UnitedHealthcare Community Plan entered New Mexico with the Turquoise Care launch on July 1, 2024, and runs ABA through United Behavioral Health d/b/a Optum — the only NM MCO with a dedicated, published state ABA program: a Provider Express program page, a New Mexico Quick Reference Guide, an NM clinical policy, and provider orientation training. Operationally it has the narrowest PA surface of any New Mexico payer: per the QRG, "All autism services do not require prior authorization with the exception of 97153 & 0373T." Clinically it defers to the state's stage model; the plumbing — Optum network, Provider Express, its own fax and claims routing — is distinct.
The Quick Reference Guide is unambiguous: all autism services are PA-free except 97153 (adaptive behavior treatment by protocol) and 0373T. That means the 97151 assessment, 97155 protocol modification, and 97156 family training all proceed without authorization — so the only PA workflow to build for UHC members is the treatment request. It goes on the New Mexico Uniform Prior Authorization Form, submitted online through the Provider Express Auth tab (a 5-step flow behind a One Healthcare ID) or by fax to 1-888-541-6691. Clinical criteria track the state program — the ASD-or-at-risk eligibility, three-stage model, and authorization cadence in the New Mexico Medicaid guide — with the NM clinical policy posted under Provider Express > ABA Information > State Medicaid ABA Programs > New Mexico.[4][3]
ABA runs on Optum's dedicated network, so credentialing and case questions live on Provider Express, not the standard UHC medical channels — tech support and chat at 1-866-209-9320, claim status at 1-888-702-2202. All autism services bill on a CMS-1500 to Payer ID 87726 (ERA 86047) via uhcprovider.com, with paper claims to Optum, PO Box 31348, Salt Lake City, UT 84131-0348. The deadline with teeth: claims must be filed within 6 months of the date of service — comfortable for clean workflows, unforgiving for backlogged ones. On rates, LOD #53 applies to UHC like every Turquoise Care MCO: the state FFS ABA fee schedule is the contractual minimum.[4]
UnitedHealthcare Community Plan publishes no ABA goal format of its own for New Mexico. Its 2026 care provider manual lists ABA only among covered behavioral health services, and Optum's Turquoise Care ABA quick reference guide covers network and billing logistics, not treatment-plan content. The state standard below governs.[10][4][5][11]
The state standard applies to every Turquoise Care MCO. MAD Supplement 24-13 (9/17/2024) is the state's ABA guidance. After the 97151 assessment, the BA "must select goals for intervention and determine how these goals will be measured." Goal development covers a list of skill areas: "adaptive and self-care skills, attending and social referencing, cognitive functioning, community participation, coping and tolerance skills, emotional development, family relationships, language and communication, play and leisure skills, pre-academic skills, self-advocacy and independence, self-management, social relationships, and vocational skills." Baseline performance should be measured and "treatment goals should be developed for each critical domain and specified in terms that are observable and measurable" (3.14.3). Targets are prioritized by risk to safety, independence and health (3.14.2). The required treatment-plan elements (3.19.1) include a Family Set goal, baseline data on each target behavior/symptom, interventions with approximate units per target, goals with objective progress measures for the authorization period, and measurable discharge criteria. The domains are developmental skill areas, not DSM-5 criteria. DSM or ICD is used for eligibility, and the ASD support level (Level 2/3) informs dosage. 8.321.2.13 NMAC makes the BA responsible for "selection and measurement of goals."[10][4][5][11]
UnitedHealthcare Community Plan publishes no parent-training hours of its own for New Mexico (2026 care provider manual; Optum Turquoise Care ABA quick reference guide). The state rule applies.[10][4][5]
The state standard, which applies to every Turquoise Care MCO: Supplement 24-13 says "Every Treatment Plan must include ample units of ABA Stage 3 97156 and 97157" (3.17.1(C)). Every plan must "Include a goal of working with the Family Set" and be "Family Set-focused... with a focus on family engagement, training, and support" (3.19.1). If family members cannot attend in person, the BA must offer alternatives such as telemedicine. 97156 needs no prior authorization, with a "Maximum number of units per 97156 for entire Family Set: thirty-two 15-minute units per week," billed once for the whole Family Set. The CMS Medicaid MUE limits 97156 to sixteen 15-minute units per day, and 97157 (also no PA) to "up to sixteen 15-minute units or four hours per day." Adult recipients may receive up to thirty-two units of either code when medically warranted. Family Sets may start 97156/97157 once the recipient's assessment is scheduled. If the family cannot attend at the agreed level, "inadequate family participation" is a listed reason for poor response, and the BA must offer alternatives.[10][4][5]
The 2026 Turquoise Care manual defers timely filing to the provider agreement ("If you don’t know your timely filing limit, refer to your Provider Agreement"), and treats a rejected claim not corrected within 90 days of the date of service as late billed. Disputes run in two steps: a claim reconsideration within 90 calendar days, answered within 30 calendar days, then a formal appeal within 60 calendar days of the occurrence, also answered within 30.[1][2][10]
Federal Medicaid rules set the payment floor for every managed care plan: a state’s contract with an MCO "must provide that the organization will meet the requirements of § 447.45(d)(2) and (d)(3)" (42 CFR 447.46) — pay 90 percent of clean claims from practitioners within 30 days of receipt and 99 percent within 90 days — unless the plan and the provider agree in writing to an alternative schedule stipulated in the contract. A "clean claim" is one that "can be processed without obtaining additional information from the provider of the service or from a third party" (42 CFR 447.45(b)).[1][2][10]
The questions that decide whether a family can start with UnitedHealthcare Community Plan of New Mexico (Turquoise Care), and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the New Mexico Medicaid rule: NMAC 8.321.2.13 imposes no upper age limit and covers Medicaid-enrolled adults, with under-21s served through EPSDT and the at-risk pathway bounded at 12–36 months. One drafting trap: the shared Turquoise Care Level of Care Guidelines (July 2024) describe ABA for members 12 months up to 21 years, because the adult expansion arrived later in NMAC 8.321.2.13 (12/10/2024) and Supplement 24-13 — cite those, not the LOC document, on an adult request.[7][8][6]
Follows the New Mexico Medicaid rule: a presumptive ASD diagnosis from a licensed practitioner within scope must have been received within three years of the referral to stage two or three; a recipient who already carries an ASD diagnosis needs no re-evaluation but does need an ISP and a medical-necessity determination; and the at-risk pathway requires no diagnosis at all.[7][8][6]
Follows the New Mexico Medicaid rule: an approved Autism Evaluation Provider confirms the presence of or risk for ASD through a comprehensive diagnostic, targeted or ASD risk evaluation, or the recipient is referred on a presumptive diagnosis from any licensed practitioner whose scope of practice allows an ASD diagnosis, received within three years of referral.[7][8][6]
Follows the New Mexico Medicaid rule for the clinical gate (Autism Evaluation Provider evaluation, ISP, referral to an approved ABA provider agency). The authorization surface is the narrowest in the state: per the plan’s Turquoise Care ABA Quick Reference Guide, "All autism services do not require prior authorization with the exception of 97153 & 0373T" — so 97151, 97155 and 97156 proceed without authorization, and the only PA workflow to build is the treatment request, filed on the New Mexico Uniform Prior Authorization Form through the Provider Express Auth tab (One Healthcare ID) or by fax to 1-888-541-6691.[7][8][6][4]
Follows the state rule — UnitedHealthcare Community Plan's own ABA documents checked this run (Optum's NM Turquoise Care ABA Quick Reference Guide and the shared Turquoise Care BH Level of Care Guidelines) publish no ABA-specific telehealth policy, so the HCA rule applies. One Optum billing rule does apply: since November 1, 2023 every Optum behavioral-health telehealth claim, Medicaid included, must carry POS 02 or POS 10; modifiers alone are not reimbursed. MAD Supplement 24-13 (section 3.2.1) says MAD "allows and encourages the utilization of telemedicine to deliver MAD ABA services," to bring home- and community-based ABA to rural and frontier areas, and points to 8.310.2 NMAC for the requirements: a HIPAA-compliant system with interactive audio and video in real time, with coverage "determined in a manner consistent with medicaid coverage for health care services provided through in person consultation." In-state BCBAs, BCaBAs, RBTs, BCATs and non-certified technicians need no telemedicine license; an out-of-state MD/DO diagnostician does. Supervision is expressly remote-capable: 97155 may be delivered through telemedicine when the BA directs the technician and the recipient by observing behavior or troubleshooting protocols (not when the BA joins in person), the recipient must be present, and the one-hour-per-20-hours minimum of 97155 still applies. Where an agency documents annually to the MCO or TPA that its transmission provider cannot support real-time video, store-and-forward can deliver up to 100% of direct 97155, with 30 to 60 extra minutes of 97155 added, but not for a non-certified technician. The assessment can be partly remote too: "A BA/Mentored BA bills Indirect 97151 when conducting interviews or discussing the Treatment Plan or Protocols with the Family Set delivered via telemedicine," and direct T1026 UD case supervision may happen onsite or be "delivered through telemedicine." The supplement names no POS code or modifier for ABA telemedicine, so confirm claim coding with the MCO or TPA.[5][9][13]
UnitedHealthcare Community Plan of New Mexico’s manual: non-urgent pre-service “Within 7 business days after receipt of all necessary and relevant documentation”; urgent/expedited “24 hours after the receipt of all necessary and relevant documentation supporting the prior authorization request”; retrospective within 30 calendar days of complete clinical information. That mirrors its HCA contract (deemed granted if missed). Federal floor on top: for rating periods that start on or after January 1, 2026, 42 CFR 438.210(d) caps standard decisions at “7 calendar days after receiving the request for service” (extendable up to 14 more calendar days), and expedited at 72 hours. The contract binds the plan to “the most rigorous standards” of the NM Prior Authorization Act, NCQA, HCA regulation or 438.210(d), so plan against 7 calendar days from receipt and the 24-hour state expedited clock. Reauthorization: Supplement 24-13 sets no day count, only that the ABA Treatment Plan Update and Progress Report “must be prepared and submitted to the MCO or TPA prior to the end of the recipient’s Prior Authorization period”. The Optum NM ABA quick reference guide publishes no lead time.[10][14][15][5]
UHC Community Plan NM’s manual: “UnitedHealthcare Community Plan is, by law, the payer of last resort for eligible members. Therefore, you must bill and obtain an EOB from any other insurance or health care coverage resource before billing UnitedHealthcare Community Plan”, attaching a complete EOB that shows the paid amount or denial reason; third-party filing deadlines sit in your Agreement. The HCA contract makes Medicaid “the payer of last resort” and adds the trap: the plan “shall deny payment on a Claim that has been denied by a third-party payer when the reason for denial is the Provider’s or Member’s failure to follow prescribed procedures, including but not limited to failure to obtain prior authorization” — so secure the commercial plan’s ABA authorization first. The same contract says “Claims for EPSDT shall be paid at the time presented for payment by the Provider and the CONTRACTOR shall bill the responsible third party”; whether an ABA claim is handled under that EPSDT pay-and-chase exception is not spelled out, so confirm with the plan before skipping the primary. TRICARE also pays ahead of Medicaid: its own secondary-payer rule exempts “a plan administered under title XIX”. The manual does not say whether the plan’s own ABA prior authorization (97153/0373T via Optum) is required while it is secondary — confirm with Optum.[10][14][16][17]
Follows the New Mexico Medicaid rule, which names none: NMAC 8.321.2.13 requires the diagnosis be made against the latest DSM or ICD and the at-risk criteria be measured by standardized assessments, without naming instruments. No plan-specific instrument list was found for this MCO either.[7][8][6]
Ask the plan: MAD Behavioral Health Policy and Billing Manual / Supplement 24-13 — hca.nm.gov blocked automated retrieval this cycle (CloudFront geo-block), so pull the MAD Behavioral Health Policy and Billing Manual and Supplement 24-13 from the HCA ABA provider page by hand, or ask the MAD ABA Manager.
Coverage decides whether UnitedHealthcare Community Plan of New Mexico (Turquoise Care) 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.
Follows the New Mexico Medicaid rule: every stage-three service requires clinical management, a BCaBA or technician implementing the plan requires case supervision from their BA or supervising BAA, and prior authorization is triggered where more than two hours of case supervision, or two hours of clinical management, per 10 hours of intervention is requested. Certification-maintenance supervision is not MAD-reimbursable.[7][8][6]
Follows the New Mexico Medicaid rule: no per-day unit ceiling, with authorization-gated intensity thresholds instead — including the inverted quirk that comprehensive treatment averaging under 20 hours a week requires prior authorization — and PA on supervision or clinical management above two hours per 10 hours of stage-three service. No plan-specific hour caps were found for this MCO.[7][8][6]
Follows the New Mexico Medicaid rule: school-setting activities with the potential to supplant educational services are excluded; a residential facility that is not itself an ABA provider must contract a MAD-enrolled ABA provider to render on site; treatment foster care is not treated as out-of-home placement; and out-of-home placement is otherwise an exclusion under the shared Turquoise Care Level of Care Guidelines apart from time-limited transition services.[7][8][6]
Follows the New Mexico Medicaid enrolment rules (Provider Type 445/099 for behavior analysts, 430/098 for technicians, MAD attestations and the criminal background registry check) with Optum’s claim plumbing on top: all autism provider services are billed on a Form CMS-1500, electronically to payer ID 87726 (ERA payer ID 86047) via uhcprovider.com, or on paper to Optum, PO Box 31348, Salt Lake City, UT 84131-0348. Submission must occur within 6 months of the date of service. Letter of Direction #53 still makes the state fee-for-service ABA fee schedule the contractual minimum.[7][8][6][4][6]
Not resolved. NMAC publishes no same-clock-time billing rule for ABA and defers to the MAD Behavioral Health Policy and Billing Manual; no plan-specific concurrent-billing rule was found for this MCO.[7][8][6]
Blocked on: The plan’s provider portal or claims line, plus the MAD Behavioral Health Policy and Billing Manual — hca.nm.gov blocked automated retrieval this cycle (CloudFront geo-block), so pull the MAD Behavioral Health Policy and Billing Manual and Supplement 24-13 from the HCA ABA provider page by hand, or ask the MAD ABA Manager.
Not resolved at the state level: NMAC makes the supervising behavior analyst responsible for treatment plan formulation and documentation but defers session-note mechanics to the MAD Behavioral Health Policy and Billing Manual, and no plan-specific documentation standard was found for this MCO.[7][8][6]
Blocked on: MAD Behavioral Health Policy and Billing Manual (ABA documentation requirements) — hca.nm.gov blocked automated retrieval this cycle (CloudFront geo-block), so pull the MAD Behavioral Health Policy and Billing Manual and Supplement 24-13 from the HCA ABA provider page by hand, or ask the MAD ABA Manager.
Yes — as a Turquoise Care MCO since July 1, 2024, with ABA administered by Optum through a dedicated New Mexico program on Provider Express, on the state's clinical criteria.
Only 97153 and 0373T. Per the plan's Quick Reference Guide, all other autism services — including the 97151 assessment, 97155, and 97156 — require no prior authorization.
On the New Mexico Uniform Prior Authorization Form, through the Provider Express Auth tab (One Healthcare ID, 5-step flow) or by fax to 1-888-541-6691.
Six months from the date of service, on a CMS-1500 to Payer ID 87726 (ERA 86047), or on paper to Optum, PO Box 31348, Salt Lake City, UT 84131-0348.
Follows the state rule. Not at the start. New Mexico Medicaid lets a non-certified behavior technician render ABA if they are 18 or older, have a high-school diploma, pass the New Mexico criminal background registry check, complete 4 hours of ASD training and at least 20 of the 40 RBT/BCAT training hours before serving, and then hold an RBT or BCAT certificate within their first six continuous months. If they miss that deadline they must stop until certified.
Yes, under the state rule in MAD Supplement 24-13: 97155 may be delivered by real-time telemedicine with the recipient present, and by store-and-forward only where the agency documents no real-time option.
It publishes no format of its own; the state standard (Supplement 24-13) applies — measurable goals for each critical developmental domain, prioritized by safety risk, not DSM-5 criteria.
No plan-specific figure; the state rule applies — every plan "must include ample units" of 97156/97157, with 97156 PA-free up to 32 units per week for the Family Set.
Ninety calendar days for a claim reconsideration, then 60 calendar days for a formal appeal; each is answered within 30 calendar days.
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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