For an intake team in Georgia, a UnitedHealthcare card means three layers at once: the carrier's national clinical policy, Georgia's autism insurance mandate (O.C.G.A. § 33-24-59.10 (Ava’s Law)), and the plan's funding type deciding which of the two actually binds. This guide stacks them in order.
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 and an operational flag when utilization falls below 80% of authorized hours. That clinical policy is national — what changes in Georgia is the legal floor underneath it: the state mandate below governs what fully-insured plans must cover, 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 Georgia.[1]
Ava’s Law requires state-regulated accident and sickness plans (including the state employee health plan) to cover ASD treatment for individuals 20 years of age or under, with ABA nominally cappable at $35,000 per year — and no limits allowed on the number of visits. The statute exempts employers with 10 or fewer employees, and insurers can seek a one-year opt-out if an actuary certifies the mandate raises average premiums more than 1%. Self-funded ERISA plans are exempt by federal preemption. Federal mental-health parity (MHPAEA) generally makes the dollar and age caps hard to enforce against covered large-group plans — a payer applying the $35K cap to a large-group member is a red flag to escalate, not accept.[2][3]
We checked: UnitedHealthcare / Optum publishes no Georgia-specific ABA policy, form, or supplement — the national policy plus the state mandate is the whole picture. That’s worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where Georgia-specific answers come from, not a carrier document.[1]
Georgia now licenses behavior analysts: HB 412 (2022) created the Georgia Behavior Analyst Licensing Board under the Secretary of State, with licensure built on BCBA certification. Confirm your supervising analysts hold the Georgia license when credentialing with any commercial plan. On rates: UnitedHealthcare does not publish commercial ABA fee schedules for Georgia (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement, so treat rate expectations as a contracting conversation, not a lookup.[4]
The questions that decide whether a family can start with UnitedHealthcare / Optum in Georgia, and what they have to bring. Each maps onto something intake should ask on the first call.
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. On the treating side Optum requires a master’s- or doctoral-level BCBA, a credentialed licensed behavioral health clinician with attested ABA expertise, or a BCaBA or non-licensed individual under the direct supervision of one of those; in Georgia the analyst must additionally hold a Georgia Behavior Analyst Licensing Board licence under HB 412.[1]
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]
Optum’s ABA Supplemental Clinical Criteria publish no age limit — coverage turns on a valid ASD diagnosis and medical necessity. The age term in Georgia comes from Ava’s Law (individuals 20 years of age or under on state-regulated plans, with ≤10-employee groups exempt and self-funded ERISA plans preempted), and there is no Georgia entry in Optum’s ABA State Mandates criteria to add anything on top. Federal parity generally makes the mandate’s age cap hard to enforce against covered large-group plans.[1][6][2]
Ask the plan: Plan funding type and employer size, then a live benefits verification — the mandate, not the carrier criteria, is what carries the age term.
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.
It depends on how the plan is funded. A fully insured UnitedHealthcare plan sold in Georgia follows the Ensuring Transparency in Prior Authorization Act. A standard request gets notice "within 7 calendar days of obtaining all necessary information to make such authorization or adverse determination" (O.C.G.A. 33-46-26). Urgent requests get notice "no later than 72 hours after receiving all information needed" (33-46-27). A missed deadline means "automatic authorization" of the service (33-46-29), with a narrow de minimis exception. Both clocks start only once the plan has everything it needs, so send a complete packet. The Act also binds DCH contracts under the State Health Benefit Plan. A self-funded employer plan is governed by ERISA instead: "not later than 15 days after receipt of the claim," with one 15-day extension, and 72 hours for urgent care. No reauthorization lead time is published for UnitedHealthcare ABA in Georgia.[7][8][9]
Ask the plan: Benefits verification with UnitedHealthcare: ask whether the plan is fully insured (Georgia prior-authorization law), self-funded (ERISA), or the State Health Benefit Plan, and the plan's reauthorization lead time.
Between two parents' group plans, Georgia's coordination-of-benefits rule uses the birthday rule: "The benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year." "Birthday" means month and day only. If the birthdays match, the plan that has covered the parent longer pays first. For separated or divorced parents, the order is the custodial parent's plan, then the step-parent's, then the non-custodial parent's, unless a court decree assigns health costs to one parent. That rule governs fully insured group plans. A self-funded employer plan sets its own order in its plan document. The UnitedHealthcare plan pays before Georgia Medicaid, which is payer of last resort and still wants its own ABS PA when secondary. It also pays before TRICARE, which pays only after other coverage. When the child also has CHAMPVA, the UnitedHealthcare plan pays first: "If you have any other type of other health insurance, CHAMPVA will pay secondary."[10][11][12][13]
Ask the plan: UnitedHealthcare member services / benefits verification: confirm funding type and the COB order in the plan document, and collect the other parent's plan, each parent's date of birth and any custody decree at intake.
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, with an operational flag when utilization falls below 80% of authorized hours — 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.
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. Optum publishes no Georgia entry in its ABA State Mandates document, so nothing state-specific applies on top.[1][5][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.
Coverage decides whether UnitedHealthcare / Optum in Georgia 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.
Optum’s commercial reimbursement policy publishes no supervision percentage or caseload cap — it refers providers to the ABA Coding Coalition for supervision requirements. What it does police is the boundary: “CPT codes 97153 and 97155 may not be billed for technician training,” including training a technician new to the organization 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 not separately reimbursable.[5]
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 — technician on 97153, 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).”[5]
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/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, 2 at ≥ 23, and so on).[5]
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.[5]
No signature rule is published, but the documentation burden is explicit where money turns on it: services billed on the same date must be “separate, distinct, and clearly documented in the progress notes,” and if documentation does not clearly separate them the claim may be denied. Who signs, and within what window, is not stated.[5]
Blocked on: The UnitedHealthcare/Optum provider manual and your participation agreement’s documentation clause.
Not addressed in the commercial ABA reimbursement policy — it sets codes, modifiers, units and concurrency but no place-of-service rule.
Ask the plan: UnitedHealthcare/Optum provider services and the member’s benefit document; Optum’s published ABA State Mandates document carries no Georgia entry, so nothing state-specific applies on top.
Yes — under the carrier's national policy for ASD, layered on Georgia's mandate (O.C.G.A. § 33-24-59.10 (Ava’s Law)) for fully-insured plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.
Ava’s Law requires state-regulated accident and sickness plans (including the state employee health plan) to cover ASD treatment for individuals 20 years of age or under, with ABA nominally cappable at $35,000 per year — and no limits allowed on the number of visits. See the mandate section above for ages, caps, and exemptions — and remember federal parity limits how hard the numeric caps can be enforced against group plans.
Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against the Georgia Medicaid fee schedule where one exists, and treat rate-setting as part of contracting.
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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