** 1-800-445-1638 (Optum Claims Customer Service Line)
- **Phone menu path:** Verify member eligibility via the number on the back of the member’s ID card or through Provider Express/UHCprovider.com; all ABA codes require PA except 97151/97152 — submit online via the ABA Treatment Form or fax 1-888-541-6691.
- **Hours:** Provider Express Support Center: 7:00 a.m.–9:00 p.m. CT
- **Portal:** [Optum Provider Express (ABA prior authorization)](https://www.providerexpress.com)
- **Fax:** 1-888-541-6691 (Optum ABA prior-authorization fax)

Questions to ask on a verification call:

- Is there a daily or weekly unit cap for 97153–97155 treatment codes?
- Does telehealth require a specific modifier (GT/95) for ABA codes under this member’s ACC/DD plan?
- What POS codes are accepted for home vs. clinic ABA sessions?
- What’s the current rate for 97156/97157, since AHCCCS lists them “By Report”?

### VOB data sources

- https://www.optum.com/ (accessed 2026-07-23)
- https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/azaba/azABA_Provider_Orient.pdf (accessed 2026-07-23)
- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.azahcccs.gov/Resources/Downloads/EDIchanges/AZ270_271_CG.pdf (accessed 2026-07-23)
- https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/300/320S.pdf (accessed 2026-07-23)
- https://www.azahcccs.gov/AHCCCS/Downloads/PublicNotices/rates/FinalPublicNotice_RateChanges_20231101_ABA.pdf (accessed 2026-07-23)
- https://azahcccs.gov/PlansProviders/Downloads/FFSrates/ABA/FY26_Final_ABA_FeeSchedule.xlsx (accessed 2026-07-23)

## Common questions

### Does UnitedHealthcare Community Plan of Arizona cover ABA?

Yes — through Optum's AZ AHCCCS ABA Program. Assessment codes 97151/97152 need no PA; all other ABA codes require authorization via Provider Express or fax, with a detailed treatment-request documentation list.

### Does UHC require an autism diagnosis for AHCCCS ABA?

No — Optum's Arizona orientation states verbatim that an ASD diagnosis is not required for ABA services for Arizona Medicaid members. Medical necessity, supported by assessment, governs.

### How do I submit an ABA authorization to UHC in Arizona?

The online ABA Treatment Form on providerexpress.com, or fax 1-888-541-6691. Claims go separately through UHCprovider.com (payer ID 03432) within 90 days of the date of service.

## Primary sources

1. [Optum — Arizona AHCCCS Autism/ABA Program provider orientation (BH4129)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/azaba/azABA_Provider_Orient.pdf)
2. [UHC Community Plan — Arizona DDD program page](https://www.uhc.com/communityplan/arizona/plans/medicaid/developmental-disabilities)
3. [AMPM 320-S — Behavior Analysis Services (AHCCCS)](https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/300/320S.pdf)
4. [azfamily — Nearly 1K Arizona children lose in-network ABA (3/5/2026)](https://www.azfamily.com/2026/03/05/nearly-1k-arizona-children-with-autism-lose-aba-therapy-coverage/)
5. [UnitedHealthcare Community Plan of Arizona — 2026 Care Provider Manual (ACC / ALTCS / DD)](https://www.uhcprovider.com/content/dam/provider/docs/public/admin-guides/comm-plan/AZ-Provider-Manual.pdf)
6. [AHCCCS — Prior Authorization Metrics for Medical Items and Services, CY2025 (3/31/2026)](https://www.azahcccs.gov/Resources/Downloads/PriorAuthorizationMetricAnnualReports/CMS_PA_Mandate_Report_Final_033026.pdf)
7. [42 CFR 438.210(d) — Medicaid managed care authorization decision timeframes](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-D/section-438.210)
8. [AHCCCS ACOM 434 — Coordination of Benefits and Third-Party Liability (eff. 5/2/2025)](https://www.azahcccs.gov/shared/Downloads/ACOM/PolicyFiles/400/434.pdf)
9. [32 CFR 199.8 — TRICARE double coverage (secondary to other plans, primary to Medicaid)](https://www.ecfr.gov/current/title-32/subtitle-A/chapter-VII/subchapter-M/part-199/section-199.8)
10. [VA — CHAMPVA Guidebook (updated 1/1/2025), CHAMPVA as secondary payer](https://www.va.gov/files/2025-12/CHAMPVA-Guidebook.pdf)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.