---
title: UnitedHealthcare Community Plan of New Mexico ABA coverage (Turquoise Care MCO).
url: "https://carelu.com/payers/unitedhealthcare-community-plan-new-mexico"
markdown_url: "https://carelu.com/payers/unitedhealthcare-community-plan-new-mexico.md"
state: NM (New Mexico)
payer: UnitedHealthcare Community Plan of New Mexico (Turquoise Care)
kind: Medicaid managed care plan (MCO)
parent_program: New Mexico Medicaid (Turquoise Care)
description: "How UnitedHealthcare Community Plan administers New Mexico Medicaid ABA — Optum's dedicated Turquoise Care ABA program, PA carved down to just 97153 and 0373T, Provider Express submission, the 6-month claims deadline, and the NM Uniform Prior Authorization Form."
last_reviewed: October 2026
vob_data_updated: 2026-10-15
---

# UnitedHealthcare Community Plan of New Mexico ABA coverage (Turquoise Care MCO).

_Payer Guide · UHC Community Plan (NM) · Last updated October 2026 · 12 primary sources_

> Optum-run ABA; PA only on 97153 & 0373T; Provider Express; 6-month claim deadline.

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.

This plan administers the **New Mexico Medicaid (Turquoise Care)** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [New Mexico Medicaid (Turquoise Care) guide](https://carelu.com/payers/new-mexico-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Not required — QRG: "All autism services do not require prior authorization with the exception of 97153 & 0373T" [4]
- **Prior auth for treatment**: Required only for 97153 and 0373T — NM Uniform PA Form via Provider Express (One Healthcare ID) or fax 1-888-541-6691 [4]
- **Autism diagnosis required?**: State rule — ASD dx within 3 years, or the documented at-risk-for-ASD pathway (NMAC 8.321.2.13) [7]

## At a glance

- **Plan type:** Turquoise Care MCO — ABA administered by Optum (United Behavioral Health)
- **Clinical rules:** State stage model (NMAC 8.321.2 / Supplement 24-13); NM policy on Provider Express
- **Prior auth:** ONLY 97153 and 0373T — everything else, assessment included, is PA-free
- **Submission:** Provider Express Auth tab (One Healthcare ID) or fax 1-888-541-6691; NM Uniform PA Form
- **Claims:** uhcprovider.com, Payer ID 87726 (ERA 86047); filed within 6 months of DOS, CMS-1500
- **Rates:** Must pay at least the state FFS ABA fee schedule (LOD #53)

## The narrowest PA surface in New Mexico

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]

## Claims plumbing and deadlines

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]

## Does UnitedHealthcare Community Plan (Turquoise Care) require treatment-plan goals in a set format, such as by DSM-5 criteria?

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]

## Does UnitedHealthcare Community Plan (Turquoise Care) require parent training, and how many hours?

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]

## What are UnitedHealthcare Community Plan of New Mexico’s claim dispute deadlines?

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]

## Intake gates

The questions that decide whether a family can start with UnitedHealthcare Community Plan of New Mexico (Turquoise Care), and what they have to bring.

- **Age limit**: 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]
- **Diagnosis recency**: 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]
- **Who may diagnose**: 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]
- **Referral required?**: 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]
- **Telehealth**: 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]
- **Prior-auth decision time**: 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]
- **Other insurance (who pays first)**: 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]
- **Diagnostic tools required** _(ask the plan)_: 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.

## Delivery and billing rules

Coverage decides whether UnitedHealthcare Community Plan of New Mexico (Turquoise Care) 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**: 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]
- **Daily limits / MUEs**: 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]
- **Place of service**: 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]
- **Bill as provider**: 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]
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: 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. [7][8][6]

## What intake should collect for UnitedHealthcare Community Plan of New Mexico (Turquoise Care)

- **Diagnosis or at-risk documentation:** State rule: ASD dx within 3 years of referral, or the at-risk pathway — then book the assessment; no PA on 97151.
- **One Healthcare ID access:** The 97153/0373T treatment auth submits through the Provider Express Auth tab — confirm portal access before the first case.
- **Planned weekly intensity:** The state's under-20-hrs/week comprehensive-treatment PA quirk applies within the state criteria — plan hours deliberately.
- **Clean-claims cadence:** The 6-months-from-DOS filing deadline makes billing hygiene an intake-to-revenue concern, not just a back-office one.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How UnitedHealthcare Community Plan of New Mexico (Turquoise Care) ABA benefits route and read on an eligibility check. Data last updated 2026-10-15.

### EDI routing

- **Payer ID (Change Healthcare / Optum):** 87748 — UNRESOLVED CONFLICT: the Optum NM Turquoise Care ABA QRG cited in the guide prose says claims Payer ID 87726 (ERA 86047); UHC's own current affiliate claims payer list shows NM Medicaid = 87748 (87726 = NM Dual SNP, "Former 87726") and 86047 = New Jersey (NM ERA appears under a multi-state row, candidate 04567). Reconcile via the current UHC Community Plan NM ABA/behavioral QRG or UHC EDI support before automating.
- **Supports 270/271 eligibility:** Yes
- **Real-time eligibility:** Yes
- **Behavioral health administrator:** Optum Behavioral Health (network administrator)
- **BH administrator payer ID:** 87748 — Optum is the BH network administrator, but claims route to the UHC Community Plan Medicaid payer ID (87748), not a separate Optum payer ID — no two-hop on claims. ERA ID unresolved (see changeHealthcare).
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Not required (LOD #53 fee schedule: "Prior Auth: NO") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97152 | Yes | Not required (LOD #53 fee schedule: "Prior Auth: NO") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97153 | Yes | Required (LOD #53 fee schedule: "Prior Auth: YES") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97154 | Yes | Not required (LOD #53 fee schedule: "Prior Auth: NO") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97155 | Yes | Not required (LOD #53 fee schedule: "Prior Auth: NO") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97156 | Yes | Not required (LOD #53 fee schedule: "Prior Auth: NO") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97157 | Yes | Not required (LOD #53 fee schedule: "Prior Auth: NO") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 97158 | Yes | Not required (LOD #53 fee schedule: "Prior Auth: NO") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 0362T | Yes | Not required (LOD #53 fee schedule: "Prior Auth: NO") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |
| 0373T | Yes | Required (LOD #53 fee schedule: "Prior Auth: YES") | — | home, clinic / office, community, school, telehealth (modality allowed; NM ABA-specific POS numbers not published in the fee schedule/Supplement) | Allowed as a modality — MAD Supplement 24-13 (3.2.1) "allows and encourages the utilization of telemedicine to deliver MAD ABA services" under 8.310.2 NMAC (real-time audio + video); 97155 explicitly by telemedicine with the recipient present (store-and-forward only in documented no-broadband cases), indirect 97151 family interviews by telemedicine. No ABA-specific POS/modifier is published — confirm with the MCO/TPA. | U5 (Qualifying Psychologist), U4 (BCBA-D), U3 (BCBA), U9 (BCaBA), U1 (Behavior Technician), UA/UB group size (97154/97158) |

Code notes:

- **97151:** Optum-administered; the NM Turquoise Care QRG confirms the state PA surface exactly — only 97153 & 0373T require PA; submit on the NM Uniform PA Form via Provider Express or fax 1-888-541-6691. Stage 2 BCBA assessment; done annually. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **97152, 97157, 0362T:** Optum-administered; the NM Turquoise Care QRG confirms the state PA surface exactly — only 97153 & 0373T require PA; submit on the NM Uniform PA Form via Provider Express or fax 1-888-541-6691. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **97153:** Optum-administered; the NM Turquoise Care QRG confirms the state PA surface exactly — only 97153 & 0373T require PA; submit on the NM Uniform PA Form via Provider Express or fax 1-888-541-6691. Adaptive behavior treatment by protocol — the primary PA-gated code. State PA quirk (Supplement 24-13 §3.17.1(A)): comprehensive treatment averaging UNDER 20 hrs/week requires PA regardless. Also PA-gated: >2 hrs T1026 UC/UD supervision per 10 hrs Stage 3. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **97154:** Optum-administered; the NM Turquoise Care QRG confirms the state PA surface exactly — only 97153 & 0373T require PA; submit on the NM Uniform PA Form via Provider Express or fax 1-888-541-6691. Group adaptive behavior treatment; UA (group 2–4) / UB (group 5–8) size modifiers. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **97155:** Optum-administered; the NM Turquoise Care QRG confirms the state PA surface exactly — only 97153 & 0373T require PA; submit on the NM Uniform PA Form via Provider Express or fax 1-888-541-6691. Protocol modification / supervision; ≥1 hr per 20 hrs of Stage 3 (97153/97154/97156) required with the recipient present. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **97156:** Optum-administered; the NM Turquoise Care QRG confirms the state PA surface exactly — only 97153 & 0373T require PA; submit on the NM Uniform PA Form via Provider Express or fax 1-888-541-6691. Family adaptive behavior treatment guidance. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **97158:** Optum-administered; the NM Turquoise Care QRG confirms the state PA surface exactly — only 97153 & 0373T require PA; submit on the NM Uniform PA Form via Provider Express or fax 1-888-541-6691. Group family guidance; UA/UB size modifiers. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).
- **0373T:** Optum-administered; the NM Turquoise Care QRG confirms the state PA surface exactly — only 97153 & 0373T require PA; submit on the NM Uniform PA Form via Provider Express or fax 1-888-541-6691. Extra-technician / intensifying protocol. State PA quirk (Supplement 24-13 §3.17.1(A)): comprehensive treatment averaging UNDER 20 hrs/week requires PA regardless. Also PA-gated: >2 hrs T1026 UC/UD supervision per 10 hrs Stage 3. Verify via: HCA/MCO — per-code daily unit caps are not published in NM primary sources (limits are program-level: comprehensive 30–40 hrs/wk, focused 10–25, the <20-hrs/wk PA quirk).

### Medicaid rates

Source: Not separately published by UnitedHealthcare Community Plan of New Mexico. Under LOD #53 the NM Medicaid FFS ABA fee schedule (see new-mexico-medicaid rates) is the ENFORCEABLE MINIMUM UnitedHealthcare Community Plan of New Mexico and its sub-vendors must pay, retroactive to 1/1/2025 — so the floor is verified even though UnitedHealthcare Community Plan of New Mexico's actual contracted/paid rate at or above it is not published. Effective 2025-01-01 (floor).

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | ≥ $112.65 (U3) / $130.94 (U5/U4) — LOD #53 floor | 15min | — |
| 97152 | ≥ $58.33 (U3) / $65.47 (U5/U4) — LOD #53 floor | 15min | — |
| 97153 | ≥ $19.85 (U1) / $23.35 (U9) / $32.31 (U3) — LOD #53 floor | 15min | — |
| 97154 | ≥ $11.43 (U1) / $18.59 (U3) — LOD #53 floor | 15min | — |
| 97155 | ≥ $39.69 (U3) / $55.55 (U5/U4) — LOD #53 floor | 15min | — |
| 97156 | ≥ $25.78 (U3) / $35.79 (U5/U4) — LOD #53 floor | 15min | — |
| 97157 | ≥ $51.59 (U3) / $71.43 (U5/U4) — LOD #53 floor | 15min | — |
| 97158 | ≥ $12.69 (U3) / $15.88 (U5/U4) — LOD #53 floor | 15min | — |
| 0362T | ≥ $112.29 (U3) / $130.94 (U5/U4) — LOD #53 floor | 15min | — |
| 0373T | ≥ $107.13 (U3) / $119.05 (U5/U4) — LOD #53 floor | 15min | — |

### Contacts

- **Benefits by phone:** Yes
- **Provider services phone:** 1-888-702-2202
- **Portal:** [Provider Express (One Healthcare ID) / uhcprovider.com](https://public.providerexpress.com)
- **Fax:** 1-888-541-6691 (Treatment Authorization Request Form — 97153/0373T PA)

Questions to ask on a verification call:

- Please confirm the correct claims payer ID for UHC Community Plan of New Mexico ABA billing — the plan's own QRG says 87726, but UHC's current affiliate claims payer list says 87748.
- Please confirm the correct Electronic Remittance Advice (ERA) payer ID — the QRG says 86047, which UHC's national list maps to New Jersey, not New Mexico.
- Is there a published per-code daily/weekly unit cap for ABA beyond the state's program-level hour ranges?
- Are ABA-specific telehealth POS codes or modifiers used for UHC Community Plan billing?

### VOB data sources

- https://www.uhcprovider.com/content/dam/provider/docs/public/resources/edi/Payer-List-UHC-Affiliates-Strategic-Alliances.pdf (accessed 2026-07-23)
- https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/NMTurquoiseCareABAQRG.pdf (accessed 2026-07-23)
- 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; source document older than 18 months)
- https://downloads.conduent.com/content/usa/en/document/270-payer-guide-medicaid-5010.pdf (accessed 2026-07-23)
- https://downloads.conduent.com/content/usa/en/document/eligibility-gateway-companion-guide.pdf (accessed 2026-07-23)
- https://www.hca.nm.gov/wp-content/uploads/FInal-LOD-53-Applied-Behavioral-Analysis-ABA-Fee-Schedule-Rates.pdf (accessed 2026-07-23)
- https://www.hca.nm.gov/wp-content/uploads/24-13-Supplement-ABA-Guidance.pdf (accessed 2026-07-23)

## Common questions

### Does UnitedHealthcare Community Plan of New Mexico cover ABA?

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.

### Which ABA codes need prior authorization with UHC in New Mexico?

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.

### How do I submit the UHC NM treatment 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.

### What is the claims deadline for UHC NM ABA?

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.

### Do ABA technicians need RBT certification for UnitedHealthcare Community Plan (New Mexico Medicaid)?

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.

### Can BCBA supervision (97155) be done by telehealth for UnitedHealthcare Community Plan members?

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.

### Does UnitedHealthcare Community Plan require ABA goals to be organized by DSM-5 criteria in New Mexico?

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.

### How much parent training does UnitedHealthcare Community Plan expect in New Mexico?

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.

### How long do I have to dispute a UnitedHealthcare Community Plan of New Mexico claim?

Ninety calendar days for a claim reconsideration, then 60 calendar days for a formal appeal; each is answered within 30 calendar days.

## Primary sources

1. [42 CFR 447.46 — Timely claims payment by MCOs (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-447/subpart-A/section-447.46)
2. [42 CFR 447.45 — Timely claims payment (clean-claim definition; 90% in 30 days, 99% in 90 days) (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-447/subpart-A/section-447.45)
3. [Optum Provider Express — New Mexico ABA Program](https://public.providerexpress.com/content/ope-provexpr/us/en/clinical-resources/autismABA2/abaNM.html)
4. [NM Turquoise Care ABA Network Quick Reference Guide (BH0000747_12162024)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/NMTurquoiseCareABAQRG.pdf)
5. [MAD Supplement 24-13 — ABA Guidance (state criteria)](https://www.hca.nm.gov/wp-content/uploads/24-13-Supplement-ABA-Guidance.pdf)
6. [Letter of Direction #53 — ABA Fee Schedule Rates (MCO rate floor)](https://www.hca.nm.gov/wp-content/uploads/FInal-LOD-53-Applied-Behavioral-Analysis-ABA-Fee-Schedule-Rates.pdf)
7. [NMAC 8.321.2.13 Applied Behavior Analysis (Cornell LII)](https://www.law.cornell.edu/regulations/new-mexico/N-M-Admin-Code-SS-8.321.2.13)
8. [Turquoise Care BH Level of Care Guidelines (ABA Stage 3, defers to NMAC 8.321.2)](https://www.bcbsnm.com/turquoise-care/pdf/tc-bh-level-care-guidelines-nm.pdf)
9. [8.310.2.12(M) NMAC — Telehealth services (srca.nm.gov, amended 1/1/2025)](https://www.srca.nm.gov/parts/title08/08.310.0002.html)
10. [UnitedHealthcare Community Plan of New Mexico Care Provider Manual (2026)](https://www.uhcprovider.com/content/dam/provider/docs/public/admin-guides/comm-plan/NM-UHCCP-Provider-Manual.pdf)
11. [8.321.2.13 NMAC — Applied Behavior Analysis (srca.nm.gov)](https://www.srca.nm.gov/parts/title08/08.321.0002.html)
12. [UnitedHealthcare Community Plan of New Mexico — Bulletins and newsletters](https://www.uhcprovider.com/en/health-plans-by-state/new-mexico-health-plans/nm-comm-plan-home/nm-cp-news.html)
13. [Optum — Telehealth Billing Quick Reference Guide (BH01511, updated September 2025)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/home/Telehealth_Billing_Guide_Updates.pdf)
14. [Turquoise Care Medicaid Managed Care Services Agreement — UnitedHealthcare, Amendment 5 (signed 12/2025), §§ 4.5.19.8, 4.19.11](https://www.hca.nm.gov/wp-content/uploads/TCUHC_24-630-8000-0030_CA5_Signed.pdf)
15. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes](https://www.ecfr.gov/current/title-42/section-438.210)
16. [8.302.3 NMAC — Third Party Liability Provider Responsibilities](https://www.srca.nm.gov/parts/title08/08.302.0003.html)
17. [10 U.S.C. 1079(i)(1) — TRICARE pays after other coverage except Medicaid](https://www.govinfo.gov/content/pkg/USCODE-2023-title10/html/USCODE-2023-title10-subtitleA-partII-chap55-sec1079.htm)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.