Select Health ABA coverage in Utah: Medicaid ACO vs. commercial.

No recency window is published on either side. Utah Medicaid states none (see our Utah Medicaid guide), and Select Health's commercial ABA Preauthorization Form distinguishes an initial request, which requires the diagnostic evaluation report, from a concurrent request, which requires an updated treatment plan with progress data — without dating the diagnosis. Policy #630 confirms this directly: it requires the DSM-5/ICD-10 diagnosis "obtained by an appropriate... licensed provider" but states no maximum age for that diagnosis.^[5][9][4]

For SelectHealth Community Care (Medicaid) members this is not a Select Health question: ABA is carved out of every Utah Medicaid ACO to state fee-for-service, so the Utah Medicaid rule governs — the diagnosis may be rendered by any clinician authorized under the scope of their licensure and trained in the use and interpretation of the selected assessment tool. For commercial members the Utah mandate's definition is narrower and stricter: a board-certified neurologist, psychiatrist or pediatrician with ASD experience, or an experienced licensed psychologist.^{[9][12][7][10]}

For SelectHealth Community Care (Medicaid) members this is not a Select Health question: ABA is carved out of every Utah Medicaid ACO to state fee-for-service, so the Utah Medicaid rule governs — no specific instrument is mandated, but the DSM-5 determination must rest on evidence-based standardized measures and the completed tool accompanies the initial PA. For commercial members, Select Health's ABA Preauthorization Form requires the diagnostic evaluation report on an initial request, and Policy #630's Utah-specific rule likewise names no required instrument — just "medically necessary assessments, evaluations, or tests" behind the diagnosis. The policy's background section separately lists the M-CHAT-R/F as an example general ASD screening tool and reproduces the full DSM-5 criteria A–E, but does not make any one instrument mandatory for ABA authorization; continuation reviews instead look for progress measured on "validated scales (e.g. Vineland Adaptive Behavior Scales 3 (VABS-3), the Adaptive Behavior Assessment Scale (ABAS), VB-MAPP, or ABLLS)."^{[9][5][10][4]}

For SelectHealth Community Care (Medicaid) members this is not a Select Health question: ABA is carved out of every Utah Medicaid ACO to state fee-for-service, so the Utah Medicaid rule governs — an order or prescription for ABA from a licensed clinician authorized to prescribe it is required in the initial packet and renewed annually. For commercial members, Select Health requires preauthorization on its own ABA Preauthorization Form (commercialUMintake@imail.org, fax 801-442-0825), with Utah decisions due within 14 days absent expedited review; Policy #630 — now directly confirmed — publishes no separate physician-referral requirement beyond the diagnosing-provider rule itself.^{[9][5][10][4]}

For SelectHealth Community Care (Medicaid) members this is not a Select Health question: ABA is carved out of every Utah Medicaid ACO to state fee-for-service, so the Utah Medicaid rule governs — the January 2026 ASD manual lets behavior identification assessments (97151) and supervision of a technician or assistant analyst (97155) occur by remote access technology when clinically appropriate, plus parent training, but not technician-delivered 97153/97154 or QHP-delivered group 97158; synchronous two-way video only, POS 02 (Section I also accepts POS 10). For commercial members the Preauthorization Form collects a weekly ABA schedule by setting (office, home, other), and Policy #630 — now directly confirmed — states no telehealth-specific modality rule of its own for ABA.^{[9][12][5][10][4]}

Commercial members: Select Health's own 2026 ABA Preauthorization Form sets the clock — "Once Select Health receives this form, we have the following decision time frames to make a benefit determination (unless an expedited review is requested): For Commercial Plans: 14 days (Utah)." Expedited review is available only if the standard time frame could seriously jeopardize life, health or the ability to regain maximum function, or leave severe pain unmanaged. Utah requires fully insured plans' adverse-determination procedures to comply with 29 CFR 2560.503-1, which caps an urgent pre-service decision at 72 hours after receipt. From January 1, 2027 Utah Code 31A-22-650 (SB 319, 2026) tightens insurers to "no later than seven calendar days after the day on which the insurer receives all necessary information," and 72 hours for urgent care. Select Health separately distinguishes an initial request (diagnostic evaluation report) from a concurrent request (updated treatment plan with progress data). Community Care (Medicaid) members: the plan's manual gives 14 calendar days standard and 72 hours urgent for its own preauthorizations, but this guide records ABA as routing to Utah Medicaid fee-for-service, where the state's clock applies instead.^{[5][2][14][15][16]}

Ask the plan: Select Health Health Services, 800-442-5305: the reauthorization lead time for ABA concurrent requests, which neither the form nor the manual states.

Commercial members follow the standard order in Select Health's manual, which tracks Utah's COB rule. For a child on both parents' plans, "The benefits of the plan of the parent whose birthday falls earlier in the calendar year are determined before those of the plan of the parent whose birthday falls later in the year" (month and day only; same birthday goes to the plan that covered the parent longer). Divorced or separated parents: a court decree naming the responsible parent controls; joint custody without one uses the birthday rule. "Because of the government's role in subsidizing care for members enrolled in CHAMPUS/TRICARE and MEDICAID, these policies are always considered secondary to another plan" — so Select Health commercial pays before a child's Medicaid or TRICARE. When Select Health is secondary, the COB information must reach it "within 12 months after the claim was processed by the primary plan." Community Care (Medicaid) members: Medicaid is payer of last resort; for ABA routed to fee-for-service, Utah Medicaid's own TPL rules apply (other coverage exhausted first, 6-month transition to an in-network provider).^[2][17][9]

For SelectHealth Community Care (Medicaid) members this is not a Select Health question: ABA is carved out of every Utah Medicaid ACO to state fee-for-service, so the Utah Medicaid rule governs — no upper age limit, PRISM showing ages 1 and older including adult plans. For Select Health commercial members, the Utah mandate sets the floor where it applies: Utah Code § 31A-22-642 imposes no age limit on individual and large-group plans entered or renewed since 1/1/2020, but small-group plans are not named by the statute and self-funded ERISA plans are exempt. Select Health's own Policy #630 independently backs this up for the plans it does bind: access to both comprehensive and focused ABA "should not be restricted by age, cognitive level, diagnosis, or co-occurring conditions," unless a state mandate says otherwise.^{[8][11][7][10][4]}

Ask the plan: A live benefits verification of the member's market segment (individual, small-group, large-group or self-funded) — the mandate's protections do not reach small-group or self-funded business.

For SelectHealth Community Care (Medicaid) members this is not a Select Health question: ABA is carved out of every Utah Medicaid ACO to state fee-for-service, so the Utah Medicaid rule governs — the QHP must supervise at least 10% of technician or assistant-analyst direct-service time, at least half of it direct supervision. For commercial members, Select Health Policy #630 sets its own floor: "Services should be supervised at a minimum of 5% of direct service hours and should be supervised at least monthly," with services delivered directly by or under the supervision of a licensed behavior analyst, BCBA, or licensed psychologist. The policy also authorizes additional billable QHP protocol-modification/direction time — 1 to 2 hours per 10 hours of treatment by protocol — based on functional-impairment severity.^{[9][12][10][4]}

For SelectHealth Community Care (Medicaid) members this is not a Select Health question: ABA is carved out of every Utah Medicaid ACO to state fee-for-service, so the Utah Medicaid rule governs — limits are set per 26-week authorization period, not per day (97153 up to 780 hours; 97155 plus H0032 capped at 84 combined hours). On the commercial side the Utah mandate removed hour caps for individual and large-group plans entered or renewed since 1/1/2020 — the 600-hours-a-year floor survives only on legacy pre-2020 plans — but small-group and self-funded plans sit outside the statute. Select Health Policy #630 itself sets no hard unit cap but ties authorized hours to severity: a guide table bands weekly hours by how far maladaptive behavior, social communication, and self-care skills fall below the population mean — "None" (<1 SD) gets 0 hrs/week, "Mild" (>1 SD) 1–4 hrs/week, "Moderate" (>1.5 SD) 4–7 hrs/week, "Severe" (>2 SD) 7–10 hrs/week — plus a separate assessment-units guide (functional analysis 8–16 units, focused treatment 16–24 units, comprehensive treatment 32 units; 1 unit = 15 minutes). Authorization is reviewed for adjustment up or down at least every 6 consecutive months.^{[9][7][10][4]}

For SelectHealth Community Care (Medicaid) members this is not a Select Health question: ABA is carved out of every Utah Medicaid ACO to state fee-for-service, so the Utah Medicaid rule governs — technicians and assistant analysts work under a QHP who is responsible for all work performed, with credential modifiers (HP, HO, HN) on supervision codes and group-size modifiers on group codes; enrolment runs through state PRISM, not Select Health. For commercial members, Policy #630 requires that "ABA services must be provided directly or supervised by licensed behavior analysts (in states with Behavior analyst licensure laws), board-certified behavior analysts, or licensed psychologists ... unless state mandates, plan documents or contracts require otherwise"; where an unlicensed or non-BACB-certified provider delivers the service under an allowed exception, that work must still carry direction and supervision "in line with practice standards." No separate claim-attribution/NPI rule beyond that is published.^{[9][12][10][4]}

For SelectHealth Community Care (Medicaid) members this is not a Select Health question: ABA is carved out of every Utah Medicaid ACO to state fee-for-service, so the Utah Medicaid rule governs — home, community and clinic settings are payable across the same day, while school ASD services route to the School-Based Skills Development benefit and the January 2026 manual says Medicaid "shall not reimburse fee-for-service ABA services in school-based settings" beyond the analyst's part in the school care-plan meeting. For commercial members, Select Health's ABA Preauthorization Form collects a full weekly schedule by setting (office, home, other) plus school and other-therapy schedules and IEP/ISP/504/ARD status, which is how setting is actually adjudicated; Policy #630 adds only that "community-based treatments are optimized" with documented collaboration among stakeholders including school psychologists, without naming allowed POS codes.^{[9][5][10][4]}

Ask the plan: Select Health UM (commercialUMintake@imail.org, 800-442-4566) — Policy #630 does not publish specific POS codes, so confirm with the plan directly.

For SelectHealth Community Care (Medicaid) members this is not a Select Health question: ABA is carved out of every Utah Medicaid ACO to state fee-for-service, so the Utah Medicaid rule governs — 97155 contemplates the QHP simultaneously directing a technician with the member present, while a behavior analyst personally delivering 97153/97154 may not also bill analyst-level services. Select Health Policy #630 lists the full CPT set it covers (0362T, 0373T, 96202-96203, 97151-97158) and its own code descriptions mirror AMA language — "97155 ... may include simultaneous direction of technician" — but the policy states no explicit rule on billing 97153 and 97155 for overlapping clock time; this is now confirmed as a genuine gap in the retrieved policy, not a missing document.^{[9][12][10][4]}

Ask the plan: Select Health UM (commercialUMintake@imail.org, 800-442-4566) — Policy #630 does not state a concurrent-billing rule, so this is plan-level claims-adjudication guidance, not a document gap.

For SelectHealth Community Care (Medicaid) members this is not a Select Health question: ABA is carved out of every Utah Medicaid ACO to state fee-for-service, so the Utah Medicaid rule governs — the treatment plan must carry the name and signature of the QHP who conducted the assessment and developed it, with an attestation of medical necessity. Select Health Policy #630 requires the treatment plan to "identify all staff that will work with the member" and date services are scheduled to start, but — now directly confirmed — publishes no specific signature or co-signer rule of its own for commercial members.^{[9][12][10][4]}

Ask the plan: Select Health UM (commercialUMintake@imail.org, 800-442-4566) — Policy #630 does not publish a signature standard, so confirm documentation requirements with the plan directly.