UnitedHealthcare Community Plan of Texas (STAR, STAR Kids, CHIP) applies the state's TMPPM Autism Services criteria — it publishes no distinct Texas ABA clinical policy, and Optum's national ABA state-mandates supplement has no Texas entry. What it does differently is routing: behavioral health, ABA included, is carved out to UHC's designated behavioral health network run by Optum. That carve-out is the single most important thing to know about this plan, because it explains a fact that misleads new providers constantly: ABA codes are absent from UHC's Texas medical PA lists — not because PA isn't required, but because ABA never travels through the medical pipeline at all.
UHC's STAR Kids medical prior-authorization list (effective 11/1/2025) does not contain ABA codes 97151–97158 — and a provider who reads that as "no PA needed" is walking into denials. The codes are missing because behavioral health services are carved out to the plan's designated behavioral network, administered by Optum: ABA authorization requests go through that BH pipeline (phone 888-887-9003, with the UnitedHealthcare Provider Portal as the submission surface), not the medical PA tool. The state benefit's PA requirement applies in full — TMPPM criteria, prescriber referral, 3-year dx recency, the 90/90/180 cadence. Route it correctly on day one and set family expectations against the plan's published timelines: routine PA decisions within 3 business days, expedited within 72 hours. Third-party sources also cite a BH intake fax (877-940-1972), though we could not verify that number against a UHC primary source — confirm it on the portal before relying on it.[1][2]
Optum's national ABA supplemental clinical criteria document (BH803ABA) lists state-specific overlays for a handful of states — and Texas is not one of them. With no distinct plan policy either, the TMPPM governs Medicaid medical necessity for UHC members exactly as it does everywhere else in Texas: same diagnoser list, same recency rule, same hour caps, same telehealth restrictions. Build your clinical documentation to the state baseline and treat Optum as the intake mechanism, not a second rulebook.[3]
The questions that decide whether a family can start with UnitedHealthcare Community Plan of Texas, and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the Texas Medicaid (TMPPM) rule: birth through 20 years of age on the date of service, with eligibility ending the day of the 21st birthday. CHIP members are excluded from the ABA benefit. Optum administers the authorization but adds no Texas overlay — its ABA State Mandates supplemental criteria contain no Texas entry.[4][3]
Follows the Texas Medicaid (TMPPM) rule: the ASD diagnosis must be made or reconfirmed within 3 years of initiation or recertification; past 3 years a comprehensive re-evaluation of ASD symptom severity levels per DSM criteria is required first. Optum administers the authorization but adds no Texas overlay — its ABA State Mandates supplemental criteria contain no Texas entry.[4][3]
Follows the Texas Medicaid (TMPPM) rule: a developmental pediatrician, neurologist, psychiatrist, licensed psychologist, or an interdisciplinary diagnostic team (a physician, PA or NP in consultation with qualified child specialists with autism expertise). Optum administers the authorization but adds no Texas overlay — its ABA State Mandates supplemental criteria contain no Texas entry.[4][3]
Follows the Texas Medicaid (TMPPM) rule: a reliable, valid, standardized diagnostic assessment tool or combination of tools — the manual names the ADOS, ADI-R and CARS as examples. Screening instruments alone (STAT, M-CHAT-R) do not substitute. Optum administers the authorization but adds no Texas overlay — its ABA State Mandates supplemental criteria contain no Texas entry.[4][3]
Follows the Texas Medicaid (TMPPM) rule: a signed, dated prescriber referral for the evaluation, signed within 60 calendar days before or on the anticipated evaluation date; and for treatment a signed, dated referral from a physician or allowed practitioner (MD/DO, PA, NP, or CNS with delegated authority) stating frequency and duration, signed on or before the service start date and no more than 3 months old. Since 4/1/2025 the prescriber signature is no longer required on the CCP PA form for the 90-day extension. Optum administers the authorization but adds no Texas overlay — its ABA State Mandates supplemental criteria contain no Texas entry.[4][3][6]
Follows the Texas Medicaid (TMPPM) rule: synchronous audio-visual only, modifier 95, on 97151, 97155, 97156, 97158 and 99366. One-on-one direct treatment delivered to the child by a behavior technician or LaBA must be in person — telehealth is prohibited for BT/LaBA-delivered direct service. Optum administers the authorization but adds no Texas overlay — its ABA State Mandates supplemental criteria contain no Texas entry.[4][3]
Three business days on a complete request: "We will render a decision for prior authorizations submitted electronically or by fax, and which include complete supporting documentation" within three business days; expedited reviews within 72 hours. The Care Provider Manual's table words the standard as "Within 3 working days of receipt of medical record information required but no longer 14 calendar days of receipt," and adds that "For members younger than 21 years of age, we allow up to 7 days for any necessary additional information." Incomplete requests: a letter listing what is missing goes out within 3 business days; if nothing arrives by the end of the third business day the request may be denied after medical-director review, and "The request will be decisioned no later than the 10th business day from receipt of the request." Renewals: an existing authorization "can be requested to continue that service as a prior authorization with[in] 60 days of the end of the previously approved authorization period." ABA requests route through the plan's Optum behavioral health pipeline.[7][8][9][10]
"UnitedHealthcare Community Plan is the payer of last resort. Other coverage should be billed as the primary carrier. When billing UnitedHealthcare Community Plan, submit the primary payer's Explanation of Benefits or remittance advice with the claim." The EOB must show the paid amount or denial reason. "The date on the other carrier's payment correspondence starts the timely filing period" for the Medicaid claim, and under the 110-day rule, if the other insurer "has not responded to or has delayed payment on a claim for more than 110 days from the date the claim was billed, we will consider the claim for reimbursement." The manual does not say whether the plan's own ABA authorization is still needed when it pays second — request it through Optum anyway.[8][11]
Coverage decides whether UnitedHealthcare Community Plan of Texas pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Follows the Texas Medicaid (TMPPM) rule: the manual sets no numeric ratio of its own, requiring LBAs to directly supervise LaBAs and behavior technicians in accordance with Texas licensure and deferring to the certifying body's minimums — for RBT-credentialed staff the BACB floor of supervision on at least 5% of service hours each month with two face-to-face contacts. Only direct supervision, where the LBA observes the LaBA or BT with the child, is reimbursable (under 97155); indirect supervision is unpaid.[4][3][5]
Follows the Texas Medicaid (TMPPM) rule: concurrent billing is prohibited — Texas Medicaid will not reimburse multiple ABA providers during one session with the child when more than one provider is present. The single exception is when the family and the child receive separate services and the child is not present in the family session. Total authorized hours may be requested under either 97153 or 97155 and billed as the code matching the service actually delivered — not both for the same clock time with the child present.[4][3]
Follows the Texas Medicaid (TMPPM) rule: direct treatment is capped at 8 hours (32 units) per day combined across 97153, 97154, 97155 and 97158; 97151 is capped at 6 hours (24 units) per evaluation and per re-evaluation; group treatment runs 2 to 8 children. Authorization periods are two consecutive 90-day terms then recertifications of up to 180 days.[4][3]
Follows the Texas Medicaid (TMPPM) rule: rendering ABA providers must sign each entry with full signature and credentials, with additional supervisory signatures per state licensure. Treatment notes carry the child's name, date of service, start and stop times, goals addressed, progress and a summary of interventions; 97155/97158 notes add protocol-modification decision points. The 97151 evaluation and the 90-day progress summary each need a dated signature from the LBA and from the parent or caregiver.[4][3]
Follows the Texas Medicaid (TMPPM) rule: home, clinic, office and community settings are payable. In schools, services delivered by a behavior technician as a shadow, an aide, or as general support are excluded; school personnel participating to coordinate care are not counted as duplicate providers, and interdisciplinary team meetings bill under 99366 against an ABA PA. BT and LaBA direct treatment must be in person in every setting.[4][3]
Follows the Texas Medicaid (TMPPM) rule: only the LBA enrolls in Texas Medicaid and bills. LaBAs and behavior technicians may not enroll — their services go out under the supervising LBA's NPI with the credential modifier identifying who rendered (HO = LBA, HN = LaBA, HM = behavior technician; 97151 takes HO only, 97155/97156/97158 take HO or HN). The LBA must directly employ or contract with every LaBA and BT on the team. Authorization for these claims routes through the plan's designated behavioral health network (Optum) at 888-887-9003, not UHC's medical PA pipeline.[4][2]
Yes — the state Autism Services benefit on TMPPM criteria. Authorization runs through UHC's designated behavioral health network (Optum), not the medical PA pipeline.
Because behavioral health is carved out to Optum's BH network — the medical PA list doesn't govern ABA. PA is still required; it just routes through the BH pipeline at 888-887-9003.
No — Optum's ABA state-mandates supplement has no Texas entry, and the plan publishes no distinct TX policy, so the TMPPM criteria govern. Optum is the UM intake, not a separate rulebook.
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.
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