---
title: UnitedHealthcare Community Plan of Hawaii ABA coverage (QUEST Integration).
url: "https://carelu.com/payers/unitedhealthcare-community-plan-hawaii"
markdown_url: "https://carelu.com/payers/unitedhealthcare-community-plan-hawaii.md"
state: HI (Hawaii)
payer: UnitedHealthcare Community Plan of Hawaii
kind: Medicaid managed care plan (MCO)
parent_program: Hawaii Medicaid (Med-QUEST / QUEST Integration)
description: "How UnitedHealthcare Community Plan of Hawaii handles the Med-QUEST ABA benefit — Optum (United Behavioral Health) manages ABA through Provider Express, treatment authorizations, the conflicting guidance on assessment PA, claims to payer ID 87726, and telehealth rules."
last_reviewed: September 2026
---

# UnitedHealthcare Community Plan of Hawaii ABA coverage (QUEST Integration).

_Payer Guide · UnitedHealthcare Community Plan · Hawaii · Last updated September 2026 · 10 primary sources_

> QUEST Integration plan. ABA is managed by Optum (United Behavioral Health) since 2016 — authorizations through Provider Express or fax.

UnitedHealthcare Community Plan is a QUEST Integration plan, and its ABA benefit is run by Optum, not the medical plan. Optum’s Hawaii QUEST ABA page says United Behavioral Health, operating as Optum, "assumed management of the Medicaid autism program benefits for Hawaii QUEST Integration members" from January 1, 2016. The plan’s June 2026 PA list sends ABA to Optum: "For ABA Therapy, submit by fax or Provider Express." The 2026 Hawai‘i QUEST provider manual lists Optum (providerexpress.com, payer ID 87726) for behavioral health eligibility, claims, benefits, authorization and appeals. Benefits verification and authorization go to Optum, not the medical line.

This plan administers the **Hawaii Medicaid (Med-QUEST / QUEST Integration)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [Hawaii Medicaid (Med-QUEST / QUEST Integration) guide](https://carelu.com/payers/hawaii-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment** _(ask the plan)_: Conflicting sources — Optum’s 2022 Hawaii QUEST orientation says "Prior authorization not required for assessments," its 2022 quick reference guide says "All autism services require prior authorization," and the live Provider Express page offers assessment authorizations [2][3][1]
  - Ask the plan: Optum Hawaii QUEST ABA team via Provider Express or 1-888-980-8728 — ask whether 97151/97152 need authorization before the assessment.
- **Prior auth for treatment**: Required — Optum manages the ABA benefit; submit the Treatment Authorization Request through Provider Express or by fax (1-888-541-6691), with the assessment results [5][1][3]
- **Autism diagnosis required?**: Yes — a documented DSM-5 ASD diagnosis, under 21, QUEST Integration coverage (Optum eligibility criteria); trial ABA for suspected ASD with qualifying diagnoses such as global developmental delay or language disorders [2][7]

## At a glance

- **Plan type:** QUEST Integration plan (UnitedHealthcare Community Plan)
- **Behavioral health:** Optum (United Behavioral Health) manages ABA since Jan 1, 2016 — providerexpress.com
- **Benefit source:** Med-QUEST memo QI-2431 / FFS 24-13 (IBT / ABA)
- **Treatment PA:** Required — Provider Express portal or fax 1-888-541-6691
- **Assessment PA:** Conflicting Optum documents — confirm before scheduling
- **Claims:** Payer ID 87726; CMS-1500; 365-day filing

## Optum runs the ABA benefit

Both network and out-of-network providers manage ABA in the Provider Express secure portal (a One Healthcare ID is required): verify coverage, request ABA assessment and treatment authorizations, send more information, and track status. Optum’s Hawaii orientation sets eligibility as under 21, covered by QUEST Integration, with a documented DSM-5 ASD diagnosis. It allows a trial of ABA for suspected ASD (qualifying diagnoses include global developmental delay, social communication disorder and language disorders). It asks for the continuation request at least two weeks before the period ends. Medical necessity is judged against Optum’s ABA clinical criteria. [1][2][3][4][5][6]

On the assessment the Optum documents disagree. The 2022 orientation says "Prior authorization not required for assessments (but referral may be required from the PCP)." The 2022 quick reference guide says "All autism services require prior authorization," and the live portal page lists "Request ABA assessment and treatment authorizations." Confirm before booking 97151. Credentialing (2022): BCBAs need active BACB certification, state licensure, 6 months of supervised ABA experience and $1M/$1M liability; groups need a BCBA on staff and RBT-level technicians. [1][2][3][4][5][6]

## Intake gates

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

- **Age limit**: Under 21 (Optum Hawaii eligibility criteria and the MQD memo). The 2026 plan manual: children "younger than 21 years of age who have an autism spectrum disorder diagnosis may receive applied behavior analysis." [2][6][7]
- **Diagnosis recency**: No recency window stated by Optum’s Hawaii material or the MQD memo. Optum’s ABA criteria want the DSM-5 diagnosis and severity level confirmed and documented by the diagnosing clinician. [2][4][7]
- **Who may diagnose**: MQD memo list (developmental-behavioral or developmental pediatrician, neurologist, pediatrician, psychiatrist, psychologist, other licensed ASD-expert practitioner). Optum’s criteria: a state-licensed physician, psychologist or other state-licensed clinician qualified to diagnose. [7][4]
- **Diagnostic tools required**: Optum’s ABA criteria require the diagnosis and severity to be confirmed "using at least one clinically validated tool" — screening tools (e.g., M-CHAT), second-level tools (CARS-2, STAT, RITA-T) or formal diagnostic tools (ADI-R, ADOS-2, DISCO). The MQD memo asks for evidence-based assessments. [4][7]
- **Telehealth**: Optum’s 2022 Hawaii orientation: BCBAs only (for HI QUEST) may deliver ABA supervision and caregiver training by telehealth after attesting as an Optum virtual-visits provider — bill 97155 or 97156 with place of service 02. MQD memo QI-2527 governs telehealth generally (audio-video, modifier 95/GT/GQ). [2][8]
- **Prior-auth decision time**: The federal managed-care limit applies: 7 calendar days for standard decisions (rating periods from January 1, 2026; extendable by 14) and 72 hours expedited. Continuation requests are due at least two weeks before the approved period ends (MQD memo and Optum orientation). [9][7][2]
- **Referral required?** _(plan-dependent)_: Optum’s 2022 orientation: for assessments, "referral may be required from the PCP." The 2026 plan manual says behavioral health referrals to Optum need no PCP referral. [2][6]
  - Ask the plan: Optum Hawaii QUEST ABA team, 1-888-980-8728.
- **Other insurance (who pays first)** _(plan-dependent)_: Medicaid is secondary to all other insurance (MQD memo), so the plan pays after any commercial coverage. The 2026 manual says UnitedHealthcare applies coordination-of-benefits rules. Whether Optum requires its own ABA authorization when secondary is not stated. TRICARE pays after other coverage except Medicaid; CHAMPVA pays last. [7][6][10][12][13]
  - Ask the plan: Optum Hawaii QUEST ABA team, 1-888-980-8728 — confirm PA when secondary.

## Delivery and billing rules

Coverage decides whether UnitedHealthcare Community Plan of Hawaii 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**: Optum’s ABA criteria (applied to this program) require direct case supervision of 1–2 hours for every 10 hours of direct treatment per week, consistent with CASP — the same ratio as the MQD memo, which adds direct supervision of at least 5% of BCaBA and RBT hours. Technicians work under a BCBA or licensed clinician; Optum’s Hawaii credentialing expects a BCBA to directly supervise technicians in joint sessions. [4][7][2]
- **Session-note signature**: Optum’s ABA criteria require daily progress notes with place of service, start and stop times, who delivered the service, the service type, who attended, the interventions, and the credentials of those present, plus all supervision documentation. No signature timing rule is stated. [4]
- **Place of service**: Settings per the MQD memo — clinic, home or community named in the treatment plan; school ABA by DOE under the IEP; nothing outside Hawaii. Optum asks how many hours a week the child is in school and wants coordination with the IEP; goals "must not be educational or academic in nature." [7][2]
- **Bill as provider**: Optum’s 2022 Hawaii orientation: "Rendering supervisor (BCBA/BCBA-D) will bill for all services under the supervisory protocol," with the rendering provider named in field 31; payment goes to the group when contracted as a group. Claims go on the CMS-1500 to payer ID 87726, within 365 days. The MQD memo’s HO/HN/HM credential modifiers apply to Hawaii Medicaid ABA. [2][3][7]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: The MQD memo allows 97153 and 97155 concurrently when both codes’ criteria are met and they carry different modifiers. Optum’s Hawaii material does not address it, and Med-QUEST’s 2024 rate-study meetings noted that plans differed on allowing concurrent RBT + BCBA billing. [7][11]
  - Ask the plan: Optum Hawaii QUEST ABA team, 1-888-980-8728 — ask whether claims for 97153 + 97155 at the same time pay.
- **Daily limits / MUEs** _(ask the plan)_: No published per-day or per-week cap; Optum authorizes hours against its ABA criteria per request. The MQD memo sets no cap. [4][7]
  - Ask the plan: Optum Care Advocate at authorization.

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

- **Optum benefits check:** Verify ABA eligibility in Provider Express or through the behavioral health number on the card — not the medical line.
- **QUEST enrollment confirmation:** Confirm QUEST Integration enrollment and that UnitedHealthcare Community Plan is the assigned plan.
- **ASD diagnosis and age:** Documented DSM-5 ASD, under 21. For suspected ASD, the working diagnosis for a trial period.
- **Assessment authorization status:** Optum’s documents conflict on 97151 — ask before the assessment.

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

## Common questions

### Does UnitedHealthcare Community Plan of Hawaii cover ABA therapy?

Yes — as a QUEST Integration plan it delivers the Med-QUEST ABA benefit for members under 21 with ASD, managed by Optum (United Behavioral Health) since 2016.

### Does Optum administer ABA for this plan?

Yes. The plan’s PA list says "For ABA Therapy, submit by fax or Provider Express," and the provider manual lists Optum for behavioral health authorizations and claims (payer ID 87726).

### Does the assessment need prior authorization?

Optum’s documents conflict — its 2022 orientation says no, its 2022 quick reference guide says all autism services need PA. Confirm with Optum before the assessment.

## Primary sources

1. [Optum Provider Express — Hawaii QUEST ABA Program page](https://public.providerexpress.com/content/ope-provexpr/us/en/clinical-resources/autismABA2/abaHI.html)
2. [Optum — Hawaii QUEST Integration ABA Provider Orientation (BH4131, 05/2022)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/hiABA/hiABAOrientation.pdf)
3. [Optum — QUEST Integration Health Plan ABA Program Quick Reference Guide (BH4051, 04/2022)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/hiABA/hiABAQRG.pdf)
4. [Optum Behavioral Health — Supplemental Clinical Criteria: Applied Behavior Analysis (annual review Aug 2025, interim Apr 2026)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/abaSCC.pdf)
5. [UnitedHealthcare Community Plan of Hawaii — Prior authorization requirements (effective June 1, 2026)](https://www.uhcprovider.com/content/dam/provider/docs/public/commplan/hi/prior-authorization/HI-UHCCP-Prior-Authorization-Effective-6-1-2026.pdf)
6. [UnitedHealthcare Community Plan — 2026 Care Provider Manual, Hawai‘i QUEST](https://www.uhcprovider.com/content/dam/provider/docs/public/admin-guides/comm-plan/HI-Care-Provider-Manual.pdf)
7. [Med-QUEST memo QI-2431 / FFS 24-13 (Dec 31, 2024) — Coverage of IBT for children under 21 with ASD: Guidelines for ABA (Attachments A–C)](https://medquest.hawaii.gov/content/dam/formsanddocuments/provider-memos/qi-memos/qi-memos-2024/QI-2431,%20FFS%2024-13%20Replaces%20QI-2301,%20FFS%2023-01%20Coverage%20of%20IBT%20for%20treatment%20of%20children%20under%2021%20years%20of%20age%20with%20ASD_Guidelines%20for%20ABA._FINAL%20(part%201)%20-%20signed.pdf)
8. [Med-QUEST memo QI-2527 / FFS 25-12 / CCS-2509 — Telehealth Implementation (Dec 8, 2025)](https://medquest.hawaii.gov/content/dam/formsanddocuments/provider-memos/qi-memos/qi-memos-2025/QI-2527%20FFS%2025-12%20CCS-2509%20%20Telehealth%20Implementation%20-%20signed.pdf)
9. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-438/subpart-D/section-438.210)
10. [42 CFR 433.139 — Medicaid payment of claims involving third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
11. [Med-QUEST / Milliman — ABA policy and rates updates presentation (Oct 30, 2024)](https://medquest.hawaii.gov/content/dam/formsanddocuments/plans-and-providers/fee-for-service/20241030%20-%20ABA%20Policy%20and%20Rates%20Updates%20Presentation.pdf)
12. [10 U.S.C. 1079(i)(1) — TRICARE pays after other coverage except Medicaid](https://www.govinfo.gov/content/pkg/USCODE-2023-title10/html/USCODE-2023-title10-subtitleA-partII-chap55-sec1079.htm)
13. [38 CFR 17.270 — CHAMPVA is the last payer](https://www.ecfr.gov/current/title-38/section-17.270)

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.