UnitedHealthcare Community Plan of New York hands its ABA benefit to Optum (United Behavioral Health of New York, I.P.A., Inc.) — and Optum's orientation for the plan says it plainly: all ABA services require prior authorization. The clinical criteria underneath are deliberately state-deferent — Optum's New York Medicaid entry in its national State Mandates document copies the state's eligibility and referral rules essentially verbatim — so the work at this plan isn't arguing medical necessity against a foreign standard; it's running the state's own rules through Optum's PA machinery on providerexpress.com.
Where the state FFS layer needs only a referral, UHC's plan requires prior authorization for every ABA service. The assessment PA goes in as an online ABA Assessment request on providerexpress.com; the treatment PA follows through the portal or by calling the Autism Care Advocate with the member's name and ID, diagnosis, and a description of the treatment plan, and authorization status is viewable online. Two claim-killers to design around: claims deny without an authorization on file, and requesting additional units beyond the auth requires a new PA — "over limit" is a listed denial reason. No hour caps are published; treat authorized units as the operative ceiling.[1]
Optum's ABA State Mandates supplemental criteria (BH 803ABA, effective January 2026) carries an explicit "New York Medicaid and Child Health Plus (CHP)" entry that restates the state criteria: under 21, ASD and/or Rett syndrome, and the 2-year practitioner referral including the DSM-5 Diagnostic Checklist. So the referral packet you'd assemble for FFS is the same clinical foundation here — the difference is that it feeds a PA request instead of going straight to service. Operational extras from the orientation: telehealth is allowed for supervision (97155) and caregiver training (97156/97157) once you're approved as a virtual-visits provider, billed with POS 02; and LBAs may form group practices, while CBAAs may work in one but cannot own one.[2][1][4][3]
What a concurrent review must show. Optum’s national ABA criteria (interim review April 2026), applied together with the New York Medicaid state-mandate criteria, require updated documentation at each continued-treatment review with progress “assessed and documented for each targeted symptom and behavior… including the same modes of measurement that were utilized for baseline measurement” — mastery rates, change scores and updated standardized adaptive measures — and an analysis plus modified interventions when there is no demonstrable progress within 6 months. Underneath, the state manual requires treatment-plan updates at least every 6 months with baseline data and “current data expressed by the same data collection method as the baseline data.” Neither requires graphs as such.[2][1][4][3]
UnitedHealthcare Community Plan sets its own filing limit in its provider agreement and manual; New York law sets the floor. Ins. Law § 3224-a, which covers New York insurers, Article 43 corporations and Article 44 HMOs, requires claims to be submitted within 120 days of the date of service unless the contract is more favorable to the provider — and for Medicaid managed care contracts lets the parties agree on a different period "but in no event less than ninety days." Undisputed claims must be paid within 30 days of receipt when submitted electronically and 45 days on paper, with interest at the greater of the corporate-tax rate or 12% per annum when paid late.[9][10][5][6][1][7]
Electronic Visit Verification does not reach ABA: the Department of Health’s EVV list for fee-for-service and managed care Medicaid covers personal care and home health care codes (CDPAP, home care, HCBS habilitation and respite) and no ABA code (97151–97158).[9][10][5][6][1][7]
UHC Community Plan’s own figures, from its 2026 New York manual: the behavioral-health chapter lists “Timely filing guidelines (within 120 days of date of service)” for Optum-managed services and says “Electronic clean claims, including adjustments, will be adjudicated within 30 days of receipt.” Rejected claims: “If a claim is rejected, and corrections are not received within 90 days from date of service or close of business from the primary carrier, the claim is considered late billed.” The claims-dispute grid says a corrected-claim resubmission must be received “within 45 business days” (UHC responds within 30 business days) and a reconsideration within 90 business days. For secondary claims, “the date on the other carrier’s payment correspondence starts the timely filing period.” Payment is electronic through OptumPay (no paper checks); the manual publishes no weekly payment cycle or submission cut-off.[9][10][5][6][1][7]
For Medicaid managed care specifically, the state’s model contract adds a payment rule: the plan “shall make payments to Participating Providers and to Non-Participating Providers, as applicable, for items and services covered under this Agreement on a timely basis, consistent with the claims payment procedures described in SIL § 3224-a,” and must comply with 42 CFR 447.45(d)(5) and (6).[9][10][5][6][1][7]
Code set: Optum’s New York Medicaid ABA orientation lists CPT 97151–97158 as the billable ABA codes, with no Category III or HCPCS H-code. For a Medicaid member, the state baseline is narrower still: New York Medicaid’s ABA fee schedule (effective October 1, 2026) and the eMedNY manual’s billing table carry only CPT 97151–97158 — no 0362T or 0373T and no HCPCS H-code (H0031, H0032, H2019, H2014).[9][10][5][6][1][7]
Taxonomy is mandatory. “Starting August 1, 2025, UnitedHealthcare Community Plan care providers must include an NPI and taxonomy code when submitting claims”; a missing taxonomy rejects an electronic claim as incomplete and denies a paper claim. Report the billing provider’s taxonomy in Loop 2000A PRV (paper: box 33b with qualifier ZZ) and the rendering provider’s in Loop 2310B/2420A PRV (paper: box 24J with ZZ in 24I). Optum’s New York Medicaid ABA orientation says the same for ABA: “An NPI number and taxonomy code is always required on all claims,” and “Timely filing for NY Medicaid is 120 days from date of service.”[9][10][5][6][1][7]
The questions that decide whether a family can start with UnitedHealthcare Community Plan of New York, and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the New York Medicaid rule, restated verbatim in Optum’s own criteria: “enrollees may be eligible for ABA if they are under age 21 and have received a diagnosis of autism spectrum disorder and/or Rett Syndrome as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5).” No minimum age; no adult pathway.[2][3]
Follows the New York Medicaid rule: Optum’s New York Medicaid/CHP entry copies the state’s referral clock — “referrals for ABA services are valid for no more than two years” and must include the date of initial diagnosis — and states no separate maximum age for the diagnostic evaluation. Optum’s national criteria add no recency rule either; their clock is the review cycle.[2][3]
Follows the New York Medicaid rule, restated in Optum’s State Mandates supplement: “the NYS Medicaid member must be referred for ABA services by a NYS-licensed and NYS Medicaid-enrolled physician (including psychiatrists and developmental/behavioral pediatricians), psychologist, psychiatric nurse practitioner, pediatric nurse practitioner, or physician assistant.” Delivery is separate and state-specified: “ABA services are provided by Licensed Behavior Analyst (LBA), Certified Behavior Analyst Assistant (CBAA) working under the supervision of LBAs, or other individuals specified under Article 167 of NYS education law.”[2][3]
Follows the New York Medicaid rule: Optum’s New York entry requires the referral to carry the “DSM-5 Diagnostic Checklist for ASD diagnoses” and the symptom severity level/level of support, and names no instrument beyond that. Optum’s national criteria do publish a two-tier instrument list (CARS-2, ADI-R, ADOS-2, DISCO for diagnosis; ATEC, VB-MAPP, ABLLS-R, AFLS, PEAK, SSIS, RBS-R, SRS, Vineland, CFQL-2 for setting intensity), but the New York Medicaid entry is the state-specific criteria set for this plan — confirm with the Autism Care Advocate which applies to a given request.[2][4]
Follows the New York Medicaid rule for the clinical content — the 2-year practitioner referral with the seven required elements, DSM-5 checklist included — but the process is the inverse of fee-for-service: “all ABA services require prior authorization.” The assessment PA goes in as an online ABA Assessment request on providerexpress.com; the treatment PA follows through the portal or by calling the Autism Care Advocate with the member’s name and ID, diagnosis and a description of the treatment plan. Claims deny without an authorization on file, and requesting units beyond the authorization needs a new PA.[2][1]
The most specific telehealth answer of any New York Medicaid plan: telehealth is allowed for supervision (97155) and caregiver training (97156 and 97157) once the practice is approved as a virtual-visits provider, billed with place of service 02. Direct technician-delivered treatment is not on that list, and neither is the assessment: the Optum NY Medicaid ABA orientation (2025) describes the virtual service as “ABA supervision and/or caregiver training via telehealth,” even though its billing line tells approved providers to put “the same procedure code you would use for an in-person service, 97151, 97152, 97153, 97154, 97155, 97156 or 97157” on the claim with POS 02 — so get the Care Advocate’s written OK before running a 97151/97152 assessment remotely. Optum’s national criteria add only best-practice framing — telehealth options “are not intended to supplant in-person service; rather, they are intended to supplement the traditional in-person service delivery model.”[1][4]
Every ABA service is prior-authorized through Optum (providerexpress.com). UHC’s 2026 New York manual decides a non-urgent pre-service request “within 3 business days of receipt of medical record information required, but no longer than 14 calendar days of receipt,” an urgent request “within 72 hours of receipt of an expedited authorization request,” and a concurrent review “within 24 hours or next business day following.” Note the outer limit: federal rules cap standard Medicaid managed-care decisions at 7 calendar days for plan rating periods starting on or after January 1, 2026, so the manual’s 14-day ceiling is looser than the current floor — plan around the 3-business-day clock and escalate anything past 7 days. Neither the manual nor Optum’s NY ABA materials set a reauth submission lead time; each concurrent request needs updated diagnoses, other services, medications, school hours, parent participation, progress and discharge criteria.[5][1][11]
“UnitedHealthcare Community Plan is, by law, the payer of last resort for eligible members. Therefore, you must bill and obtain an explanation of benefits (EOB) from any other insurance or health care coverage resource before billing UnitedHealthcare Community Plan… Please attach a copy of the EOB to the submitted claim.” The EOB must be complete enough to show the paid amount or denial reason, and “the date on the other carrier’s payment correspondence starts the timely filing period for submission to UnitedHealthcare Community Plan.” Neither the manual nor Optum’s ABA materials say whether Optum’s ABA prior authorization is still required when UHC is secondary — confirm with Optum (1-866-362-3368) before relying on the primary plan’s approval.[5]
Coverage decides whether UnitedHealthcare Community Plan of New York 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 York Medicaid rule, which the state applies to FFS and managed care alike: “an LBA can supervise no more than six CBAAs/unlicensed individuals at a time,” “LBAs are required to supervise unlicensed individuals for a minimum of five percent of the hours the unlicensed individual spends providing behavior analysis services each calendar month,” and “supervision must include at least two face-to-face, real-time contacts per month” with the LBA observing service delivery in at least one. Supervision may run over synchronous audio-and-video where on-site is impractical. 97155 counts toward the 5% “only when the LBA joins the patient and the unlicensed individual during a treatment session to direct the unlicensed individual/technician in implementing a new or modified treatment protocol.” CBAAs need direct supervision, and the supervisor “should assess each patient’s/client’s progress at least every 6 months… and review and sign treatment notes and reports prepared by the CBAA supervisee.” Optum layers network requirements on top: LBAs must hold active BCBA certification plus the New York license plus a NY Medicaid ID, CBAAs need their own Medicaid ID, and a virtual-visits attestation is required for telehealth supervision. “LBAs may form a group practice. CBAAs may work in a group practice but cannot own a group practice.” Optum’s national ABA Supplemental Clinical Criteria (BH803ABASCC082025, interim review April 2026) lists New York Medicaid among the states whose state-mandate criteria are applied together with it (the state criteria control where they conflict), and it adds a dosage floor: “Consistent with CASP standards of care, direct case supervision is required 1–2 hours for every 10 hours of direct treatment per week.” Neither Optum document sets a technician caseload cap of its own beyond the state’s six.[3][2][1][4]
No hour caps are published — treat the authorized units as the operative ceiling, because “over limit” is a listed denial reason and additional units require a new prior authorization rather than an adjustment. Optum’s national criteria decline to set a numeric ceiling on evidence grounds and note that “full time ABA programs are rare,” while flagging utilization below 80% of authorized hours at review.[1][4]
Follows the New York Medicaid rule: the LBA supervisor must “review and sign treatment notes and reports prepared by the CBAA supervisee,” and documentation of supervision itself “should be recorded in the patient file.” Clinical documentation must carry the treatment plan with assessment and goals, the goal data, total hours of service per week by who delivered them, and the location(s) of services. Records are kept “for a minimum of six years and, for minors, until the patient turns 22 years of age.” Optum publishes no additional New York Medicaid signature rule; its national criteria require only that behavior analysts “identify their services accurately and include all required information on reports, bills, invoices, requests for reimbursement, and receipts.”[3][4]
Follows the New York Medicaid rule, restated in Optum’s State Mandates entry: “LBAs and CBAAs may work in any setting that may legally provide ABA services. Examples of such settings may include: private practice, settings where patients/clients reside full-time or part-time, clinics, hospitals, residences, and community settings” — and NYS Medicaid does not reimburse ABA in a school setting. Optum’s national criteria exclude the same functional overlap: “1:1 aid delivered simultaneously during classroom instruction, or services covered under the Individuals with Disabilities Education Act (IDEA),” while allowing teacher training, meetings with school personnel and school observations as coordination.[2][3][4]
Optum defers to the state and then to itself on enrollment: “ABA providers offering services to a Medicaid Managed Care (MMC) enrollee must contact the enrollee’s specific MMC Plan(s) for coverage, billing, and reimbursement guidance,” and network LBAs must carry a NY Medicaid ID alongside the license and BCBA certification, with CBAAs holding their own Medicaid ID. At the fee-for-service layer New York is explicit: LBAs bill “using the LBA’s National Provider Identification (NPI) number for the ‘Billing’ provider and/or ‘Supervising’ provider,” with “the NPI number of the CBAA that provided the ABA service… reported as the ‘Rendering’ provider on each claim”; for unlicensed aides and LBA limited-permit holders the supervising LBA’s NPI fills all three roles. CBAAs cannot bill directly and enroll as OPRA providers. Confirm the managed-care claim format on Provider Express before billing.[2][1][3]
Ask the plan: Provider Express or the Autism Care Advocate line for the MMC claim format — the eMedNY roles above are the FFS reference.
Not published. Optum’s New York Medicaid entry restates state eligibility and referral rules and says nothing about billing 97153 and 97155 for the same clock time; the national Supplemental Clinical Criteria govern medical necessity rather than claim edits, and the state manual is silent.[2][4][3]
Ask the plan: The Autism Care Advocate line or Provider Express provider services, plus UnitedHealthcare Community Plan of New York’s reimbursement policies.
Yes — for NY Medicaid members under 21 with ASD or Rett syndrome, on the state's clinical criteria, but with prior authorization required on all ABA services through Optum's providerexpress.com portal.
Submit the online ABA Assessment request on providerexpress.com for the assessment, then the treatment request through the portal or the Autism Care Advocate line with member info, diagnosis, and the treatment plan. Status is viewable online.
Supervision (97155) and caregiver training (97156/97157), yes, once your practice is an approved Optum virtual-visits provider; bill POS 02. Optum’s orientation does not name the 97151/97152 assessment as a virtual service, so get written approval first.
No — Optum's New York Medicaid/CHP entry copies the state criteria (under 21, ASD/Rett, 2-year referral with DSM-5 checklist). What differs is process: everything is PA-gated, unlike fee-for-service.
Six at a time. New York Medicaid, which applies the rule to fee-for-service and managed care alike, says an LBA "can supervise no more than six CBAAs/unlicensed individuals at a time," must supervise each for at least 5% of their monthly service hours, and must hold at least two face-to-face real-time contacts a month, observing service delivery in one. In New York the supervisor must be a NYSED-licensed behavior analyst; BCBA certification alone is not a license.
Your contract sets it, but New York Ins. Law § 3224-a bars a Medicaid managed care contract from setting less than 90 days from the date of service (120 days is the default without a contract term). Clean electronic claims must be paid within 30 days, paper within 45.
No. Optum’s New York Medicaid ABA materials list CPT 97151–97158 only, and the state ABA fee schedule carries the same eight codes with no H-codes.
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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