---
title: "UnitedHealthcare / Optum ABA coverage in Florida: the intake guide."
url: "https://carelu.com/payers/unitedhealthcare-florida"
markdown_url: "https://carelu.com/payers/unitedhealthcare-florida.md"
state: FL (Florida)
payer: UnitedHealthcare / Optum in Florida
kind: Commercial insurance
description: "How UnitedHealthcare / Optum covers ABA for Florida families — the national two-step authorization, Optum's Florida State Mandates entry covering ABA for Down syndrome, the Geller Act (§ 627.6686), Florida's no-license BCBA landscape, and what intake should verify."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# UnitedHealthcare / Optum ABA coverage in Florida: the intake guide.

_Payer Guide · UnitedHealthcare · Florida · Last updated September 2026 · 7 primary sources_

> Optum criteria (BH803ABASCC) + a real FL State Mandates entry: Down syndrome ABA covered.

For an intake team in Florida, a UnitedHealthcare card means three layers at once: the carrier's national clinical policy, Florida's autism insurance mandate (the Steven A. Geller Autism Coverage Act, § 627.6686, Fla. Stat.), and the plan's funding type deciding which of the two actually binds. This guide stacks them in order — and Florida is one of the states where Optum publishes a genuine state-specific supplement, extending ABA coverage to Down syndrome for mandate-covered plans.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — step 1 of Optum's two-step authorization (assessment auth via Provider Express) [1]
- **Prior auth for treatment**: Required — step 2 (treatment auth); reviews every 4–6 months [1]
- **Autism diagnosis required?**: Yes — DSM-5-TR ASD confirmed with a validated tool (ADI-R, ADOS-2, etc.) [1]

## At a glance

- **Covers ABA?:** Yes — for ASD per the national policy; + Down syndrome for FL mandate-covered plans
- **State mandate:** § 627.6686, Fla. Stat. (insurers) + § 641.31098 (HMOs) — Geller Act
- **Mandate age:** Under 18 (or 18+ still in high school), dx of a developmental disability by age 8
- **Mandate caps:** $36,000/yr; $200,000 lifetime (CPI-adjusted; parity-limited)
- **Exempt from mandate:** Individual, individually underwritten, and small-group plans; self-funded ERISA
- **Licensure:** None — no FL behavior analyst license; BCBA/FL-CBA credential (s. 393.17)

## The national policy, applied in Florida

UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months. That clinical policy is national — what changes in Florida is the legal floor underneath it: the state mandate below governs what covered group plans must include, while self-funded employer plans answer to ERISA and federal parity instead. Plan funding type is therefore the first fact to establish on every benefits check. The full national policy breakdown lives in our UnitedHealthcare / Optum guide; this page covers what changes in Florida. [1]

## The Florida mandate: what it guarantees (and doesn't)

The Steven A. Geller Autism Coverage Act (2008) requires coverage in group plans issued or delivered in Florida after April 1, 2009 — in practice fully-insured large-group plans and the state employee plan under § 627.6686, with companion § 641.31098 reaching large-group HMO contracts. It explicitly excludes individual-market, individually underwritten, and small-employer plans. The eligible individual is narrow: under 18 (or 18 and older but still in high school) AND diagnosed with a developmental disability at 8 years of age or younger. Covered services include well-child ASD screening plus speech, OT, PT, and applied behavior analysis — and unusually for a state mandate, it covers treatment of Down syndrome as well as ASD. ABA benefits cap at $36,000 annually and $200,000 lifetime, with an annual CPI-medical adjustment; ABA providers must be certified under s. 393.17, Fla. Stat. or licensed under chapters 490/491. Self-funded ERISA plans sit outside state reach, and MHPAEA's ban on dollar-value treatment limits arguably neuters the caps for parity-subject plans. Florida DFS consumer guidance notes individual and small-group plans generally cover ABA via the ACA EHB benchmark plus parity even though the mandate doesn't reach them. [3][4]

## Optum's Florida-specific criteria: Down syndrome ABA

Florida has its own entry in Optum's ABA State Mandates supplemental criteria (policy BH 803ABA STM12026, effective January 2026): for Florida members on mid- and large-group fully-insured plans (not individual or small-group), ABA is covered for the treatment of Down syndrome, and speech, physical, and occupational therapy plus ABA must be covered to the same extent as the existing Florida autism mandate. That makes UnitedHealthcare the carrier whose published criteria explicitly operationalize the Geller Act's Down syndrome extension — for an intake team, a Down syndrome inquiry on a fully-insured mid/large-group UHC plan is a coverable case, not an automatic ASD-only decline. Confirm funding type and group size before promising it. [2]

## UnitedHealthcare Medicaid in Florida

A family saying "we have UnitedHealthcare" in Florida may actually be on the carrier's Medicaid plan — UnitedHealthcare Community Plan of Florida, whose Behavior Analysis program Optum has managed since the February 2025 SMMC carve-in. That plan follows the state Medicaid rules (no autism diagnosis required, portal-only PA on Provider Express), not this commercial policy. Verify which line of business the card belongs to, and use the dedicated guide for the Medicaid plan. [7]

## Licensure & rates in Florida

Florida has no state behavior-analyst license — it is absent from the BACB's list of states with licensure laws. The operative credential is BACB certification (BCBA/BCaBA/RBT); s. 393.17, Fla. Stat. requires the state to recognize BACB certification, and legacy Florida Certified Behavior Analysts (FL-CBA, administered by BACB since 2003) remain recognized — the Geller Act itself keys ABA coverage to s. 393.17 certification or chapter 490/491 licensure. On rates: UnitedHealthcare does not publish commercial ABA fee schedules for Florida (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement. The Florida Medicaid schedule is the local floor to benchmark against, and it is low: 97153 pays $12.26 per 15-minute unit. [5]

## Intake gates

The questions that decide whether a family can start with UnitedHealthcare / Optum in Florida, and what they have to bring.

- **Who may diagnose**: State-licensed and scope-qualified: “a valid diagnosis of ASD (or other applicable diagnosis as required by governing laws) must be issued by a state licensed physician, psychologist, or other state licensed clinician qualified to make such diagnosis according to the diagnostic criteria based on the DSM-5-TR.” The diagnosing clinician — not the ABA provider — confirms and documents both the diagnosis and the severity level. Note the parenthetical: “or other applicable diagnosis as required by governing laws” is what carries Florida’s Down syndrome path, since Optum’s Florida State Mandates entry covers ABA “for the treatment of Down Syndrome” on mid- and large-group fully-insured plans. [1][2]
- **Diagnostic tools required**: Optum publishes the fullest instrument taxonomy of the national carriers, in two stages. For the diagnosis, “the DSM-5 diagnosis and severity level are confirmed and documented by the diagnosing clinician using at least one clinically validated tool (not an all-inclusive list),” across first-level screening tools (ABC, CHAT/M-CHAT, CSBS-DP-IT-Checklist, ASQ, AQ, CAST), second-level screening tools (CARS/CARS-2, RITA-T, STAT) and formal diagnostic tools (ADI-R, ADOS/ADOS-2, DISCO). For treatment intensity, the plan must be set from baseline measurement “with the use of at least one of the following validated measurement tools”: ATEC, VB-MAPP, ABLLS/ABLLS-R, AFLS, PEAK, SSIS, RBS-R, SRS, Vineland (VABS) or CFQL-2 — with the caveat that “measurement tools should be individualized and will not be the same for all individuals or programs.” The ABA provider separately completes a standard or functional behavioral assessment, caregiver interviews, direct observation, record review, a baseline skills assessment and norm-referenced instruments against age-matched peers. [1]
- **Age limit** _(plan-dependent)_: Optum’s ABA Supplemental Clinical Criteria publish no age limit — coverage turns on a valid ASD diagnosis and medical necessity. Two age-bearing layers sit above it in Florida. The Geller Act: under 18, or 18 and older and still in high school, with the developmental-disability diagnosis made at 8 years of age or younger, for fully-insured large-group and state-employee plans only. And Optum’s own Florida entry in its ABA State Mandates criteria, which reaches “mid and large group fully insured (does not include individual and small)” plans. Federal parity limits how hard age terms can be enforced against covered group plans. [1][2][3]
  - Ask the plan: Plan funding type and group size before anything else — they decide whether the mandate layer applies at all.
- **Referral required?** _(plan-dependent)_: No referral requirement is published; the gate is authorization. “Prior authorization is required for ABA (unless otherwise specified or mandated by contract or law),” run as Optum’s two-step structure on Provider Express — assessment authorized first, then treatment — with continued-service reviews every 4–6 months. Whether a specific plan also requires a PCP referral is a benefit-design question. [1]
  - Ask the plan: A live benefits verification plus Provider Express — confirm whether the plan layers a referral requirement on top of the two-step authorization.
- **Prior-auth decision time** _(plan-dependent)_: No Florida statute sets the decision deadline: § 627.42392, Fla. Stat. governs the prior authorization form, not the clock. The federal claims rule sets the floor for employer plans, whether insured or self-funded, and for non-grandfathered individual and marketplace plans: a pre-service decision “not later than 15 days after receipt of the claim,” with one 15-day extension, and urgent care “not later than 72 hours after receipt” (29 CFR 2560.503-1(f)(2); 45 CFR 147.136). A plan may be faster. [8][9][10]
  - Ask the plan: Optum Behavioral Health (number on the member ID card): the plan’s standard and urgent turnaround for ABA requests, whether the clock starts at receipt or at a complete request, and how far ahead of expiry a reauthorization must be filed. Also ask whether the plan is grandfathered, since grandfathered plans are outside 45 CFR 147.136.
- **Other insurance (who pays first)** _(plan-dependent)_: For a child covered on both parents’ group plans, Florida’s COB statute sets the order: “The benefits of the policy or plan of the parent whose birthday, excluding year of birth, falls earlier in a year are determined before” the other parent’s. For divorced or separated parents, the order is the custodial parent’s plan, then the custodial parent’s spouse’s plan, then the non-custodial parent’s, unless a court decree assigns health costs to one parent. The statute reaches group policies and group plans issued in Florida; whether a self-funded employer plan follows it or its own plan document’s COB clause is a question for that plan. Public coverage pays after this plan. Medicaid is the payer of last resort (Rule 59G-1.052). TRICARE “pays after all other health insurance, except for” Medicaid. CHAMPVA “is always the secondary payer, except to Medicaid.” If the other plan denies because its rules were not followed, including its prior authorization, TRICARE “may also deny the claim.” So get this plan’s authorization even when a public program is secondary. [11][12][13][14]
  - Ask the plan: Ask the family for both parents’ cards and birth dates, and ask the employer or HR whether each plan is fully insured (Florida statute order applies) or self-funded (the plan document’s COB clause applies).
- **Diagnosis recency** _(ask the plan)_: Not published. The Supplemental Clinical Criteria require a valid DSM-5-TR ASD diagnosis confirmed with at least one clinically validated tool, but set no maximum age on that diagnosis and no re-diagnosis interval. What Optum does clock is the review cycle — continued-service reviews every 4–6 months — and the documentation standard that assessment instruments be norm-referenced against age-matched peers and used to “assess developmental gains as a result of interventions,” which implies current rather than historical scores without naming a window. [1]
  - Ask the plan: Optum Behavioral Health provider services and Provider Express — ask whether an evaluation older than a given date triggers re-evaluation before an ABA authorization.
- **Telehealth** _(ask the plan)_: Not published as a coded benefit. The Supplemental Clinical Criteria treat telehealth as a best-practice reference rather than a rule — pointing providers to the “Practice Parameters for Telehealth-Implementation of Applied Behavior Analysis, Second Edition” for “designing, implementing, and operating ABA services delivered via telehealth in a broad range of clinical settings (e.g., home, clinic, school)” and noting that “the telehealth options presented are not intended to supplant in-person service; rather, they are intended to supplement the traditional in-person service delivery model.” No code list, place-of-service code or unit limit for telehealth appears in the criteria, and Optum’s commercial ABA reimbursement policy is silent on telehealth entirely. [1][6]
  - Ask the plan: Optum Behavioral Health provider services and the member’s benefit document — confirm which ABA codes pay by telehealth, and under which place-of-service code, before scheduling remote sessions.

## Delivery and billing rules

Coverage decides whether UnitedHealthcare / Optum in Florida 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**: No percentage or caseload cap — the commercial reimbursement policy refers providers to the ABA Coding Coalition for supervision requirements. What Optum polices is the boundary: “CPT codes 97153 and 97155 may not be billed for technician training,” including training a technician new to the organisation on a client’s programming or on reassessment-driven goal changes; and 97155 “should be reported only for services where the QHP is either engaged directly with the patient or is directing a technician in implementing a modified protocol with the patient” — treatment planning is an indirect service and is not separately reimbursable. The clinical criteria add the credential chain: technicians work “under the applicable supervision of a BCBA or licensed behavioral health clinician” and “should be registered behavior technicians (RBT) or another appropriately certified behavior technician as allowable by state mandate,” with an explicit warning that a parent serving as their own child’s RBT creates an ethics conflict for the supervising BCBA. [6][1]
- **Concurrent billing (97153 + 97155)**: Yes, with a single-provider exclusion. “Can I report 97153 or 97154 with 97155 concurrently? A. Yes, as long as the criteria in the descriptors of both codes are met. A single QHP may not report 97153 or 97154 with 97155 concurrently.” So the concurrency has to be two people — a technician on 97153 and an analyst on 97155 directing them with the patient present. Separately, 97155 and 97156 may both pay on the same date of service only if the services are separate, distinct and clearly documented; “a single provider can’t bill for both simultaneously (e.g., in the same 15-minute block).” [6]
- **Daily limits / MUEs**: Optum publishes its own per-day table on top of CMS MUEs — maximum frequency per day: 97151 32 units (8 hrs), 97152 16 (4 hrs), 97153 32 (8 hrs), 97154 18 (4.5 hrs), 97155 24 (6 hrs), 97156 16 (4 hrs), 97157 16 (4 hrs), 97158 16 (4 hrs), 0362T 16 (4 hrs), 0373T 32 (8 hrs). MUEs otherwise apply per CMS guidance, and billing above 32 units a day of 97153 “may be subject to non-reimbursement or recovery.” Time is counted on the CMS 15-minute rule (1 unit at 8 minutes or more, 2 at 23 or more, and so on). The Geller Act’s $36,000-a-year and $200,000-lifetime ABA caps are dollar limits rather than unit limits, and are arguably unenforceable against parity-subject group plans. [6][3]
- **Bill as provider**: One provider-level modifier per line, matching whoever actually rendered the service: HM = Registered Behavior Technician (less than bachelor’s level), HN = BCaBA (bachelor’s level), HO = BCBA or master’s-level licensed clinician, HP = BCBA-D or doctoral-level licensed clinician. A billable ABA-supervisor service is billed with the applicable CPT code plus HO. Stacking level modifiers is a denial risk: “billing multiple provider-level modifiers (HN, HM, HO, HP) on the same service line same service and same DOS is not appropriate and may result in claim denial.” Indirect work has no code of its own — it is bundled into the direct-service code. Florida adds no licensure layer, so BACB certification (or the legacy FL-CBA, or Chapter 490/491 licensure) is the operative credential. [6][3]
- **Place of service** _(ask the plan)_: The commercial ABA reimbursement policy sets codes, modifiers, units and concurrency but no place-of-service rule; the clinical criteria only require the place of service to appear on every daily progress note, and the treatment plan to be coordinated with the school and any IFSP/IEP. Florida is one of the states where Optum publishes a genuine state supplement, but it is a covered-condition rule rather than a setting rule: for Florida members on mid- and large-group fully-insured plans, “Applied Behavior Analysis (ABA) is covered for the treatment of Down Syndrome. Speech therapy, physical therapy, occupational therapy, and ABA must be covered to the same extent as the existing Florida autism mandate.” [1][2][6]
  - Ask the plan: UnitedHealthcare/Optum provider services and the member’s benefit document for whether school, community or group-home ABA is payable on that plan.

## What intake should collect for UnitedHealthcare / Optum in Florida

- **Plan funding type + group size:** Fully insured mid/large-group triggers both the mandate and Optum's Down syndrome coverage; individual/small-group and self-funded ERISA are exempt.
- **Line of business:** Commercial vs. UnitedHealthcare Community Plan of Florida (Medicaid) — different rules, different guide.
- **Member ID + card photo:** Enough to run a live benefits verification — the only reliable answer on limits and cost-sharing.
- **Diagnosis report:** DSM-5-TR ASD with a validated tool for the standard path — or the Down syndrome diagnosis for the Florida mandate path.
- **Age + diagnosis-age history:** The mandate keys to under-18 (or in high school) with the developmental-disability dx made by age 8 — flag edge cases for parity analysis.

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

## Verification of benefits (VOB) data

How UnitedHealthcare / Optum in Florida ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00192
- **Payer ID (Availity):** 87726
- **Payer ID (Change Healthcare / Optum):** 87726
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** Optum Behavioral Health
- **BH administrator payer ID:** 87726 — pVerify separately lists a distinct "UHG007 United Healthcare - Optum Behavioral Solutions" code (this file's PVERIFY_PAYER_LIST, March 2026 snapshot) — this may be used for real-time 270/271 eligibility specifically even though claims settle on 87726 (confirmed directly via Optum's own Provider Express EDI page); confirm which ID a live eligibility check actually returns before automating on 87726 alone.
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### How the 271 reports ABA benefits

- **ABA benefit bucket (service type code):** MH — UHC's own EDI feed (87726) formally supports MH/A4-A8 with financial detail, but whether members whose ABA benefit is carved to Optum Behavioral Health actually receive populated MH-flavor detail through this SAME feed — versus a referral/vendor-lookup stub via the guide's own documented EB*U 'vendor' segment mechanism — is not resolved by any source found this pass. Confirm via Provider Express / UHC provider services for the specific plan.
- **Deductible applies to ABA:** yes — Same open question as abaBenefitBucket — confirm whether the carved-out BH benefit populates deductible detail on this feed.
- **Cost-share type:** plan-dependent — Both copay and coinsurance are structurally supported per plan; which applies to a given member is plan-document-specific.
- **271 response quality for ABA:** high

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required — two-step Optum authorization (assessment, then treatment); continued-service review every 4–6 months | 32 units/day (≤8 hrs) per day | — | — | HN, HO, HP |
| 97152 | Yes | Required — two-step Optum authorization (assessment, then treatment); continued-service review every 4–6 months | 16 units/day (≤4 hrs) per day | — | — | HN, HM, HO, HP |
| 97153 | Yes | Required — two-step Optum authorization (assessment, then treatment); continued-service review every 4–6 months | 32 units/day (≤8 hrs) per day | — | — | HN, HM, HO, HP |
| 97154 | Yes | Required — two-step Optum authorization (assessment, then treatment); continued-service review every 4–6 months | 18 units/day (≤4.5 hrs) per day | — | — | HN, HM, HO, HP |
| 97155 | Yes | Required — two-step Optum authorization (assessment, then treatment); continued-service review every 4–6 months | 24 units/day (≤6 hrs) per day | — | — | HN, HO, HP |
| 97156 | Yes | Required — two-step Optum authorization (assessment, then treatment); continued-service review every 4–6 months | 16 units/day (≤4 hrs) per day | — | — | HN, HO, HP |
| 97157 | Yes | Required — two-step Optum authorization (assessment, then treatment); continued-service review every 4–6 months | 16 units/day (≤4 hrs) per day | — | — | HN, HO, HP |
| 97158 | Yes | Required — two-step Optum authorization (assessment, then treatment); continued-service review every 4–6 months | 16 units/day (≤4 hrs) per day | — | — | HN, HO, HP |
| 0362T | Yes | Required — two-step Optum authorization (assessment, then treatment); continued-service review every 4–6 months | 16 units/day (≤4 hrs) per day | — | — | — |
| 0373T | Yes | Required — two-step Optum authorization (assessment, then treatment); continued-service review every 4–6 months | 32 units/day (≤8 hrs) per day | — | — | — |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** Unit caps and modifiers sourced from Optum's national ABA Reimbursement Policy (2022RP501A) — the FL-specific Supplemental Clinical Criteria contains no CPT codes at all; applied here absent a confirmed FL-specific override (same finding as vob/georgia.ts). Verify via: Provider Express / UHC provider services.

### Contacts

- **Provider services phone:** 877-842-3210
- **Phone menu path:** Optum Behavioral Health provider services / 24/7 behavioral health & substance-use support: 877-614-0484. UnitedHealthcare Provider Portal technical support: 866-842-3278, option 1.
- **Portal:** [Provider Express (Optum Behavioral Health)](https://public.providerexpress.com/)

Questions to ask on a verification call:

- Do you support real-time 270/271 eligibility checks on payer ID 87726, or is it batch only?
- Does ABA eligibility route through payer ID 87726, or does Optum Behavioral Health use a separate ID (e.g., UHG007) for 270/271 checks?
- Is the ABA cost share a copay or coinsurance for this member’s plan?
- Is the copay charged per visit or per day?
- Does the out-of-pocket maximum apply to ABA benefits?
- What places of service are allowed for ABA, and is telehealth covered for any code?

### VOB data sources

- 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://public.providerexpress.com/content/ope-provexpr/us/en/admin-resources/claim-tips/electronic-claim-submission-and-electronic-data-interchange.html (accessed 2026-07-23)
- https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/abaSCC.pdf (accessed 2026-07-23)
- https://www.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23)
- https://www.uhcprovider.com/content/dam/provider/docs/public/resources/edi/EDI-270-271-Companion-Guide-005010X279A1.pdf (accessed 2026-07-23)
- https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/reimbPolicies/abaReimburs2020s.pdf (accessed 2026-07-23)
- https://www.uhcprovider.com/en/contact-us.html (accessed 2026-07-23)

## Common questions

### Does UnitedHealthcare cover ABA therapy in Florida?

Yes — under Optum's national two-step authorization for ASD, layered on Florida's Geller Act (§ 627.6686) for covered fully-insured group plans. Self-funded, individual, and small-group plans sit outside the mandate, so verify plan funding type first.

### Does UnitedHealthcare cover ABA for Down syndrome in Florida?

For mid- and large-group fully-insured Florida plans, yes — Optum's ABA State Mandates supplement explicitly covers ABA for the treatment of Down syndrome, mirroring the Florida mandate's unusual Down syndrome extension. It does not apply to individual or small-group plans; confirm funding type and group size.

### What does the Florida autism mandate require?

For covered group plans: screening, speech, OT, PT, and ABA for eligible individuals — under 18 (or 18+ in high school) diagnosed with a developmental disability by age 8 — with ABA capped at $36,000/year and $200,000 lifetime (CPI-adjusted). Federal parity limits how hard the dollar caps can be enforced against group plans.

### What does UnitedHealthcare pay for ABA in Florida?

Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against the Florida Medicaid BA schedule (97153 at $12.26/unit) and treat rate-setting as part of contracting.

## Primary sources

1. [Optum ABA Supplemental Clinical Criteria (BH803ABASCC)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/abaSCC.pdf)
2. [Optum — ABA State Mandates supplemental criteria (BH 803ABA STM12026)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/scc/ABA_SCC_SM.pdf)
3. [Fla. Stat. § 627.6686 (2024)](https://www.flsenate.gov/Laws/statutes/2024/627.6686)
4. [FL Dept. of Financial Services — ASD coverage overview](https://www.myfloridacfo.com/division/consumers/consumerprotections/autism-spectrum-disorder)
5. [BACB — U.S. Licensure of Behavior Analysts](https://www.bacb.com/u-s-licensure-of-behavior-analysts/)
6. [Optum — Applied Behavior Analysis (ABA) Reimbursement Policy, Commercial (2022RP501A)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/reimbPolicies/abaReimburs2020s.pdf)
7. [UHC Community Plan FL — SMMC Behavioral Analysis Program QRG](https://www.uhcprovider.com/content/dam/provider/docs/public/commplan/fl/resources/FL-BAP-QRG.pdf)
8. [§ 627.42392, Fla. Stat. — Prior authorization (2026)](https://www.flsenate.gov/Laws/Statutes/2026/627.42392)
9. [29 CFR 2560.503-1 — ERISA claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
10. [45 CFR 147.136 — internal claims and appeals, group and individual coverage (eCFR)](https://www.ecfr.gov/current/title-45/section-147.136)
11. [§ 627.4235, Fla. Stat. — Coordination of benefits](https://www.flsenate.gov/Laws/Statutes/2025/627.4235)
12. [Rule 59G-1.052, F.A.C. — Third-Party Liability Requirements (AHCA)](https://ahca.myflorida.com/content/download/5929/file/59G_1052_TPL_Requirements.pdf?version=1)
13. [TRICARE — Using Other Health Insurance](https://www.tricare.mil/Plans/OHI)
14. [VA — CHAMPVA: Information for Outpatient Providers (IB 10-1587, updated 9/20/2023)](https://www.va.gov/COMMUNITYCARE/docs/pubfiles/factsheets/FactSheet_01-20.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.