--- title: "UnitedHealthcare & Optum ABA: the authorization guide." url: "https://carelu.com/payers/unitedhealthcare-optum" markdown_url: "https://carelu.com/payers/unitedhealthcare-optum.md" state: US (national) payer: UnitedHealthcare / Optum kind: Commercial insurance description: "How UnitedHealthcare covers ABA through Optum Behavioral Health: the two-step authorization via Provider Express, 4–6 month reviews, code clusters, supervision standards, and telehealth attestation." last_reviewed: September 2026 vob_data_updated: 2026-07-23 --- # UnitedHealthcare & Optum ABA: the authorization guide. _Payer Guide · UnitedHealthcare / Optum · Last updated September 2026 · 2 primary sources_ > Two-step auth via Provider Express, 4–6 month reviews, code clusters. UnitedHealthcare administers ABA through Optum Behavioral Health, with authorization running through the Provider Express portal as a two-step process — assessment first, then treatment. Optum's Supplemental Clinical Criteria are among the most operationally specific in the industry (down to utilization thresholds and code clusters), which cuts both ways: more rules to satisfy, but also more predictability for an intake team that knows them. ## Prior authorization and diagnosis at a glance - **Prior auth for the assessment**: Required — step 1 of the two-step authorization (assessment auth) [1][2] - **Prior auth for treatment**: Required — step 2 (treatment auth) [1][2] - **Autism diagnosis required?**: Yes — DSM-5-TR ASD confirmed with a validated tool (ADI-R, ADOS-2, etc.) [1][2] ## At a glance - **Covers ABA?:** Yes — via Optum Behavioral Health - **Prior auth:** Two-step: assessment auth, then treatment auth (Provider Express) - **Review cadence:** Every 4–6 months, per account/state law - **Code structure:** 4 clusters; units shift within a cluster - **Supervision:** 1–2 hrs per 10 direct hrs; min 1 hr 97155/case/month - **Utilization flag:** <80% of authorized hours (2-week window) gets scrutiny ## The two-step authorization Step one authorizes the assessment: functional behavior assessment, caregiver interviews, direct observation, record review, baseline skills, and norm-referenced instruments. Step two authorizes treatment based on what the assessment produced. Both run through Provider Express. For most commercial plans without a state-specific carve-out, the standard Optum Supplemental Clinical Criteria (BH803ABASCC) apply. [1] The diagnosis bar: DSM-5-TR ASD from a state-licensed physician, psychologist, or other qualified clinician, confirmed with at least one clinically validated tool (ADI-R, ADOS-2, DISCO — or second-level tools like CARS-2, RITA-T, STAT). [1] ## Code clusters — and why intake data shapes them Optum authorizes in four clusters: assessment (97151, 97152), direct care (97153, 97154), multi-staff (0362T, 0373T), and QHP services (97155–97158). Units can flex within a cluster without a new authorization — a genuinely useful operational buffer. Concurrent billing is allowed for supervision (97153+97155), group oversight (97154+97155), and parent training alongside direct care (97153+97156). Not covered: team meetings without the member, 1:1 classroom aides, and services owed under IDEA — which is why intake should capture the school/IEP picture precisely. [1] ## Continued-service reviews Reviews land every 4–6 months and want progress documented per targeted behavior using the same measurement methods as baseline — mastered-program rates, change scores, updated standardized adaptive measures. Two operational tripwires matter for scheduling and intake: inadequate progress within 6 months requires documented reasons plus treatment modification, and utilization below 80% of authorized hours over a two-week window draws scrutiny. Families whose availability can't support the authorized intensity are a reauthorization risk from day one — capture real availability honestly at intake. [1] ## Telehealth 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 — not a replacement for — in-person care. [2] ## How UnitedHealthcare / Optum works state by state The clinical policy above is national, but three state-level layers change what a family's card actually buys: the state autism mandate (what fully-insured plans must cover), the carrier's state Medicaid plans (which follow the state Medicaid rules, not this commercial policy), and plan funding type (self-funded ERISA plans can carve benefits differently). - **Georgia** (mandate: Ava’s Law (O.C.G.A. § 33-24-59.10)): fully-insured UnitedHealthcare / Optum plans issued in Georgia sit under the state mandate. State Medicaid baseline: [Georgia Medicaid guide](https://carelu.com/payers/georgia-medicaid). - **North Carolina** (mandate: N.C.G.S. § 58-3-192 (autism coverage)): fully-insured UnitedHealthcare / Optum plans issued in North Carolina sit under the state mandate. For Medicaid members, UnitedHealthcare / Optum operates [UnitedHealthcare Community Plan of North Carolina](https://carelu.com/payers/unitedhealthcare-community-plan-north-carolina) (each covered by its own guide). State Medicaid baseline: [North Carolina Medicaid guide](https://carelu.com/payers/north-carolina-medicaid). - **Indiana** (mandate: Indiana autism insurance mandate (IC 27-8-14.2)): fully-insured UnitedHealthcare / Optum plans issued in Indiana sit under the state mandate. For Medicaid members, UnitedHealthcare / Optum operates [UnitedHealthcare Community Plan of Indiana](https://carelu.com/payers/unitedhealthcare-community-plan-indiana) (each covered by its own guide). State Medicaid baseline: [Indiana Medicaid (IHCP) guide](https://carelu.com/payers/indiana-medicaid). - **Virginia** (mandate: Virginia autism insurance mandate (§ 38.2-3418.17)): fully-insured UnitedHealthcare / Optum plans issued in Virginia sit under the state mandate. For Medicaid members, UnitedHealthcare / Optum operates [UnitedHealthcare Community Plan of Virginia](https://carelu.com/payers/unitedhealthcare-community-plan-virginia) (each covered by its own guide). State Medicaid baseline: [Virginia Medicaid (DMAS) guide](https://carelu.com/payers/virginia-medicaid). - **Tennessee** (mandate: Tenn. Code Ann. § 56-7-2367 (neurological parity)): fully-insured UnitedHealthcare / Optum plans issued in Tennessee sit under the state mandate. For Medicaid members, UnitedHealthcare / Optum operates [UnitedHealthcare Community Plan of Tennessee](https://carelu.com/payers/unitedhealthcare-community-plan-tennessee) (each covered by its own guide). State Medicaid baseline: [TennCare (Tennessee Medicaid) guide](https://carelu.com/payers/tenncare-tennessee-medicaid). - **Ohio** (mandate: Ohio autism insurance mandate (R.C. 3923.84)): fully-insured UnitedHealthcare / Optum plans issued in Ohio sit under the state mandate. For Medicaid members, UnitedHealthcare / Optum operates [UnitedHealthcare Community Plan of Ohio](https://carelu.com/payers/unitedhealthcare-community-plan-ohio) (each covered by its own guide). State Medicaid baseline: [Ohio Medicaid guide](https://carelu.com/payers/ohio-medicaid). - **New Jersey** (mandate: P.L. 2009, c.115 (N.J.S.A. 17:48-6ii et al.)): fully-insured UnitedHealthcare / Optum plans issued in New Jersey sit under the state mandate. For Medicaid members, UnitedHealthcare / Optum operates [UnitedHealthcare Community Plan (NJ FamilyCare)](https://carelu.com/payers/unitedhealthcare-community-plan-new-jersey) (each covered by its own guide). State Medicaid baseline: [NJ FamilyCare (New Jersey Medicaid) guide](https://carelu.com/payers/new-jersey-medicaid). - **Maryland** (mandate: Habilitative services mandate (Md. Ins. § 15-835 + COMAR 31.10.39.03)): fully-insured UnitedHealthcare / Optum plans issued in Maryland sit under the state mandate. State Medicaid baseline: [Maryland Medicaid (Medical Assistance) guide](https://carelu.com/payers/maryland-medicaid). - **Colorado** (mandate: Colorado autism insurance mandate (C.R.S. § 10-16-104(1.4))): fully-insured UnitedHealthcare / Optum plans issued in Colorado sit under the state mandate. State Medicaid baseline: [Health First Colorado (Colorado Medicaid) guide](https://carelu.com/payers/colorado-medicaid). - **Utah** (mandate: Utah autism insurance mandate (Utah Code § 31A-22-642; caps removed 2020)): fully-insured UnitedHealthcare / Optum plans issued in Utah sit under the state mandate. State Medicaid baseline: [Utah Medicaid guide](https://carelu.com/payers/utah-medicaid). - **Arizona** (mandate: Steven’s Law (A.R.S. § 20-826.04; dollar caps repealed by SB 1590, 2025)): fully-insured UnitedHealthcare / Optum plans issued in Arizona sit under the state mandate. For Medicaid members, UnitedHealthcare / Optum operates [UnitedHealthcare Community Plan of Arizona](https://carelu.com/payers/unitedhealthcare-community-plan-arizona) (each covered by its own guide). State Medicaid baseline: [AHCCCS (Arizona Medicaid) guide](https://carelu.com/payers/arizona-ahcccs). - **New York** (mandate: NY autism mandate (Ins. Law §§ 3216(i)(25), 3221(l)(17), 4303(ee))): fully-insured UnitedHealthcare / Optum plans issued in New York sit under the state mandate. For Medicaid members, UnitedHealthcare / Optum operates [UnitedHealthcare Community Plan of New York](https://carelu.com/payers/unitedhealthcare-community-plan-new-york) (each covered by its own guide). State Medicaid baseline: [New York Medicaid (NYS DOH / eMedNY) guide](https://carelu.com/payers/new-york-medicaid). - **New Mexico** (mandate: New Mexico autism insurance mandate (NMSA 1978 § 59A-22-49)): fully-insured UnitedHealthcare / Optum plans issued in New Mexico sit under the state mandate. For Medicaid members, UnitedHealthcare / Optum operates [UnitedHealthcare Community Plan of New Mexico (Turquoise Care)](https://carelu.com/payers/unitedhealthcare-community-plan-new-mexico) (each covered by its own guide). State Medicaid baseline: [New Mexico Medicaid (Turquoise Care) guide](https://carelu.com/payers/new-mexico-medicaid). - **Missouri** (mandate: Missouri autism insurance mandate (RSMo § 376.1224)): fully-insured UnitedHealthcare / Optum plans issued in Missouri sit under the state mandate. State Medicaid baseline: [MO HealthNet (Missouri Medicaid) guide](https://carelu.com/payers/missouri-medicaid). - **Texas** (mandate: Texas autism mandate (Tex. Ins. Code § 1355.015)): fully-insured UnitedHealthcare / Optum plans issued in Texas sit under the state mandate. For Medicaid members, UnitedHealthcare / Optum operates [UnitedHealthcare Community Plan of Texas](https://carelu.com/payers/unitedhealthcare-community-plan-texas) (each covered by its own guide). State Medicaid baseline: [Texas Medicaid (THSteps-CCP) guide](https://carelu.com/payers/texas-medicaid). - **Massachusetts** (mandate: ARICA — Ch. 207, Acts of 2010 (M.G.L. c. 175 § 47AA et al.)): fully-insured UnitedHealthcare / Optum plans issued in Massachusetts sit under the state mandate. State Medicaid baseline: [MassHealth (Massachusetts Medicaid) guide](https://carelu.com/payers/masshealth-massachusetts-medicaid). - **Florida** (mandate: Steven A. Geller Autism Coverage Act (§ 627.6686, Fla. Stat.)): fully-insured UnitedHealthcare / Optum plans issued in Florida sit under the state mandate. For Medicaid members, UnitedHealthcare / Optum operates [UnitedHealthcare Community Plan of Florida](https://carelu.com/payers/unitedhealthcare-community-plan-florida) (each covered by its own guide). State Medicaid baseline: [Florida Medicaid — Behavior Analysis Services (AHCA) guide](https://carelu.com/payers/florida-medicaid). - **Kansas** (mandate: Kansas autism insurance mandate (K.S.A. 40-2,194)): fully-insured UnitedHealthcare / Optum plans issued in Kansas sit under the state mandate. For Medicaid members, UnitedHealthcare / Optum operates [UnitedHealthcare Community Plan of Kansas](https://carelu.com/payers/unitedhealthcare-community-plan-kansas) (each covered by its own guide). State Medicaid baseline: [KanCare (Kansas Medicaid) guide](https://carelu.com/payers/kansas-medicaid). - **Nebraska** (mandate: Neb. Rev. Stat. § 44-7,106 (autism coverage, 25 hr/wk cap)): fully-insured UnitedHealthcare / Optum plans issued in Nebraska sit under the state mandate. For Medicaid members, UnitedHealthcare / Optum operates [UnitedHealthcare Community Plan of Nebraska](https://carelu.com/payers/unitedhealthcare-community-plan-nebraska) (each covered by its own guide). State Medicaid baseline: [Nebraska Medicaid (Heritage Health) guide](https://carelu.com/payers/nebraska-medicaid). - **Idaho** (mandate: No autism statute — DOI Bulletin 18-02 (habilitative-parity floor, plan years from 2019)): fully-insured UnitedHealthcare / Optum plans issued in Idaho sit under the state mandate. State Medicaid baseline: [Idaho Medicaid guide](https://carelu.com/payers/idaho-medicaid). - **Iowa** (mandate: Iowa autism mandates (Iowa Code §§ 514C.31, 514C.28; caps and age limits removed by H.F. 330 from 1/1/2026)): fully-insured UnitedHealthcare / Optum plans issued in Iowa sit under the state mandate. State Medicaid baseline: [Iowa Medicaid (IA Health Link) guide](https://carelu.com/payers/iowa-medicaid). - **Oklahoma** (mandate: Nick’s Law (36 O.S. § 6060.21; age and hour caps removed 2022)): fully-insured UnitedHealthcare / Optum plans issued in Oklahoma sit under the state mandate. State Medicaid baseline: [Oklahoma Medicaid (SoonerCare / SoonerSelect) - Oklahoma Health Care Authority guide](https://carelu.com/payers/oklahoma-medicaid). - **Michigan** (mandate: Michigan autism mandate (MCL 500.3406s, 550.1416e; through age 18, $50K/$40K/$30K caps allowed)): fully-insured UnitedHealthcare / Optum plans issued in Michigan sit under the state mandate. State Medicaid baseline: [Michigan Medicaid guide](https://carelu.com/payers/michigan-medicaid). - **Hawaii** (mandate: Luke’s Law (HRS § 431:10A-133; under 14, $25,000/yr ABA cap)): fully-insured UnitedHealthcare / Optum plans issued in Hawaii sit under the state mandate. For Medicaid members, UnitedHealthcare / Optum operates [UnitedHealthcare Community Plan of Hawaii](https://carelu.com/payers/unitedhealthcare-community-plan-hawaii) (each covered by its own guide). State Medicaid baseline: [Hawaii Medicaid (Med-QUEST / QUEST Integration) guide](https://carelu.com/payers/hawaii-medicaid). - **California** (mandate: SB 946 autism mandate (H&S § 1374.73, Ins. Code § 10144.51; no age or dollar caps)): fully-insured UnitedHealthcare / Optum plans issued in California sit under the state mandate. State Medicaid baseline: [Medi-Cal (California Medicaid) guide](https://carelu.com/payers/medi-cal-california-medicaid). - **Pennsylvania** (mandate: Act 62 of 2008 (40 P.S. § 764h; under 21, CPI-adjusted cap $51,908 for 2026)): fully-insured UnitedHealthcare / Optum plans issued in Pennsylvania sit under the state mandate. State Medicaid baseline: [Pennsylvania Medicaid (Medical Assistance) guide](https://carelu.com/payers/pennsylvania-medicaid). ## Intake gates The questions that decide whether a family can start with UnitedHealthcare / Optum, and what they have to bring. - **Who may diagnose**: 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] - **Diagnostic tools required**: 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] - **Referral required?**: 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] - **Telehealth**: 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] - **Age limit** _(plan-dependent)_: 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. - **Prior-auth decision time** _(plan-dependent)_: 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). - **Other insurance (who pays first)** _(plan-dependent)_: 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. - **Diagnosis recency** _(ask the plan)_: 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. ## Delivery and billing rules Coverage decides whether UnitedHealthcare / Optum 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**: 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] - **Concurrent billing (97153 + 97155)**: 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] - **Place of service**: 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] - **Daily limits / MUEs** _(ask the plan)_: 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. - **Session-note signature** _(ask the plan)_: 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. - **Bill as provider** _(ask the plan)_: 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. ## What intake should collect for UnitedHealthcare / Optum - **Member ID + card photo:** Plus subscriber details for the benefits check. - **Diagnosis + validated tool:** DSM-5-TR diagnosis, diagnosing clinician, and which instrument confirmed it (ADI-R, ADOS-2, etc.). - **School / IEP status:** IDEA-covered services are excluded from coverage — the school picture must be precise. - **Real family availability:** Authorized hours the family can't attend become an 80%-utilization problem at review. - **Caregiver participation capacity:** Caregiver involvement and progress are review criteria — set expectations at intake. Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf ## Verification of benefits (VOB) data How UnitedHealthcare / Optum 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 - **Supports 270/271 eligibility:** Yes - **Behavioral health administrator:** Optum Behavioral Health ### 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 — step 1 of Optum's two-step authorization (assessment auth via Provider Express), then step 2 treatment auth; continued-service reviews every 4–6 months | plan-dependent — Optum's national Reimbursement Policy 2022RP501A default is 32 units/day (≤8 hrs); state mandates and ASO/fully-insured plan terms can override this figure per plan-dependent — day, per Optum default; confirm against the specific plan | plan-dependent | Tele-supervision and virtual family training allowed with an approved Optum virtual-visits attestation on Provider Express (framed as a supplement to, not replacement for, in-person care); no per-code telehealth-eligibility list found nationally | HN, HO, HP | | 97152 | Yes | Required — step 1 of Optum's two-step authorization (assessment auth via Provider Express), then step 2 treatment auth; continued-service reviews every 4–6 months | plan-dependent — Optum's national Reimbursement Policy 2022RP501A default is 16 units/day (≤4 hrs); state mandates and ASO/fully-insured plan terms can override this figure per plan-dependent — day, per Optum default; confirm against the specific plan | plan-dependent | Tele-supervision and virtual family training allowed with an approved Optum virtual-visits attestation on Provider Express (framed as a supplement to, not replacement for, in-person care); no per-code telehealth-eligibility list found nationally | HN, HM, HO, HP | | 97153 | Yes | Required — step 1 of Optum's two-step authorization (assessment auth via Provider Express), then step 2 treatment auth; continued-service reviews every 4–6 months | plan-dependent — Optum's national Reimbursement Policy 2022RP501A default is 32 units/day (≤8 hrs); state mandates and ASO/fully-insured plan terms can override this figure per plan-dependent — day, per Optum default; confirm against the specific plan | plan-dependent | Tele-supervision and virtual family training allowed with an approved Optum virtual-visits attestation on Provider Express (framed as a supplement to, not replacement for, in-person care); no per-code telehealth-eligibility list found nationally | HN, HM, HO, HP | | 97154 | Yes | Required — step 1 of Optum's two-step authorization (assessment auth via Provider Express), then step 2 treatment auth; continued-service reviews every 4–6 months | plan-dependent — Optum's national Reimbursement Policy 2022RP501A default is 18 units/day (≤4.5 hrs); state mandates and ASO/fully-insured plan terms can override this figure per plan-dependent — day, per Optum default; confirm against the specific plan | plan-dependent | Tele-supervision and virtual family training allowed with an approved Optum virtual-visits attestation on Provider Express (framed as a supplement to, not replacement for, in-person care); no per-code telehealth-eligibility list found nationally | HN, HM, HO, HP | | 97155 | Yes | Required — step 1 of Optum's two-step authorization (assessment auth via Provider Express), then step 2 treatment auth; continued-service reviews every 4–6 months | plan-dependent — Optum's national Reimbursement Policy 2022RP501A default is 24 units/day (≤6 hrs); state mandates and ASO/fully-insured plan terms can override this figure per plan-dependent — day, per Optum default; confirm against the specific plan | plan-dependent | Tele-supervision and virtual family training allowed with an approved Optum virtual-visits attestation on Provider Express (framed as a supplement to, not replacement for, in-person care); no per-code telehealth-eligibility list found nationally | HN, HO, HP | | 97156 | Yes | Required — step 1 of Optum's two-step authorization (assessment auth via Provider Express), then step 2 treatment auth; continued-service reviews every 4–6 months | plan-dependent — Optum's national Reimbursement Policy 2022RP501A default is 16 units/day (≤4 hrs); state mandates and ASO/fully-insured plan terms can override this figure per plan-dependent — day, per Optum default; confirm against the specific plan | plan-dependent | Tele-supervision and virtual family training allowed with an approved Optum virtual-visits attestation on Provider Express (framed as a supplement to, not replacement for, in-person care); no per-code telehealth-eligibility list found nationally | HN, HO, HP | | 97157 | Yes | Required — step 1 of Optum's two-step authorization (assessment auth via Provider Express), then step 2 treatment auth; continued-service reviews every 4–6 months | plan-dependent — Optum's national Reimbursement Policy 2022RP501A default is 16 units/day (≤4 hrs); state mandates and ASO/fully-insured plan terms can override this figure per plan-dependent — day, per Optum default; confirm against the specific plan | plan-dependent | Tele-supervision and virtual family training allowed with an approved Optum virtual-visits attestation on Provider Express (framed as a supplement to, not replacement for, in-person care); no per-code telehealth-eligibility list found nationally | HN, HO, HP | | 97158 | Yes | Required — step 1 of Optum's two-step authorization (assessment auth via Provider Express), then step 2 treatment auth; continued-service reviews every 4–6 months | plan-dependent — Optum's national Reimbursement Policy 2022RP501A default is 16 units/day (≤4 hrs); state mandates and ASO/fully-insured plan terms can override this figure per plan-dependent — day, per Optum default; confirm against the specific plan | plan-dependent | Tele-supervision and virtual family training allowed with an approved Optum virtual-visits attestation on Provider Express (framed as a supplement to, not replacement for, in-person care); no per-code telehealth-eligibility list found nationally | HN, HO, HP | | 99366 | Not confirmed (see code notes) | — | — | plan-dependent | — | — | | 0362T | Yes | Required — step 1 of Optum's two-step authorization (assessment auth via Provider Express), then step 2 treatment auth; continued-service reviews every 4–6 months | plan-dependent — Optum's national Reimbursement Policy 2022RP501A default is 16 units/day (≤4 hrs); state mandates and ASO/fully-insured plan terms can override this figure per plan-dependent — day, per Optum default; confirm against the specific plan | plan-dependent | Tele-supervision and virtual family training allowed with an approved Optum virtual-visits attestation on Provider Express (framed as a supplement to, not replacement for, in-person care); no per-code telehealth-eligibility list found nationally | — | | 0373T | Yes | Required — step 1 of Optum's two-step authorization (assessment auth via Provider Express), then step 2 treatment auth; continued-service reviews every 4–6 months | plan-dependent — Optum's national Reimbursement Policy 2022RP501A default is 32 units/day (≤8 hrs); state mandates and ASO/fully-insured plan terms can override this figure per plan-dependent — day, per Optum default; confirm against the specific plan | plan-dependent | Tele-supervision and virtual family training allowed with an approved Optum virtual-visits attestation on Provider Express (framed as a supplement to, not replacement for, in-person care); no per-code telehealth-eligibility list found nationally | — | Code notes: - **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 99366, 0362T, 0373T:** Unit caps sourced from Optum's national ABA Reimbursement Policy (2022RP501A), shipped as 'plan-dependent' at the national-guide level since state mandates and ASO/fully-insured status can each override the default. Verify via: Provider Express / UHC provider services. ### Contacts - **Provider services phone:** 1-877-614-0484 (Provider Express — Behavioral Health/ABA) - **Phone menu path:** Provider Express secure-portal technical support runs a separate line, 1-866-209-9320, same hours — use 877-614-0484 for BH/ABA authorization and eligibility questions, not portal login issues. - **Hours:** Mon-Fri 7:00am-7:00pm CT - **Portal:** [Provider Express](https://public.providerexpress.com/) Questions to ask on a verification call: - Does ABA route through Optum Behavioral Health, or directly through UnitedHealthcare medical benefits for this specific plan? - What EDI payer ID routes the BH-side 270/271 eligibility check for this plan, and does eligibility itself require a second hop to Optum, or only the PA/UM step? - Do the national Reimbursement Policy (2022RP501A) daily unit caps apply to this specific plan, or does a state mandate/ASO plan document override them? - What place-of-service settings are allowed for ABA, and is telehealth permitted beyond tele-supervision/virtual family training? - Is 99366 (interdisciplinary team meeting) a covered, billable benefit under this plan? ### 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) - 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://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/abaFAQ.pdf (accessed 2026-07-23) - https://public.providerexpress.com/content/ope-provexpr/us/en/contact-us.html (accessed 2026-07-23) - https://public.providerexpress.com/content/ope-provexpr/us/en/about-us/provider-express-support.html (accessed 2026-07-23) ## Common questions ### Does UnitedHealthcare require prior authorization for ABA? Yes — a two-step process via Optum's Provider Express portal: an assessment authorization first, then a treatment authorization, generally under Optum's Supplemental Clinical Criteria unless state law specifies otherwise. ### How often does Optum review ABA authorizations? Most continued-service reviews occur every 4–6 months, requiring progress data measured the same way as baseline, updated standardized measures, and documented caregiver involvement. ### What happens if a family uses fewer hours than authorized? Utilization below 80% of authorized hours over a two-week period draws scrutiny at review. Intake should capture realistic availability so the requested intensity matches what the family can actually attend. ## 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 FAQ (Provider Express)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/abaFAQ.pdf) 3. [2026 UnitedHealthcare Care Provider Administrative Guide (Commercial, Exchange, MA) (PDF)](https://www.uhcprovider.com/content/dam/provider/docs/public/admin-guides/2026-UHC-Administrative-Guide.pdf) 4. [29 CFR § 2560.503-1(f)(2) — ERISA group health plan claim decision deadlines](https://www.ecfr.gov/current/title-29/subtitle-B/chapter-XXV/subchapter-F/part-2560/section-2560.503-1) 5. [Optum Behavioral Health Solutions National Network Manual (eff. Oct. 1, 2025) (PDF)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/netwManual/2024/NNMJune2024.pdf) 6. [42 CFR § 433.139 — Medicaid payment of claims involving third party liability](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139) 7. [32 CFR § 199.8 — TRICARE double coverage](https://www.ecfr.gov/current/title-32/subtitle-A/chapter-VII/part-199/section-199.8) 8. [VA — CHAMPVA Guidebook (updated Jan. 1, 2025) (PDF)](https://www.va.gov/files/2025-12/CHAMPVA-Guidebook.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.