UnitedHealthcare Community Plan of New York ABA coverage (Medicaid Managed Care).

Follows the New York Medicaid rule, restated verbatim in Optum’s own criteria: “enrollees may be eligible for ABA if they are under age 21 and have received a diagnosis of autism spectrum disorder and/or Rett Syndrome as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).” No minimum age; no adult pathway.^[2][3]

Follows the New York Medicaid rule: Optum’s New York Medicaid/CHP entry copies the state’s referral clock — “referrals for ABA services are valid for no more than two years” and must include the date of initial diagnosis — and states no separate maximum age for the diagnostic evaluation. Optum’s national criteria add no recency rule either; their clock is the review cycle.^[2][3]

Follows the New York Medicaid rule, restated in Optum’s State Mandates supplement: “the NYS Medicaid member must be referred for ABA services by a NYS-licensed and NYS Medicaid-enrolled physician (including psychiatrists and developmental/behavioral pediatricians), psychologist, psychiatric nurse practitioner, pediatric nurse practitioner, or physician assistant.” Delivery is separate and state-specified: “ABA services are provided by Licensed Behavior Analyst (LBA), Certified Behavior Analyst Assistant (CBAA) working under the supervision of LBAs, or other individuals specified under Article 167 of NYS education law.”^[2][3]

Follows the New York Medicaid rule: Optum’s New York entry requires the referral to carry the “DSM-5 Diagnostic Checklist for ASD diagnoses” and the symptom severity level/level of support, and names no instrument beyond that. Optum’s national criteria do publish a two-tier instrument list (CARS-2, ADI-R, ADOS-2, DISCO for diagnosis; ATEC, VB-MAPP, ABLLS-R, AFLS, PEAK, SSIS, RBS-R, SRS, Vineland, CFQL-2 for setting intensity), but the New York Medicaid entry is the state-specific criteria set for this plan — confirm with the Autism Care Advocate which applies to a given request.^[2][4]

Follows the New York Medicaid rule for the clinical content — the 2-year practitioner referral with the seven required elements, DSM-5 checklist included — but the process is the inverse of fee-for-service: “all ABA services require prior authorization.” The assessment PA goes in as an online ABA Assessment request on providerexpress.com; the treatment PA follows through the portal or by calling the Autism Care Advocate with the member’s name and ID, diagnosis and a description of the treatment plan. Claims deny without an authorization on file, and requesting units beyond the authorization needs a new PA.^[2][1]

The most specific telehealth answer of any New York Medicaid plan: telehealth is allowed for supervision (97155) and caregiver training (97156 and 97157) once the practice is approved as a virtual-visits provider, billed with place of service 02. Direct technician-delivered treatment is not on that list. Optum’s national criteria add only best-practice framing — telehealth options “are not intended to supplant in-person service; rather, they are intended to supplement the traditional in-person service delivery model.”^[1][4]

Every ABA service is prior-authorized through Optum (providerexpress.com). UHC’s 2026 New York manual decides a non-urgent pre-service request “within 3 business days of receipt of medical record information required, but no longer than 14 calendar days of receipt,” an urgent request “within 72 hours of receipt of an expedited authorization request,” and a concurrent review “within 24 hours or next business day following.” Note the outer limit: federal rules cap standard Medicaid managed-care decisions at 7 calendar days for plan rating periods starting on or after January 1, 2026, so the manual’s 14-day ceiling is looser than the current floor — plan around the 3-business-day clock and escalate anything past 7 days. Neither the manual nor Optum’s NY ABA materials set a reauth submission lead time; each concurrent request needs updated diagnoses, other services, medications, school hours, parent participation, progress and discharge criteria.^[5][1][6]

“UnitedHealthcare Community Plan is, by law, the payer of last resort for eligible members. Therefore, you must bill and obtain an explanation of benefits (EOB) from any other insurance or health care coverage resource before billing UnitedHealthcare Community Plan… Please attach a copy of the EOB to the submitted claim.” The EOB must be complete enough to show the paid amount or denial reason, and “the date on the other carrier’s payment correspondence starts the timely filing period for submission to UnitedHealthcare Community Plan.” Neither the manual nor Optum’s ABA materials say whether Optum’s ABA prior authorization is still required when UHC is secondary — confirm with Optum (1-866-362-3368) before relying on the primary plan’s approval.^[5]

Follows the New York Medicaid rule, which the state applies to FFS and managed care alike: “an LBA can supervise no more than six CBAAs/unlicensed individuals at a time,” “LBAs are required to supervise unlicensed individuals for a minimum of five percent of the hours the unlicensed individual spends providing behavior analysis services each calendar month,” and “supervision must include at least two face-to-face, real-time contacts per month” with the LBA observing service delivery in at least one. Supervision may run over synchronous audio-and-video where on-site is impractical. 97155 counts toward the 5% “only when the LBA joins the patient and the unlicensed individual during a treatment session to direct the unlicensed individual/technician in implementing a new or modified treatment protocol.” CBAAs need direct supervision, and the supervisor “should assess each patient’s/client’s progress at least every 6 months… and review and sign treatment notes and reports prepared by the CBAA supervisee.” Optum layers network requirements on top: LBAs must hold active BCBA certification plus the New York license plus a NY Medicaid ID, CBAAs need their own Medicaid ID, and a virtual-visits attestation is required for telehealth supervision. “LBAs may form a group practice. CBAAs may work in a group practice but cannot own a group practice.”^[3][2][1]

No hour caps are published — treat the authorized units as the operative ceiling, because “over limit” is a listed denial reason and additional units require a new prior authorization rather than an adjustment. Optum’s national criteria decline to set a numeric ceiling on evidence grounds and note that “full time ABA programs are rare,” while flagging utilization below 80% of authorized hours at review.^[1][4]

Follows the New York Medicaid rule: the LBA supervisor must “review and sign treatment notes and reports prepared by the CBAA supervisee,” and documentation of supervision itself “should be recorded in the patient file.” Clinical documentation must carry the treatment plan with assessment and goals, the goal data, total hours of service per week by who delivered them, and the location(s) of services. Records are kept “for a minimum of six years and, for minors, until the patient turns 22 years of age.” Optum publishes no additional New York Medicaid signature rule; its national criteria require only that behavior analysts “identify their services accurately and include all required information on reports, bills, invoices, requests for reimbursement, and receipts.”^[3][4]

Follows the New York Medicaid rule, restated in Optum’s State Mandates entry: “LBAs and CBAAs may work in any setting that may legally provide ABA services. Examples of such settings may include: private practice, settings where patients/clients reside full-time or part-time, clinics, hospitals, residences, and community settings” — and NYS Medicaid does not reimburse ABA in a school setting. Optum’s national criteria exclude the same functional overlap: “1:1 aid delivered simultaneously during classroom instruction, or services covered under the Individuals with Disabilities Education Act (IDEA),” while allowing teacher training, meetings with school personnel and school observations as coordination.^[2][3][4]

Optum defers to the state and then to itself on enrollment: “ABA providers offering services to a Medicaid Managed Care (MMC) enrollee must contact the enrollee’s specific MMC Plan(s) for coverage, billing, and reimbursement guidance,” and network LBAs must carry a NY Medicaid ID alongside the license and BCBA certification, with CBAAs holding their own Medicaid ID. At the fee-for-service layer New York is explicit: LBAs bill “using the LBA’s National Provider Identification (NPI) number for the ‘Billing’ provider and/or ‘Supervising’ provider,” with “the NPI number of the CBAA that provided the ABA service… reported as the ‘Rendering’ provider on each claim”; for unlicensed aides and LBA limited-permit holders the supervising LBA’s NPI fills all three roles. CBAAs cannot bill directly and enroll as OPRA providers. Confirm the managed-care claim format on Provider Express before billing.^[2][1][3]

Ask the plan: Provider Express or the Autism Care Advocate line for the MMC claim format — the eMedNY roles above are the FFS reference.

Not published. Optum’s New York Medicaid entry restates state eligibility and referral rules and says nothing about billing 97153 and 97155 for the same clock time; the national Supplemental Clinical Criteria govern medical necessity rather than claim edits, and the state manual is silent.^[2][4][3]

Ask the plan: The Autism Care Advocate line or Provider Express provider services, plus UnitedHealthcare Community Plan of New York’s reimbursement policies.