UnitedHealthcare / Optum ABA coverage in Maryland: the intake guide.

A DSM-5-TR autism spectrum diagnosis from a state-licensed physician, psychologist, or other qualified clinician. Optum asks for the diagnosing clinician and the instrument at the assessment-authorization step, so both are intake fields.^[1]

The diagnosis must be confirmed with at least one clinically validated tool. Optum names first-level instruments — the ADI-R, the ADOS-2 and the DISCO — and accepts second-level tools including the CARS-2, the RITA-T and the STAT. Capture which instrument was used, by whom and when; “diagnosed by Dr. X” without a named tool is the most common reason an Optum assessment request stalls.^[1]

Gated on the provider, not just the code. Tele-supervision and virtual family training require the provider to be an approved Optum virtual-visits provider with a completed attestation on Provider Express, and the authorization itself must note virtual delivery. Optum frames telehealth as a supplement to in-person care rather than a replacement for it, so a request built mostly on remote hours should expect pushback.^[6]

Two answers, and plan funding type picks between them. The carrier's national ABA policy states no age limit. Maryland's habilitative-services mandate does: for Maryland-regulated insurers, nonprofit health service plans and HMOs, habilitative services must be covered “until at least the end of the month the enrollee turns 19,” and COMAR 31.10.39.03 pins its no-denial hour floors to age bands — up to 25 hours/week for ages 18 months through 5 years and up to 10 hours/week for ages 6 through 18, with more when medically necessary. Self-funded ERISA plans are exempt from all of it, so establish funding type before quoting either bound.^[3][2]

Ask the plan: Benefits verification on the specific plan, via the payer portal or the number on the member’s card — ask whether the plan is Maryland-regulated (an insurer, nonprofit health service plan or HMO, which the habilitative-services mandate and COMAR 31.10.39.03 age bands reach) or a self-funded ERISA plan (exempt). If it is self-funded, ask what age limit and weekly hour limit the plan document sets for ABA before you quote either bound to the family.

On a fully-insured Maryland plan, yes — and it is a prescription, not a note. COMAR 31.10.39.03 conditions the mandated benefit on a comprehensive evaluation, a prescription with treatment goals from the PCP or a specialty physician, and annual review by the prescriber. Capture the prescriber and the prescription date at intake, and diary the annual renewal: a lapsed prescription is a coverage problem, not a paperwork one. Self-funded ERISA plans are outside the mandate, and for those the carrier's own authorization requirements are the only gate.^[3][2]

Ask the plan: Benefits verification on the specific plan, via the payer portal or the number on the member’s card — confirm funding type first. On a Maryland-regulated plan, capture the prescriber and prescription date and diary the annual prescriber review COMAR 31.10.39.03 requires. On a self-funded ERISA plan, ask the carrier whether it requires a referral or prescription at all, since the mandate does not reach it and only the carrier’s own authorization rules apply.

UHC notifies coverage decisions “within the time required by law,” so the clock depends on how the plan is funded. If the child’s plan is fully insured in Maryland, Insurance §15-10B-06 sets the clock: an initial request is decided “within 2 working days after receipt of the information necessary to make the determination,” “additional visits or days of care submitted as part of an existing course of treatment or treatment plan within 1 working day,” emergency requests within 24 hours, and a reviewer missing information must say so within 3 calendar days. Maryland’s teeth: “If a private review agent fails to make a determination within the time limits required under this section, the request shall be deemed approved.” Mental-health treatment plans must be accepted on the MIA uniform treatment plan form. If the employer self-funds, ERISA’s floor applies instead: pre-service decisions “not later than 15 days after receipt of the claim” (one 15-day extension allowed), urgent claims within 72 hours. Optum (UHC’s behavioral arm) sets the reauth window: call the ABA/Autism queue “no more than 30 days prior to the current approvals on file expiring,” with all clinical information ready; retrospective reviews take up to 30 calendar days.^{[8][9][10][6][11]}

Ask the plan: the member services or behavioral health number on the ID card — ask whether the plan is fully insured (and in which state) or self-funded, and for its UM decision timeframes

UHC administers COB “according to the member’s benefit plan and in accordance with law.” Optum: “You are responsible for determining if the member has other insurance coverage. If so, you should bill the primary insurance carrier first, then notify Optum of your findings”; as secondary, payment goes up to Optum’s contracted rate and you may not balance-bill. Maryland has not yet adopted a COB regulation: the Insurance Administration says contract COB provisions “have historically been reviewed for consistency with the NAIC Model, but the Model has not been formally adopted to date,” and its draft COMAR 31.10.53 (comments closed August 2026) would codify the NAIC birthday rule (“The plan of the parent whose birthday falls earlier in the calendar year is the primary plan”) and exclude Medicaid from the definition of a plan — so Maryland Medicaid always pays after the commercial plan.^{[8][11][12][13]}

Ask the plan: the carrier’s eligibility response (Availity or the ID-card number) for an other-insurance record, and both parents’ birth dates and custody arrangements at intake; a self-funded plan follows its own plan document

Optum publishes no recency rule for the ASD diagnosis in its Supplemental Clinical Criteria as cited here; what it does set is a review cadence downstream — continued-service reviews every 4–6 months requiring updated standardized adaptive measures and progress measured the same way as baseline.^[1]

Ask the plan: Optum provider services or the assessment-authorization request on Provider Express — ask whether an evaluation of this age will be accepted before scheduling.

Optum's Supplemental Clinical Criteria set supervision at 1–2 hours per 10 hours of direct treatment, with a floor of at least one hour of 97155 per case per month. In Maryland the supervising analyst must additionally hold the state Licensed Behavior Analyst credential, required to practice behavior analysis since January 2015.^[1][5]

Permitted in three named pairs: supervision alongside direct care (97153 + 97155), group oversight (97154 + 97155), and parent training alongside direct care (97153 + 97156). Not covered at all: team meetings without the member present, 1:1 classroom aides, and services owed under IDEA.^[1]

Optum's exclusions are the operative setting rule: team meetings without the member, 1:1 classroom aides, and any service owed under IDEA are not covered, which makes the school and IEP picture a coverage question rather than a background one. Optum's Maryland State Mandates entry goes further in the member's favour for fully-insured plans — it reproduces COMAR's allowance of school as a service location, while keeping IDEA/IEP obligations outside the benefit.^[1][2]

Optum does not authorize against a per-day unit ceiling; it authorizes in four code clusters — assessment (97151, 97152), direct care (97153, 97154), multi-staff (0362T, 0373T) and QHP services (97155–97158) — and units flex within a cluster without a new authorization. The number that actually bites runs the other way: utilization below 80 percent of authorized hours over a two-week window draws scrutiny at review.^[1]

Ask the plan: The authorization letter itself on Provider Express, and Optum provider services — ask whether any per-day MUE applies to this plan on top of the cluster structure.

Not published in the Supplemental Clinical Criteria. What Optum specifies is the review packet rather than the session note: continued-service reviews every 4–6 months want progress documented per targeted behavior using the same measurement methods as baseline, mastered-program rates, change scores and updated standardized adaptive measures. Who signs an individual session note, and by when, is not stated.^[1]

Ask the plan: Optum provider services, or your Provider Express network manager — ask for the documentation standard applied at audit.

Not published in the Supplemental Clinical Criteria. Optum authorizes by code cluster and names a QHP services cluster (97155–97158) distinct from the direct-care cluster (97153, 97154), which implies a credential split on the rendering line but does not state whose NPI carries a technician-delivered 97153 claim or which degree-level modifiers apply.^[1]

Ask the plan: Optum provider services or the authorization letter on Provider Express — confirm the rendering-versus-billing NPI convention and any required modifiers before the first claim.