UMR is a third-party administrator, not an insurer. UnitedHealthcare describes it as "a wholly owned subsidiary of UnitedHealthcare, a part of UnitedHealth Group," and "a third-party administrator (TPA) for self-funded plans." The employer funds the claims and writes the plan, so two UMR cards can carry different ABA benefits.
UMR does publish one ABA document of its own: form UMF0035, ABA Therapy Documentation Requirements. It sets the diagnosis proof UMR wants, what every treatment plan must contain, how requests are submitted and how long a review takes. Whether a given member needs prior authorization at all is answered per plan, in UMR's online requirement search.
UMR's ABA form (UMF0035, edition 0824, the version its Form center links) tells providers to "disregard any prior UMR Applied Behavior Analysis (ABA) documents and use this form only." For "initial evaluations for ABA therapy or if this is a new member with UMR receiving ongoing services, you must submit proof of an autism diagnosis via the diagnostic evaluation." It adds that "IEPs and school evaluations are NOT acceptable as the sole proof of diagnosis."[1][6]
An older report is not rejected outright. "If the diagnostic report is more than four years old, please submit current documentation, reflecting the child's current behaviors and deficits (examples: IEP; physician's progress note/well-visit exam; mental health therapy note)." An IEP can therefore update an old diagnosis, but cannot replace it.[1][6]
The form does not say which credentials may make the diagnosis, which instrument (ADOS-2 or another) must be used, or which ICD-10 codes qualify. Collect the full evaluation with the diagnosing clinician's credentials, the instrument and scores, and the ICD-10 code, and ask UMR about anything the plan requires beyond that.[1][6]
UMR's Prior Authorization Requirement Search and Submission Tool "is now available for most UMR-administered group health care plans through the secure provider portal on umr.com." UMR describes its purpose as answering "Is a prior auth required or a pre determination recommended for this member, for this service, on this date, performed by this provider?" Results can read prior authorization required, medical necessity review needed/predetermination recommended, no coverage for this service, or no procedure-code requirements found. Some results depend on "patient age, dollar amount or visit threshold." Store the Decision ID each search returns.[2][3][4][5]
A predetermination is a courtesy review. UMR's predetermination form says predeterminations "have no time frame for determination," "are not considered urgent or expedited and cannot be reviewed if the service has been provided."[2][3][4][5]
Two UMR-administered plans route differently. GEHA members go through geha.com's provider portal. For West Virginia PEIA members, UMR's precertification list (as of 01/17/2024) names "Autism Spectrum Disorder Services" among the services requiring precertification.[2][3][4][5]
"All ABA therapy clinical and required information must be submitted for review via the UMR portal (umr.com), using your One Healthcare ID," and the status of every ABA request can be checked there. An older (2023) UMR copy of this form sent ABA paperwork to an outpatient behavioral fax line; the current form replaces that with portal submission. Every submission names the facility and address, the supervising BCBA's name and credentials, the member's name, date of birth, UMR ID and case reference number, the codes, hours and dates requested, and a facility contact with a valid phone number.[1][16][17]
Treatment plans must include the member's individualized goals with target dates, the ABA evaluation or functional assessment, documentation of progress for concurrent reviews, parent training goals, a transition/discharge plan, and the other services the child receives (including school) with documentation of care coordination. The form's code grid requests 97151, 97152 and 0362T in hours per six months, 97153 and 0373T in hours per week, and 97154 to 97158 in hours per week or month. 0362T and 0373T are deleted from CPT on January 1, 2027, when six new adaptive behavior codes take effect; UMR's form had not been updated for that as of November 1, 2026, so ask UMR which codes to request for dates of service from January 1, 2027.[1][16][17]
Decisions: "ABA preauthorization reviews have up to 15 days for rendered determination: no timeframe for predeterminations. ABA cases are not considered urgent or expedited." Prior authorization decisions are communicated by phone call and mailed letter; predeterminations by letter only.[1][16][17]
The federal Interoperability and Prior Authorization rule (CMS-0057-F) does not change this. It covers Medicare Advantage, Medicaid and CHIP, and QHP issuers on the federal exchanges; CMS says its authority "does not apply to health insurance issuers and group health plans outside the FFEs." A self-funded employer plan administered by UMR is not one of its impacted payers.[1][16][17]
State autism mandates regulate insurance. Under ERISA's "deemer" clause, an employee benefit plan shall not "be deemed to be an insurance company or other insurer … for purposes of any law of any State purporting to regulate insurance companies, insurance contracts." A self-funded employer plan administered by UMR is therefore generally outside the state mandate's direct reach, and the plan document is the answer. Governmental and most church plans are outside ERISA (29 U.S.C. § 1003(b)) and follow their own terms and whatever state law reaches them.[13][14][12]
UnitedHealthcare's UMR medical-policy page says the same from the payer side: "Benefit coverage for health services is determined by the member specific benefit plan document," and "In the event of a conflict, the member specific benefit plan document supersedes these policies." The UMR medical policy list on that page has no ABA or autism policy.[13][14][12]
Claims: electronic claims use payer ID 39026 "with 275 attachments enabled through your clearinghouse," or online through Optum iEDI with the same payer ID. Paper claims go to UMR, P.O. Box 211762, Eagan, MN 55121.[7][8][9][3][10]
Phone: call "the provider services number located on the plan member's ID card." Without the card, UMR lists 877-233-1800.[7][8][9][3][10]
Disputes: a pre-service appeal of a prior authorization decision is filed from the request in UMR's online tool. A post-service appeal of a denied claim uses form UMF0010, mailed to UMR – Claim Appeals, P.O. Box 30546, Salt Lake City, UT 84130-0546. A peer-to-peer discussion is requested on form UMF0057, sent by encrypted email to UHC_PeerToPeer_Scheduling@uhc.com.[7][8][9][3][10]
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). Here's the picture in the states we cover:
Fully-insured UMR plans issued in Georgia sit under the state mandate above. State Medicaid baseline: Georgia Medicaid guide →
Fully-insured UMR plans issued in North Carolina sit under the state mandate above. For Medicaid members, UMR operates UnitedHealthcare Community Plan of North Carolina — covered by its own guide, not this one. State Medicaid baseline: North Carolina Medicaid guide →
Fully-insured UMR plans issued in Indiana sit under the state mandate above. For Medicaid members, UMR operates UnitedHealthcare Community Plan of Indiana — covered by its own guide, not this one. State Medicaid baseline: Indiana Medicaid (IHCP) guide →
Fully-insured UMR plans issued in Virginia sit under the state mandate above. For Medicaid members, UMR operates UnitedHealthcare Community Plan of Virginia — covered by its own guide, not this one. State Medicaid baseline: Virginia Medicaid (DMAS) guide →
Fully-insured UMR plans issued in Tennessee sit under the state mandate above. For Medicaid members, UMR operates UnitedHealthcare Community Plan of Tennessee — covered by its own guide, not this one. State Medicaid baseline: TennCare (Tennessee Medicaid) guide →
Fully-insured UMR plans issued in Ohio sit under the state mandate above. For Medicaid members, UMR operates UnitedHealthcare Community Plan of Ohio — covered by its own guide, not this one. State Medicaid baseline: Ohio Medicaid guide →
Fully-insured UMR plans issued in New Jersey sit under the state mandate above. For Medicaid members, UMR 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 UMR plans issued in Maryland sit under the state mandate above. State Medicaid baseline: Maryland Medicaid (Medical Assistance) guide →
Fully-insured UMR plans issued in Colorado sit under the state mandate above. State Medicaid baseline: Health First Colorado (Colorado Medicaid) guide →
Fully-insured UMR plans issued in Utah sit under the state mandate above. State Medicaid baseline: Utah Medicaid guide →
Fully-insured UMR plans issued in Arizona sit under the state mandate above. For Medicaid members, UMR operates UnitedHealthcare Community Plan of Arizona — covered by its own guide, not this one. State Medicaid baseline: AHCCCS (Arizona Medicaid) guide →
Fully-insured UMR plans issued in New York sit under the state mandate above. For Medicaid members, UMR 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 UMR plans issued in New Mexico sit under the state mandate above. For Medicaid members, UMR 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 UMR plans issued in Missouri sit under the state mandate above. State Medicaid baseline: MO HealthNet (Missouri Medicaid) guide →
Fully-insured UMR plans issued in Texas sit under the state mandate above. For Medicaid members, UMR operates UnitedHealthcare Community Plan of Texas — covered by its own guide, not this one. State Medicaid baseline: Texas Medicaid (THSteps-CCP) guide →
Fully-insured UMR plans issued in Massachusetts sit under the state mandate above. State Medicaid baseline: MassHealth (Massachusetts Medicaid) guide →
Fully-insured UMR plans issued in Florida sit under the state mandate above. For Medicaid members, UMR 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 UMR plans issued in Kansas sit under the state mandate above. For Medicaid members, UMR operates UnitedHealthcare Community Plan of Kansas — covered by its own guide, not this one. State Medicaid baseline: KanCare (Kansas Medicaid) guide →
Fully-insured UMR plans issued in Nebraska sit under the state mandate above. For Medicaid members, UMR operates UnitedHealthcare Community Plan of Nebraska — covered by its own guide, not this one. State Medicaid baseline: Nebraska Medicaid (Heritage Health) guide →
Fully-insured UMR plans issued in Idaho sit under the state mandate above. State Medicaid baseline: Idaho Medicaid guide →
Fully-insured UMR plans issued in Iowa sit under the state mandate above. State Medicaid baseline: Iowa Medicaid (IA Health Link) guide →
Fully-insured UMR plans issued in Oklahoma sit under the state mandate above. State Medicaid baseline: Oklahoma Medicaid (SoonerCare / SoonerSelect) - Oklahoma Health Care Authority guide →
Fully-insured UMR plans issued in Michigan sit under the state mandate above. State Medicaid baseline: Michigan Medicaid guide →
Fully-insured UMR plans issued in Hawaii sit under the state mandate above. For Medicaid members, UMR 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 UMR plans issued in California sit under the state mandate above. State Medicaid baseline: Medi-Cal (California Medicaid) guide →
Fully-insured UMR plans issued in Pennsylvania sit under the state mandate above. State Medicaid baseline: Pennsylvania Medicaid (Medical Assistance) guide →
Fully-insured UMR plans issued in New Hampshire sit under the state mandate above. State Medicaid baseline: New Hampshire Medicaid guide →
Fully-insured UMR plans issued in Wisconsin sit under the state mandate above. State Medicaid baseline: Wisconsin Medicaid (ForwardHealth) guide →
Fully-insured UMR plans issued in South Carolina sit under the state mandate above. State Medicaid baseline: South Carolina Healthy Connections Medicaid guide →
Fully-insured UMR plans issued in Kentucky sit under the state mandate above. For Medicaid members, UMR operates UnitedHealthcare Community Plan of Kentucky — covered by its own guide, not this one. State Medicaid baseline: Kentucky Medicaid guide →
Fully-insured UMR plans issued in Washington sit under the state mandate above. For Medicaid members, UMR operates UnitedHealthcare Community Plan of Washington — covered by its own guide, not this one. State Medicaid baseline: Washington Apple Health (Medicaid) guide →
Fully-insured UMR plans issued in Connecticut sit under the state mandate above. State Medicaid baseline: Connecticut Medicaid (HUSKY Health) guide →
Fully-insured UMR plans issued in Illinois sit under the state mandate above. State Medicaid baseline: Illinois Medicaid (HFS) guide →
Fully-insured UMR plans issued in Louisiana sit under the state mandate above. State Medicaid baseline: Louisiana Medicaid (Healthy Louisiana) guide →
Fully-insured UMR plans issued in Oregon sit under the state mandate above. State Medicaid baseline: Oregon Health Plan (Medicaid) guide →
Fully-insured UMR plans issued in Minnesota sit under the state mandate above. State Medicaid baseline: Minnesota Medical Assistance (EIDBI) guide →
Fully-insured UMR plans issued in Maine sit under the state mandate above. State Medicaid baseline: MaineCare (Maine Medicaid) guide →
Fully-insured UMR plans issued in Vermont sit under the state mandate above. State Medicaid baseline: Vermont Medicaid (Green Mountain Care / DVHA) guide →
Fully-insured UMR plans issued in Alabama sit under the state mandate above. State Medicaid baseline: Alabama Medicaid guide →
Fully-insured UMR plans issued in South Dakota sit under the state mandate above. State Medicaid baseline: South Dakota Medicaid guide →
Fully-insured UMR plans issued in Nevada sit under the state mandate above. For Medicaid members, UMR operates Health Plan of Nevada (Nevada Medicaid) — covered by its own guide, not this one. State Medicaid baseline: Nevada Medicaid guide →
Fully-insured UMR plans issued in Montana sit under the state mandate above. State Medicaid baseline: Montana Medicaid guide →
Fully-insured UMR plans issued in Alaska sit under the state mandate above. State Medicaid baseline: Alaska Medicaid guide →
Fully-insured UMR plans issued in North Dakota sit under the state mandate above. State Medicaid baseline: North Dakota Medicaid guide →
Fully-insured UMR plans issued in Arkansas sit under the state mandate above. State Medicaid baseline: Arkansas Medicaid guide →
Fully-insured UMR plans issued in Rhode Island sit under the state mandate above. For Medicaid members, UMR operates UnitedHealthcare Community Plan of Rhode Island — covered by its own guide, not this one. State Medicaid baseline: Rhode Island Medicaid guide →
Fully-insured UMR plans issued in Wyoming sit under the state mandate above. State Medicaid baseline: Wyoming Medicaid guide →
Fully-insured UMR plans issued in West Virginia sit under the state mandate above. State Medicaid baseline: West Virginia Medicaid (BMS) guide →
Fully-insured UMR plans issued in District of Columbia sit under the state mandate above. State Medicaid baseline: District of Columbia Medicaid guide →
Fully-insured UMR plans issued in Mississippi sit under the state mandate above. State Medicaid baseline: Mississippi Medicaid guide →
Fully-insured UMR plans issued in Delaware sit under the state mandate above. State Medicaid baseline: Delaware Medicaid (DMAP / Diamond State Health Plan) guide →
The questions that decide whether a family can start with UMR, and what they have to bring. Each maps onto something intake should ask on the first call.
No hard expiry. "If the diagnostic report is more than four years old, please submit current documentation, reflecting the child's current behaviors and deficits (examples: IEP; physician's progress note/well-visit exam; mental health therapy note)."[1]
"ABA preauthorization reviews have up to 15 days for rendered determination: no timeframe for predeterminations. ABA cases are not considered urgent or expedited." For a self-funded ERISA plan, federal rules also cap a pre-service decision at "not later than 15 days after receipt of the claim by the plan," extendable once "for up to 15 days."[1][15]
Set by the plan document. UMR's ABA form states no age limit, and a self-funded ERISA plan is generally outside state insurance mandates, so a mandate's age band may not apply.[1][13]
Ask the plan: The Prior Authorization Requirement Search (results can depend on patient age) or provider services — ask for any ABA age limit in the plan.
UMR's ABA form asks for the diagnostic evaluation, not a physician referral, order or prescription. Whether a plan also needs a referral is plan-specific; the requirement search shows prior authorization, not referrals.[1]
Ask the plan: Provider services on the member's ID card — ask whether ABA needs a physician referral or order under this plan.
Set by the plan document's coordination-of-benefits terms. UMR asks members to report all other coverage, including, for a child of parents who are divorced or not living together, who has custody and whether a court decree assigns responsibility for health coverage.[11]
Ask the plan: Provider services on the member's ID card — confirm UMR has the other coverage on file and which plan is primary for the child.
Not published by UMR. Its ABA form requires the diagnostic evaluation as proof, but does not say which credentials may make the diagnosis. LCSW: no UMR answer is published.[1]
Ask the plan: Provider services on the member's ID card, or the predetermination review — ask which diagnosing credentials the plan accepts before booking the assessment.
Not published by UMR. Its ABA form names no required instrument, and UMR's medical policy list has no ABA policy. Collect the instrument, date and scores from the evaluation anyway.[1][12]
Ask the plan: Provider services on the member's ID card — ask whether the plan requires a specific diagnostic instrument (ADOS-2 or similar).
Not published by UMR for ABA, including whether 97151 may be done by telehealth. It is a plan question.[1]
Ask the plan: Run the Prior Authorization Requirement Search with the telehealth place of service, and ask provider services which ABA codes are payable by telehealth and with which modifier.
Coverage decides whether UMR 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.
UMR asks every ABA submission to name the supervising BCBA and that BCBA's credentials. It publishes no supervision ratio, frequency or supervision-log requirement; any such rule comes from the plan and the criteria it applies.[1]
Ask the plan: The number on the member's ID card, or the predetermination review itself — ask what BCBA supervision (hours of 97155 per hours of 97153, and any supervision documentation) the plan expects.
Not published by UMR. Hours are requested per code on UMR's form (per six months for assessment codes, per week or month for treatment codes); any cap on hours, visits or dollars is set by the employer's plan, and UMR's requirement search can return limits that depend on "patient age, dollar amount or visit threshold."[1][3]
Ask the plan: The Prior Authorization Requirement Search for the member, plus provider services — ask for any ABA hour, visit or dollar limit and how much has been used.
Not published by UMR for ABA. UMR's requirement search can return place-of-service criteria for a member, so payable settings (home, clinic, school, telehealth) are a plan question.[3]
Ask the plan: Run the Prior Authorization Requirement Search with the intended place of service, and ask provider services whether school-based ABA is excluded.
Not published by UMR. UMR's ABA form lists 97151 to 97158, 0362T and 0373T but says nothing about billing 97153 and 97155 for the same clock time.[1]
Ask the plan: Provider services on the member's ID card — ask whether 97153 and 97155 may overlap for this plan.
Not published by UMR. UMR's ABA form sets treatment-plan contents and requires progress documentation for concurrent reviews, but it says nothing about who signs session notes, or how late entries and amendments must be made.[1]
Ask the plan: Provider services on the member's ID card — ask which documentation standard applies at audit for this plan, including signatures and corrections to session notes.
Not published by UMR. Whose NPI carries a technician-delivered 97153 claim, and whether credential modifiers are required, depends on the plan and the provider's network agreement.[7]
Ask the plan: Provider services on the member's ID card — confirm rendering versus billing NPI and modifiers before the first claim.
UMR's ABA form (UMF0035) says that for an initial ABA evaluation, or a member new to UMR already in services, you must submit proof of an autism diagnosis from the diagnostic evaluation. An IEP or school evaluation alone is not accepted. If the report is more than four years old, add current documentation of the child's behaviors and deficits, such as a physician progress note or well-visit, a mental health therapy note, or an IEP. UMR does not publish which credentials may diagnose, which instrument is required or which ICD-10 codes qualify, so ask about the specific plan.
It depends on the employer plan. UMR says not all plans require prior authorization for ABA, and recommends a predetermination review even when prior authorization is not needed. Check the member in UMR's Prior Authorization Requirement Search in the provider portal.
UMR's current ABA form says all ABA clinical and required information must be submitted through the UMR portal at umr.com with a One Healthcare ID. An older 2023 version listed a fax line; the current form replaced it with the portal.
UMR is a wholly owned subsidiary of UnitedHealthcare and a third-party administrator for self-funded plans. The employer funds the benefit and writes the plan, so a UMR card is not a UnitedHealthcare insured plan, and its ABA rules come from UMR's forms and the employer's plan document.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 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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