UnitedHealthcare & Optum ABA: the authorization guide.

Fully-insured UnitedHealthcare / Optum plans issued in Georgia sit under the state mandate above. State Medicaid baseline: Georgia Medicaid guide →

Fully-insured UnitedHealthcare / Optum plans issued in North Carolina sit under the state mandate above. For Medicaid members, UnitedHealthcare / Optum operates UnitedHealthcare Community Plan of North Carolina — covered by its own guide, not this one. State Medicaid baseline: North Carolina Medicaid guide →

Fully-insured UnitedHealthcare / Optum plans issued in Indiana sit under the state mandate above. For Medicaid members, UnitedHealthcare / Optum operates UnitedHealthcare Community Plan of Indiana — covered by its own guide, not this one. State Medicaid baseline: Indiana Medicaid (IHCP) guide →

Fully-insured UnitedHealthcare / Optum plans issued in Virginia sit under the state mandate above. For Medicaid members, UnitedHealthcare / Optum operates UnitedHealthcare Community Plan of Virginia — covered by its own guide, not this one. State Medicaid baseline: Virginia Medicaid (DMAS) guide →

Fully-insured UnitedHealthcare / Optum plans issued in Tennessee sit under the state mandate above. For Medicaid members, UnitedHealthcare / Optum operates UnitedHealthcare Community Plan of Tennessee — covered by its own guide, not this one. State Medicaid baseline: TennCare (Tennessee Medicaid) guide →

Fully-insured UnitedHealthcare / Optum plans issued in Ohio sit under the state mandate above. For Medicaid members, UnitedHealthcare / Optum operates UnitedHealthcare Community Plan of Ohio — covered by its own guide, not this one. State Medicaid baseline: Ohio Medicaid guide →

Fully-insured UnitedHealthcare / Optum plans issued in New Jersey sit under the state mandate above. For Medicaid members, UnitedHealthcare / Optum operates UnitedHealthcare Community Plan (NJ FamilyCare) — covered by its own guide, not this one. State Medicaid baseline: NJ FamilyCare (New Jersey Medicaid) guide →

Fully-insured UnitedHealthcare / Optum plans issued in Maryland sit under the state mandate above. State Medicaid baseline: Maryland Medicaid (Medical Assistance) guide →

Fully-insured UnitedHealthcare / Optum plans issued in Colorado sit under the state mandate above. State Medicaid baseline: Health First Colorado (Colorado Medicaid) guide →

Fully-insured UnitedHealthcare / Optum plans issued in Utah sit under the state mandate above. State Medicaid baseline: Utah Medicaid guide →

Fully-insured UnitedHealthcare / Optum plans issued in Arizona sit under the state mandate above. For Medicaid members, UnitedHealthcare / Optum operates UnitedHealthcare Community Plan of Arizona — covered by its own guide, not this one. State Medicaid baseline: AHCCCS (Arizona Medicaid) guide →

Fully-insured UnitedHealthcare / Optum plans issued in New York sit under the state mandate above. For Medicaid members, UnitedHealthcare / Optum operates UnitedHealthcare Community Plan of New York — covered by its own guide, not this one. State Medicaid baseline: New York Medicaid (NYS DOH / eMedNY) guide →

Fully-insured UnitedHealthcare / Optum plans issued in New Mexico sit under the state mandate above. For Medicaid members, UnitedHealthcare / Optum operates UnitedHealthcare Community Plan of New Mexico (Turquoise Care) — covered by its own guide, not this one. State Medicaid baseline: New Mexico Medicaid (Turquoise Care) guide →

Fully-insured UnitedHealthcare / Optum plans issued in Missouri sit under the state mandate above. State Medicaid baseline: MO HealthNet (Missouri Medicaid) guide →

Fully-insured UnitedHealthcare / Optum plans issued in Texas sit under the state mandate above. For Medicaid members, UnitedHealthcare / Optum operates UnitedHealthcare Community Plan of Texas — covered by its own guide, not this one. State Medicaid baseline: Texas Medicaid (THSteps-CCP) guide →

Fully-insured UnitedHealthcare / Optum plans issued in Massachusetts sit under the state mandate above. State Medicaid baseline: MassHealth (Massachusetts Medicaid) guide →

Fully-insured UnitedHealthcare / Optum plans issued in Florida sit under the state mandate above. For Medicaid members, UnitedHealthcare / Optum operates UnitedHealthcare Community Plan of Florida — covered by its own guide, not this one. State Medicaid baseline: Florida Medicaid — Behavior Analysis Services (AHCA) guide →

Fully-insured UnitedHealthcare / Optum plans issued in Kansas sit under the state mandate above. For Medicaid members, UnitedHealthcare / Optum operates UnitedHealthcare Community Plan of Kansas — covered by its own guide, not this one. State Medicaid baseline: KanCare (Kansas Medicaid) guide →

Fully-insured UnitedHealthcare / Optum plans issued in Nebraska sit under the state mandate above. For Medicaid members, UnitedHealthcare / Optum operates UnitedHealthcare Community Plan of Nebraska — covered by its own guide, not this one. State Medicaid baseline: Nebraska Medicaid (Heritage Health) guide →

Fully-insured UnitedHealthcare / Optum plans issued in Idaho sit under the state mandate above. State Medicaid baseline: Idaho Medicaid guide →

Fully-insured UnitedHealthcare / Optum plans issued in Iowa sit under the state mandate above. State Medicaid baseline: Iowa Medicaid (IA Health Link) guide →

Fully-insured UnitedHealthcare / Optum plans issued in Oklahoma sit under the state mandate above. State Medicaid baseline: Oklahoma Medicaid (SoonerCare / SoonerSelect) - Oklahoma Health Care Authority guide →

Fully-insured UnitedHealthcare / Optum plans issued in Michigan sit under the state mandate above. State Medicaid baseline: Michigan Medicaid guide →

Fully-insured UnitedHealthcare / Optum plans issued in Hawaii sit under the state mandate above. For Medicaid members, UnitedHealthcare / Optum operates UnitedHealthcare Community Plan of Hawaii — covered by its own guide, not this one. State Medicaid baseline: Hawaii Medicaid (Med-QUEST / QUEST Integration) guide →

Fully-insured UnitedHealthcare / Optum plans issued in California sit under the state mandate above. State Medicaid baseline: Medi-Cal (California Medicaid) guide →

Fully-insured UnitedHealthcare / Optum plans issued in Pennsylvania sit under the state mandate above. State Medicaid baseline: Pennsylvania Medicaid (Medical Assistance) guide →

A DSM-5-TR autism spectrum diagnosis from a state-licensed physician, psychologist, or other qualified clinician. The credential is submission data, not background: Optum asks for the diagnosing clinician and the confirming instrument as part of the step-one assessment authorization on Provider Express.^[1]

The strictest named-tool requirement among the national commercial carriers. 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” with no named tool is the most common reason an Optum assessment request stalls at intake.^[1]

No physician referral or order is required by the Supplemental Clinical Criteria. What stands in its place is a two-step authorization through the Provider Express portal: step one authorizes the assessment — functional behavior assessment, caregiver interviews, direct observation, record review, baseline skills and norm-referenced instruments — and step two authorizes treatment based on what the assessment produced. Both are required before the corresponding service. Where state law specifies otherwise, the state-specific criteria in Optum's ABA State Mandates supplement govern instead of the standard criteria.^[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 — so a plan built on remote hours has to be requested that way, not converted later. Optum frames telehealth as a supplement to in-person care rather than a replacement for it.^[2]

The Supplemental Clinical Criteria publish no age limit for ABA. Where a state has its own entry in Optum's ABA State Mandates supplement, that entry can import a mandate's age terms for fully-insured business — Maryland's entry adopts the COMAR hour floors that run by age band — but on the national criteria age is a benefits question, decided by the plan and the state of issue.^[1]

Ask the plan: Benefits verification on the specific plan, and Optum's ABA State Mandates supplemental criteria for the state of issue.

UnitedHealthcare's 2026 Administrative Guide says "We notify you of our coverage decision within the time required by law" and, for commercial prior authorization, lists "Standard requests: up to 15 calendar days" and "Expedited requests: 72 hours" (may be extended for missing information), asking for notification "at least 15 calendar days in advance, if possible," and at least 5 business days before the service. Fully insured plans can be tighter under state utilization-review law; self-funded plans follow ERISA (15 days pre-service, one 15-day extension; 72 hours urgent). For ABA the operative lead time is Optum's: request continued services "no more than 30 days prior to the current approvals on file expiring," with all clinical information ready at the call.^[3][2][4]

Ask the plan: Benefits verification: fully insured (state UR deadlines) or self-funded/ASO (ERISA)? Confirm the continued-service window with the Optum ABA line (behavioral health number on the member card).

UnitedHealthcare: "COB is administered according to the member's benefit plan and in accordance with law." Optum puts the check on the provider — "You are responsible for determining if the member has other insurance coverage. If so, you should bill the primary insurance carrier first" — and when Optum is secondary "you will be paid up to the Optum contracted rate," with no billing the family for the difference. Neither document states the dependent-child order itself, so the birthday rule applies through state COB law on fully insured plans and through the plan document on self-funded ones. UnitedHealthcare pays ahead of Medicaid (payer of last resort by federal law — the Medicaid program may still require its own PA), TRICARE (secondary to other health insurance by law) and CHAMPVA (pays after other health insurance). To bill a secondary plan when the member has no ABA benefit, Optum's FAQ says to call the number on the card to request a denial.^{[3][5][2][6][7][8]}

Ask the plan: Benefits verification: ask which COB order and secondary-payment method the plan document uses (standard vs maintenance of benefits), and whether the plan is fully insured or self-funded.

No recency rule for the ASD diagnosis is published in the Supplemental Clinical Criteria cited here. The cadence Optum does set is downstream: continued-service reviews land every 4–6 months (per account and state law) and require progress documented per targeted behavior using the same measurement methods as baseline, plus updated standardized adaptive measures. Inadequate progress within six months requires documented reasons and a treatment modification.^[1]

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

Optum publishes both a band and a floor: supervision at 1–2 hours per 10 hours of direct treatment, and a minimum of one hour of 97155 per case per month. The floor is the one that catches people — a light month still owes an hour of billed supervision.^[1]

Permitted in three named pairs, which is more generous than most: 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 rather than a place-of-service table: team meetings without the member, 1:1 classroom aides, and any service owed under IDEA are not covered. That makes the school and IEP picture a coverage question rather than background — capture it precisely at intake, because a goal that belongs in the IEP is a goal Optum will not pay for.^[1]

Optum authorizes in four code clusters rather than against a per-day unit ceiling — 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, a genuinely useful operational buffer. The threshold that actually bites runs the other way: utilization below 80 percent of authorized hours over a two-week window draws scrutiny at review, so a family whose real availability cannot support the authorized intensity is a reauthorization risk from day one.^[1]

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