---
title: UnitedHealthcare Community Plan of New Jersey ABA coverage (NJ FamilyCare MCO).
url: "https://carelu.com/payers/unitedhealthcare-community-plan-new-jersey"
markdown_url: "https://carelu.com/payers/unitedhealthcare-community-plan-new-jersey.md"
state: NJ (New Jersey)
payer: UnitedHealthcare Community Plan (NJ FamilyCare)
kind: Medicaid managed care plan (MCO)
parent_program: NJ FamilyCare
description: "How UnitedHealthcare Community Plan administers NJ FamilyCare ABA through Optum — the November 2025 NJ criteria (no comprehensive evaluation required, ages 18 months to 21, school setting outside school hours), Provider Express intake, and contacts."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# UnitedHealthcare Community Plan of New Jersey ABA coverage (NJ FamilyCare MCO).

_Payer Guide · UHC Community Plan (NJ) · Last updated September 2026 · 5 primary sources_

> Optum-run; no comprehensive eval needed, school setting OK outside school hours, Provider Express intake.

UnitedHealthcare Community Plan administers its NJ FamilyCare ABA benefit through Optum Behavioral Health, governed by Optum's ABA supplemental criteria plus a dedicated New Jersey Medicaid entry in the ABA State Mandates document (BH803ABASTM12026, revised November 18, 2025, effective January 2026). Substantively it follows the state benefit design — but wraps it in Optum's Provider Express intake, forms, and documentation culture, a different operational world from the state baseline. Two of its written positions are genuinely family-friendly: no comprehensive diagnostic evaluation is required, and school-setting services are permitted outside normal school hours.

This plan administers the **NJ FamilyCare** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [NJ FamilyCare (New Jersey Medicaid) guide](https://carelu.com/payers/new-jersey-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — NJ FamilyCare baseline; ABA/DIR requests via Optum's dedicated NJ ABA path on Provider Express (BH intake 1-888-362-3368, option 3) [4][2]
- **Prior auth for treatment**: Required — via the Provider Express NJ ABA request path; authorization inquiry at providerexpress.com [4][2]
- **Autism diagnosis required?**: Yes — ASD (F84.0–F84.9) by a physician or psychologist; a comprehensive diagnostic evaluation is NOT required (BH803ABASTM12026) [1]

## At a glance

- **Plan type:** NJ FamilyCare MCO — BH administered by Optum
- **Clinical rules:** Optum ABA criteria + a dedicated NJ Medicaid entry (rev. 11/18/2025)
- **Diagnosis bar:** ASD dx by physician/psychologist — comprehensive evaluation NOT required
- **Ages:** 18 months to 21 years, by medical necessity — no stated hour caps
- **School setting:** Permitted outside normal school hours (newer than the state's 2020 rule)
- **Submission:** Provider Express NJ ABA path; BH intake 1-888-362-3368 (opt. 3); payer ID 87726

## The Optum NJ entry: the friendliest diagnosis bar in the state

Optum's NJ Medicaid entry states explicitly that "a comprehensive diagnostic evaluation is not required to access ABA services" — any physician or psychologist ASD diagnosis (F84.0–F84.9) opens the benefit, for members 18 months to 21 years, with coverage keyed to medical necessity and no stated NJ hour caps. It also enumerates the QHP roles and permits services in the school setting as long as they don't occur during normal school hours — a newer, looser position than the state's 2020 "no school facility" rule. For intake this means: don't hold a UHC family waiting on a full diagnostic workup, and don't rule out after-school programming on school grounds. The NJ entry was specifically revised in the November 18, 2025 interim review, so it reflects current Optum thinking. [1]

## Submission mechanics and contacts

ABA and DIR requests submit through Optum's dedicated NJ ABA page on Provider Express (the state's own contact document links abaNJ.html — the direct URL returned a 404 in mid-2026, so navigate from providerexpress.com rather than a saved bookmark); general behavioral-health PA runs by phone at 1-888-362-3368, option 3 for intake, and claims use payer ID 87726. Optum also maintains a dedicated Network Manager for Autism Services — Joelle Carrion (jcarrion@optum.com, 612-474-7148) — a named human for contracting and escalation that most plans don't offer. Rates are unverified: no NJ ABA fee schedule is published, so your Optum participation agreement is the source of truth. [2][1]

## Intake gates

The questions that decide whether a family can start with UnitedHealthcare Community Plan (NJ FamilyCare), and what they have to bring.

- **Age limit**: Two published numbers, and they differ in precision rather than in substance. The founding DMAHS newsletter sets the benefit for "any Medicaid eligible child, under the age of 21, who has been diagnosed with ASD as defined by ICD 10 diagnoses F84.0 through F84.9 by a qualified healthcare provider," delivered under EPSDT, which reaches "individuals under the age of twenty-one." Optum's New Jersey Medicaid entry adds the floor as well as the ceiling: "ABA services shall be made available to children 18 months to 21 years of age based on medical necessity," and its NJ FamilyCare provider orientation repeats it — "Must be 18 months – 21 years old," including in the specialized FamilyCare carve-out. No hour caps are attached to the age band. This is the plan the 18-month floor comes from: Optum's NJ FamilyCare provider orientation states it directly — "Must be 18 months – 21 years old," "Must have Autism Diagnosis" — and extends it to the specialized FamilyCare carve-out. Flag edge cases at either end early. [1][3]
- **Who may diagnose**: New Jersey names them twice, and the second list is narrower than the first. The newsletter's general test: "The need for ABA services must be determined by a qualified healthcare professional (QHP) capable of making a diagnosis of autism. QHPs include licensed health care professionals, who are qualified by education, training, or licensure/regulation (when applicable) to perform a professional service within his/her scope of practice." The enumerated list of acceptable QHPs "for the diagnosis and treatment planning for adaptive behavior services" is then: Physicians; Psychologists, which "Requires an active board certified behavior analyst (BCBA) certification in good standing and a qualifying doctoral-level degree (BCBA-D)"; and BCBAs, who appear for treatment planning rather than diagnosis. Optum's NJ entry restates the split: the diagnosis comes from "a physician or psychologist," and "It is not uncommon for one QHP to make the diagnosis (such as a physician) and a separate QHP (such as a BCBA) to develop and supervise the treatment plan." Optum's NJ entry is the document that states this most plainly: "The need for ABA services must be determined by a qualified healthcare professional (QHP) capable of making a diagnosis of autism, such as a physician or psychologist." [1][4]
- **Diagnostic tools required**: None required — and New Jersey is one of the few states that says so in terms. Optum's NJ Medicaid entry: "A comprehensive diagnostic evaluation is not required to access ABA services," with "ABA services … available to any child diagnosed with autism spectrum disorder as defined by ICD-10 diagnoses F84.0 through F84.9." The DMAHS newsletter names no instrument either. That makes this the friendliest diagnostic bar of the three states on this page — intake should not queue a New Jersey family for an ADOS-2 before starting the authorization. This is the plan that publishes the sentence — do not hold a UnitedHealthcare Community Plan family waiting on a full diagnostic workup. [1]
- **Referral required?**: No PCP referral and no physician order. The sequence the state sets is QHP determination, then MCO authorization: "Once an individual is properly diagnosed with ASD, the MCO shall authorize a QHP to assess the child for the development of a proposed treatment plan," and treatment follows "Contingent upon approval of the treatment plan." The genuine intake asset sits one step earlier — members still fee-for-service pending MCO enrollment are covered through Gainwell with no prior authorization required at all, so enrollment status, not a referral, is the routing question. Plan practice adds paperwork rather than a referral: Horizon wants an ASD diagnosis "script" from a QHP attached to the assessment request, which is the diagnosis document under another name. On this plan the paperwork route is Optum's: ABA and DIR requests go through the dedicated NJ ABA path on Provider Express (navigate from providerexpress.com — the saved abaNJ.html URL returned a 404 in mid-2026), with general behavioral-health PA by phone at 1-888-362-3368, option 3. [4][1]
- **Telehealth**: The one New Jersey plan with a published ABA telehealth rule, and it is specific. Optum allows BCBAs and licensed BH clinicians within contracted ABA practices to deliver ABA supervision and caregiver training by telehealth, but only after the practice becomes an approved Optum virtual-visits provider by attestation on Provider Express, and only if it alerts the Care Advocate that the services will be virtual while completing the authorization. Billing is then plain: "include the same procedure code you would use for an in-person service, 97155 or 97156, on your claim with the “02” place of service code." Direct technician treatment is not inside the carve-out, and the state publishes no ABA telehealth rule of its own. [3]
- **Prior-auth decision time**: UnitedHealthcare Community Plan of New Jersey's manual (2025 edition) prints: non-urgent pre-service "Within 14 calendar days from the receipt of the request"; urgent/expedited pre-service "Within 24 hours of receipt of the necessary information, but no later than 72 hours after receipt"; concurrent review within 24 hours or the next business day. Federal floor for every NJ FamilyCare MCO: standard decisions within 7 calendar days of the request for contract rating periods starting on or after January 1, 2026 (14 days before that), extendable by up to 14 calendar days at the member's or provider's request or when the plan justifies needing more information; expedited within 72 hours. Treat 7 calendar days as the ceiling for any contract year that began on or after January 1, 2026. ABA authorizations run through Optum. [6][7]
- **Other insurance (who pays first)**: UHC Community Plan of New Jersey: bill the commercial plan first (the manual's own example is a member covered as a dependent on a parent's plan: "the commercial plan is primary and must be billed first"), then submit COB claims "within 60 days from the date of the primary insurer's EOB or 180 days from the dates of service, whichever is later," with evidence of the first payer's payment. On authorization the manual is blunt: "Unless we have given prior authorization, we are not liable for payment if the other payer refuses payment due to a determination that the services provided were not medically necessary" — get UHC/Optum's authorization as well. State rule underneath: NJ FamilyCare pays last: "All TPL, for example, health insurance, Medicare, CHAMPUS, prepaid health plans… shall, if available, be used first and to the fullest extent." Bill the commercial plan first; supplementation claims "shall not be filed with the program unless accompanied by a statement of payment, Explanation of Benefits (EOB), or denial from the other carrier." Two traps: "No program payments shall be made when the third-party payer requires a contracting or participating provider to accept that third-party payer's payment as payment in full," and when NJ FamilyCare is secondary it pays the lesser of its allowed amount minus other payments, or the patient liability. TRICARE and CHAMPVA both pay ahead of Medicaid: TRICARE rules state "Medicaid is not a double coverage plan. In any double coverage situation involving Medicaid, CHAMPUS is always the primary payer," and CHAMPVA "assumes primary payer status" over Medicaid. [6][8][9][10][11]
- **Diagnosis recency** _(ask the plan)_: Not published. Neither the DMAHS newsletter nor Optum's New Jersey entry sets a maximum age for the diagnostic evaluation, and the state's written position runs the other way: Optum's NJ Medicaid entry says flatly that "A comprehensive diagnostic evaluation is not required to access ABA services," so there is no comprehensive evaluation whose recency could be gated. What is dated in New Jersey is the authorization rather than the diagnosis — Horizon issues 32 units of 97151 valid for 30 days, and treatment authorizations run in 6-month spans. Optum's NJ entry was specifically revised in the November 18, 2025 interim review, so the no-comprehensive-evaluation position reflects current Optum thinking rather than a legacy line. [1][4]
  - Ask the plan: The Optum Care Advocate, or BH intake at 1-888-362-3368 (option 3); the dedicated NJ ABA path lives on Provider Express.

## Delivery and billing rules

Coverage decides whether UnitedHealthcare Community Plan (NJ FamilyCare) 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 runs looser than the state on paper: its NJ FamilyCare ABA provider orientation asks only that behavior technicians be high school graduates who “receive appropriate training and supervision by BCBAs,” with the BCBA performing skills assessments and providing “direct supervision of BCaBAs/Behavior Technicians in joint sessions.” No percentage floor or caseload cap is published. Because state FFS policy names the RBT as the technician provider for 97152/97153, hire to the RBT standard — it satisfies both. [3][4]
- **Concurrent billing (97153 + 97155)**: New Jersey says yes, in writing, and draws the line precisely. “If the QHP is overseeing the activities of the technician, the time of direct supervision by the QHP shall be concurrently billable using code 97155.” But “billing for 97155 is limited to time where the QHP is either engaged directly with the patient or is directing a technician in implementing a modified protocol with the patient. Billing for supervision where the technician is not present is not allowed.” Two other concurrency rules ride along: 97156 may be billed while the RBT delivers direct treatment to the child “in a separate location”; and for 0373T “providers may not bill for the QHP time concurrently” and billing is limited to a single technician’s face-to-face time, never the combined time of multiple technicians (three technicians for two hours bills eight units, not twenty-four). This is NJ FamilyCare state policy and the operative floor for UnitedHealthcare Community Plan; no plan-specific deviation was found in UnitedHealthcare Community Plan’s published material. [4]
  - Ask the plan: UnitedHealthcare Community Plan provider services, to confirm the plan has not layered its own concurrency edit on top.
- **Daily limits / MUEs**: New Jersey publishes its own table rather than adopting a CMS MUE regime, and labels it guidance: the limits “are for guidance purposes only and may be overridden when medically necessary based on individual need” under EPSDT. Per day, in 15-minute units: 97151 32, 97152 8, 97153 32, 97154 12, 97155 24, 97156 16, 97157 16, 97158 16, 0362T 8, 0373T 32. Treat them as soft ceilings the plans enforce as edits — a request above them needs explicit EPSDT medical-necessity framing rather than a quiet resubmission. UnitedHealthcare Community Plan publishes no daily table of its own, so the state guide is what to plan against. [4]
  - Ask the plan: UnitedHealthcare Community Plan’s provider manual / claim-edit list.
- **Place of service** _(plan-dependent)_: This one has moved and the two live sources disagree. The founding DMAHS newsletter is flat: “ABA services may be provided in the therapist’s office, a community setting or the child’s home. Services may not be provided within a school facility.” Optum’s ABA State Mandates document (annual review 7/2026), whose NJ Medicaid entry tracks the same state policy, now reads: “Services may be provided in the school setting as long as services are not provided during normal school hours.” Office, home and community are settled; school is plan-dependent and moving; group home is addressed by neither. Optum adds one concrete billing instruction for the virtual half: ABA supervision and caregiver training delivered by telehealth are billed with the same code you would use in person — 97155 or 97156 — plus place-of-service 02, and the practice must first be an approved Optum virtual-visits provider (attestation on Provider Express) and must flag virtual delivery to the Care Advocate at authorization. [4][1][3]
  - Ask the plan: Optum Care Advocate, for whether school-setting delivery is authorized on a given member.
- **Bill as provider** _(ask the plan)_: Optum requires an NPI and taxonomy codes on every claim submitted for reimbursement. Which NPI carries technician-delivered 97153 — agency, supervising analyst, or rendering technician — is not stated in the NJ FamilyCare orientation; the state’s own rule is that RBTs and BCaBAs are listed under the enrolled ABA Treatment Provider’s agency enrollment rather than enrolled as billing providers. [3][5]
  - Ask the plan: Optum/UnitedHealthcare Community Plan provider services for the rendering-provider field on NJ FamilyCare ABA claims.

## What intake should collect for UnitedHealthcare Community Plan (NJ FamilyCare)

- **ASD diagnosis — any physician/psychologist:** No comprehensive evaluation needed; a plain dx opens the benefit. Don't queue families for a full workup first.
- **Age check (18 months–21 years):** Optum's NJ entry states the range explicitly — flag edge cases early.
- **Optum credentialing status:** ABA runs on the Optum behavioral network via Provider Express — separate from UHC medical.
- **School-setting plans:** Billable outside normal school hours per Optum's NJ entry — capture the school schedule to design around it.

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

## Verification of benefits (VOB) data

How UnitedHealthcare Community Plan (NJ FamilyCare) ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** UHG001 — pVerify has no NJ-specific UHC Community Plan row; UHG001 = generic "UnitedHealth Group - Community Plan." Confirm the NJ-specific mapping via pVerify payer search.
- **Payer ID (Availity):** 87726 — Claims payer ID 87726 per UHC EDI docs (appears as "UNITEDHEALTHCARE" in the stale 2012 Availity list) — confirm against a current export.
- **Payer ID (Change Healthcare / Optum):** 86047 — Change Healthcare/Optum lists 86047 = "UnitedHealthcare Community Plan / NJ" (former 86001; supports 270/271). UHC docs: claims payer ID 87726, ERA 86047 — same plan.
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** Optum Behavioral Health (network/authorization via Provider Express; claims ride the medical payer ID)
- **BH administrator payer ID:** 87726
- **ABA rides on:** medical benefit — ABA network contracted separately through Optum/Provider Express, but claims ride the medical payer ID (87726 claims / 86047 NJ community-plan line) — no separate Optum BH claims payer ID, no second EDI hop.
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 32 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97152 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 8 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97153 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 32 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97154 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 12 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97155 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 24 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97156 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 16 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97157 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 16 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97158 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 16 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 0362T | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 8 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 0373T | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 32 units/day — state "suggested" MUE limit, run by the MCOs as a claim edit; overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** Optum-administered (Provider Express NJ ABA path; BH intake 1-888-362-3368 opt. 3). Per Optum's NJ Medicaid entry (rev. 11/18/2025): no comprehensive diagnostic evaluation required (any physician/psychologist ASD dx opens the benefit), ages ~18 months to 21, school-setting services permitted outside normal school hours. No stated NJ hour caps beyond the state MUE table.

### Medicaid rates

Source: No UnitedHealthcare Community Plan NJ-specific ABA fee schedule is publicly posted; the NJ FamilyCare FFS schedule is the documented reference baseline (MCOs are not required to match it). Confirm the plan-paid rate in your participating-provider agreement. Effective 2022-02-01.

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | $25.00 | 15min | renderedBy: BCBA / BCBA-D (assessment); status: launch-era value; current status unverified — confirm in the CY2026 Procedure Master Listing |
| 97152 | $11.20 | 15min | renderedBy: RBT / BCaBA (supporting assessment); status: launch-era value; current status unverified |
| 97153 | $15.00 | 15min | renderedBy: RBT / BCaBA; status: verified current (CY2026 Q2); raised from $11.20 eff 2/1/2022 |
| 97154 | $4.80 | 15min | renderedBy: RBT / BCaBA (group); status: launch-era value; current status unverified |
| 97155 | $21.25 | 15min | renderedBy: BCBA / BCBA-D; status: verified current (CY2026 Q2) |
| 97156 | $25.00 | 15min | renderedBy: BCBA / BCBA-D (family guidance); status: verified current (CY2026 Q2) |
| 97157 | $12.40 | 15min | status: launch-era value; current status unverified |
| 97158 | $5.60 | 15min | status: launch-era value; current status unverified |
| 0362T | $25.00 | 15min | status: launch-era value; current status unverified |
| 0373T | $16.40 | 15min | status: launch-era value; current status unverified |

### Contacts

- **Provider services phone:** 1-888-362-3368
- **Phone menu path:** Enter TIN # → select option 3 (intake) → enter member ID/DOB → select "Mental Health."
- **Portal:** [Provider Express](https://www.providerexpress.com)

Questions to ask on a verification call:

- Does Optum apply any unit or hour caps beyond the state's daily MUE table for this member?
- Is eligibility checking real-time or batch?
- Can you confirm the correct pVerify payer code for this NJ Community Plan line? (our mapping is inferred, not payer-confirmed)

### VOB data sources

- https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/scc/ABA_SCC_SM.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://www.optum.com/content/dam/o4-dam/resources/pdfs/guides/professional-claims-payer-list.pdf (accessed 2026-07-23)
- https://test.njmmis.com/downloadDocuments/5010_270-271_HIPAACompanionGuide.pdf (accessed 2026-07-23)
- https://www.nj.gov/humanservices/dmhas/documents/pdf/resources/providers/DMAHS-BH-Integration-Points-of-Contact.pdf (accessed 2026-07-23)
- https://web.archive.org/web/2023/https://www.nj.gov/humanservices/dmahs/news/Provider_Newsletter_for_Applied_Behavior_Analysis_Therapy.pdf (accessed 2026-07-23)
- https://www.providerspark.com/for-providers/medicaid-rates/new-jersey/ (accessed 2026-07-23)
- https://autismnj.org/news/autism-new-jerseys-advocacy-leads-to-medicaid-rate-increase-for-aba-services/ (accessed 2026-07-23)

## Common questions

### Does UnitedHealthcare Community Plan of New Jersey cover ABA?

Yes — the NJ FamilyCare ABA benefit, administered by Optum Behavioral Health under Optum's criteria plus a dedicated NJ Medicaid entry (revised November 2025). Requests go through Provider Express's NJ ABA path.

### Does UHC NJ Medicaid require a comprehensive diagnostic evaluation for ABA?

No — Optum's NJ entry says so explicitly. An ASD diagnosis (F84.0–F84.9) from any physician or psychologist opens the benefit for members 18 months to 21 years.

### Can ABA be delivered in schools for UHC NJ members?

Yes, outside normal school hours — Optum's NJ entry permits school-setting services as long as they don't occur during the school day, a looser position than the state's original 2020 rule.

## Primary sources

1. [Optum ABA State Mandates BH803ABASTM12026 — NJ Medicaid entry](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/scc/ABA_SCC_SM.pdf)
2. [DMAHS BH Integration Points of Contact V3.1 — UHC/Optum ABA contacts](https://www.nj.gov/humanservices/dmhas/documents/pdf/resources/providers/DMAHS-BH-Integration-Points-of-Contact.pdf)
3. [Optum/UHC Community Plan — NJ FamilyCare ABA Provider Orientation (2022)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/njaba/NJ.FamilyCare.Medicaid.ABA.pdf)
4. [DMAHS Provider Newsletter Vol 30 No 06 — Provision of ABA services (4/1/2020)](https://web.archive.org/web/2023/https://www.nj.gov/humanservices/dmahs/news/Provider_Newsletter_for_Applied_Behavior_Analysis_Therapy.pdf)
5. [NJMMIS — ABA Treatment Provider FFS enrollment packet (Gainwell)](https://www.njmmis.com/documentDownload.aspx?document=Applied_Behavior_Analysis.pdf)
6. [UnitedHealthcare Community Plan of New Jersey — Care Provider Manual (2025)](https://www.uhcprovider.com/content/dam/provider/docs/public/admin-guides/comm-plan/NJ-Care-Provider-Manual.pdf)
7. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/section-438.210)
8. [Optum — UHC Community Plan of NJ Behavioral Health Provider Network Manual Addendum (2025)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/ourNetworkMain/welcomeNtwk/nj/njMedicaidManual.pdf)
9. [N.J.A.C. 10:49-7.3 — Third-party liability (TPL) benefits (LII)](https://www.law.cornell.edu/regulations/new-jersey/N-J-A-C-10-49-7-3)
10. [32 CFR 199.8 — TRICARE double coverage (eCFR)](https://www.ecfr.gov/current/title-32/section-199.8)
11. [38 CFR 17.272 — CHAMPVA benefit limitations; Medicaid exception (eCFR)](https://www.ecfr.gov/current/title-38/section-17.272)

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.