UnitedHealthcare Community Plan of Tennessee administers the TennCare ABA benefit under the shared tri-MCO program description — but unlike the other two MCOs, UHC layers its own Level of Care Guidelines (revised December 2024) on top. Those add real operational teeth: an explicit physician-order requirement, extra scrutiny for comprehensive programs above 20 hours/week, a device-attention test for telehealth ABA, and a three-month no-progress discharge rule. If a family carries UHC, plan the request against both documents.
UHC's Level of Care Guidelines require a comprehensive clinical evaluation by a Tennessee-licensed clinician and a physician order or script recommending ABA before initiation — the most explicit ordering requirement among the TennCare MCOs. Comprehensive programs above 20 hours/week "should generally only be considered" when the member has multiple needs, is within roughly the first two years of ABA, and presents at DSM-5 severity level 2–3; intensity must also leave room for rest, family time, and other activities. And maintenance-phase ABA must step down: lower intensity, caregiver-training-focused, not full-time.[2]
Requests use the universal tri-MCO form, submitted via Provider Express, fax (877) 217-6068, or secure email (tn_medicaid_aba@uhc.com); the ABA line is (800) 690-1606. Authorization lengths are set per individual need (the universal form models 26-week periods), with reassessment at the end of each authorized period. Two rules to design intake around: caregiver training is required with a documented caregiver plan — refusal or non-participation is a discharge criterion — and direct telehealth ABA is only medically necessary when the member can attend to a device for an extended period.[1][5]
UnitedHealthcare’s TennCare manual applies the same 120 days (when other coverage is primary, the period starts on the date of the primary carrier’s EOB, and a claim sent after another carrier's correspondence must arrive “within 120 days from the date on the other carrier’s correspondence”; a claim denied for more information must come back as a corrected claim “within 120 days from the date of service or 120 days of our initial denial, whichever is later”) and requires the NPI, the “taxonomy codes(s) for the billing health care providers, and Medicaid ID number for your TIN” on every claim. It points providers to the Department of Commerce and Insurance independent review process under Tenn. Code Ann. 56-32-126 for denied claims.[10][11]
TennCare’s contract with its MCOs sets the floor for every claim: a provider has “one hundred twenty (120) calendar days from the date of rendering a covered service to file a claim,” with the clock starting later for coordination-of-benefits cases and retroactive enrollment (CRA 2.12.9.28, 2.22.4.9); the MCO must pay 90% of clean claims within 30 calendar days of receipt and process 99.5% of all claims within 60 calendar days (2.22.4.2–2.22.4.3, under Tenn. Code Ann. 56-32-126). A provider who disputes a claim decision may use the TennCare Provider Independent Review of Disputed Claims process through the Tennessee Department of Commerce and Insurance (Tenn. Code Ann. 56-32-126(b)); an overturned claim must be paid within 20 calendar days of the decision (2.22.5.2). Resubmissions: the contract gives providers at least “sixty (60) days from the date of initial notice of an invalid and/or insufficient claim or one hundred twenty (120) days from the date of service, whichever is later,” to file a valid, complete claim (2.22.4.11.3), and a paid claim that needs correcting goes in as an adjustment “within 120 days of the date of payment notification” (2.22.4.11.4). With coordination of benefits, the filing clock begins on the date the third party documented resolution of the claim (2.22.4.9). Payment cycle: each MCO “shall run one (1) provider payment cycle per week, on the same day each week, as determined by the CONTRACTOR and approved in writing by TENNCARE” (A.2.22.13); the contract does not name the day or any submission cutoff, so ask the plan which day its check run closes.[10][11]
EVV does not apply to ABA. The TennCare contract requires an electronic visit verification system for personal care and home health services that require an in-home visit, as the 21st Century Cures Act requires (CRA 2.9.17.1); ABA is neither.[10][11]
No CPR or first-aid certificate is required for BCBAs or technicians in TennCare ABA. The shared TennCare MCO ABA Program Description asks for current BCBA certification with MCO credential verification, a Tennessee Licensed Behavior Analyst licence for the analyst, BACB-compliant RBTs, and a Crisis/Emergency Plan “in accordance with BACB best practices”; it names no CPR or first-aid training. Tennessee’s behavior-analyst licensing rules (1180-05) carry none either. The only CPR and first-aid requirement in the TennCare MCO contract is for workers hired through consumer direction in CHOICES and ECF CHOICES (CRA 2.9.8.7.7), not ABA staff. An employer or the setting (a school or day program) can still require it.[1][8][11]
Graphs are required. The universal ABA request form that UnitedHealthcare Community Plan uses tells providers to “attach cumulative graphs/charts of baseline data and current progress; current behavioral support plan and treatment plan including symptoms and behaviors requiring treatment, skills to be addressed, baseline measures and current progress, along with a proposed schedule of services,” including the goals achieved within the authorization period and any barriers. The shared program description lists the same “cumulative graphs/charts of baseline data and current progress” among its treatment-plan expectations, wants functioning re-measured “via standardized tools at least every two years,” and says the treatment plan “should be dated within 30 days of start date.” Neither document sets a separate data-recency window. Codes: the form's code rows are CPT 97151 through 97158 (with practitioner level noted, such as “97153 BA or RBT”); neither document lists a HCPCS H-code such as H0031 or H0032 for ABA.[4][1]
The questions that decide whether a family can start with UnitedHealthcare Community Plan of Tennessee, and what they have to bring. Each maps onto something intake should ask on the first call.
Follows the TennCare rule: EPSDT covers “children from birth through age 20 who have TennCare.” UHC’s own Level of Care Guidelines for ABA set no age limit — they instead add adolescent and young-adult content, directing that “when adolescents, young adults, or adults are receiving ABA services, it’s important to include a focus on transition to adulthood.”[6][2][1]
Follows the TennCare rule — no recency limit on the diagnosis itself, with updated functional evaluation by standardized tools expected at least every two years. UHC’s overlay puts its clock on progress rather than the diagnosis: “the patient must be reassessed at the end of each authorized period,” and “if the patient shows no meaningful measurable changes, on a norm based assessment, for period of 3 months of optimal treatment, then ABA may no longer be considered medically necessary.”[2][1]
Stricter than the shared baseline. UHC requires “a comprehensive clinical evaluation by a TN licensed clinician supporting medical necessity for ABA” and that “the member has been assigned a DSM-5 TR diagnosis of Autism or another identified diagnosis for which ABA is the least restrictive and most clinically appropriate treatment.” The guidelines name no single license for the diagnostician, but the evaluation must be a TN-licensed clinician’s and must be separate from the physician order that follows it.[2]
No named instrument, but a named battery. UHC requires that “assessments should include norm referenced assessments, skills assessments, a risk assessment, and a behavioral assessment,” and gates prior authorization on “a reasonable expectation on the part of a treating healthcare professional that the individual’s behavior will improve significantly, as measured by norm referenced assessments.” Progress and discharge decisions both turn on norm-referenced scores, so the instrument you choose at intake is the one you will be re-scored against at concurrent review.[2]
The strictest of the three TennCare MCOs: “the member will need a physician order/script recommending ABA services, based on their review of the diagnostic assessment.” That order is an initiation criterion in its own right, on top of the comprehensive clinical evaluation, and the universal form’s “Doctor’s Order Attached” checkbox is where it lands. Chase it at intake, not at submission. UHC also notes that while “the initial evaluation may be ordered by the primary care provider or specialist, the number of hours proposed by the ABA provider must be substantiated as medically necessary.”[2][4]
Per-code on the universal form, with a UHC-specific clinical gate on top: “direct Telehealth services may only be considered medically necessary when the provider has assessed that a member has core skills to attend to a device for an extended period of time.” The guidelines add that “telehealth service delivery for ABA should include an ongoing review of ethical, efficacy, and scope of practice considerations.” So document device-attention skills before requesting telehealth hours — it is a medical-necessity element, not a logistics preference. The checkbox sits on the assessment rows (97151, 97152) as well as on 97155, so assessment and BCBA-supervision hours can be requested as telehealth code by code. The form and program description set no cap on remote supervision; the BACB supervision requirements they incorporate still apply.[2][4]
UnitedHealthcare's 2026 TennCare manual sets the standard pre-service decision "Within 5 working days of receipt of medical record information required but no longer than 7 calendar days of receipt." Urgent/expedited pre-service decisions come "Within 3 days of request receipt." The TennCare contract caps expedited decisions at 72 hours from receipt and allows a 14-day extension on either track. Retrospective review takes "Within 30 calendar days of receiving all pertinent clinical information." ABA is requested through Optum Behavioral Health on the shared tri-MCO form, with 26-week authorization periods. Neither the manual nor the form publishes a reauthorization lead time.[10][11][12]
UnitedHealthcare Community Plan "is, by law, the payer of last resort." You "must bill and obtain an EOB from any other insurance or health care coverage resource before billing," then "attach a copy of the EOB to the submitted claim." The EOB "must be complete to understand the paid amount or denial reason." At authorization, providers should "Determine if the covered person has other insurance that should be billed first." Unlike Wellpoint and BlueCare, the manual publishes no pay-and-chase list. It is also silent on whether the Optum ABA authorization is still needed when UnitedHealthcare is secondary. The TennCare contract lets the MCO deny a claim the primary plan denied for "failure to obtain prior authorization." Get the commercial PA. TRICARE by statute pays only after other coverage "except in the case of a plan administered under title XIX" (Medicaid), so TRICARE goes before TennCare. CHAMPVA is the reverse: "If you are eligible under Medicaid, CHAMPVA will pay first."[10][11][13][14]
Ask the plan: Optum Behavioral Health for UnitedHealthcare Community Plan of Tennessee (1-800-690-1606) — ask whether an ABA authorization is required when a commercial plan is primary, and whether ABA for members under 21 is paid first and recovered later.
Coverage decides whether UnitedHealthcare Community Plan of Tennessee 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.
“ABA services must be located in TN and must be provided by or supervised by a TN board-certified Behavior Analyst (BCBA) or a health professional permissible under TN state law. Unlicensed persons may deliver applied behavior analysis (ABA) services under the extended authority and direction of an LBA or an LABA who is supervised by an LBA. Such persons shall not represent themselves as professional behavior analysts.” UHC also splits the work by tier: assessment, plan development, revision, caregiver observation, effectiveness monitoring and on-site crisis assistance “may be performed by a Behavioral Analyst,” while only the last four may be performed by a Behavioral Specialist. No numeric ratio is published, so the shared program description’s incorporation of the BACB supervision requirements governs.[2][1]
No per-day unit ceiling, but the only real intensity gate among the TennCare MCOs: “High frequency/Comprehensive ABA (greater than 20 hours per week) should generally only be considered when the member has multiple needs related to behaviors and social communication challenges, is early in receiving ABA services (i.e. within the first 2 years of ABA), and has a symptom severity of at least 2 or 3 per DSM-V criteria.” Proposed intensity must also leave room for “appropriate rest breaks, nutrition breaks, family time and time for play or non-learning activities,” and maintenance-phase ABA “should be at a lower intensity of services… these programs should not be comprehensive or full time in nature.” Authorization length is set by the MCO to the individual’s needs.[2]
UnitedHealthcare’s 2026 Tennessee manual sets it for every behavioral health record: "All entries in the treatment record include the responsible clinician’s name, professional degree, license, and relevant ID number," "The record is in blue or black ink," and "Any error must be lined through so that it can still be read, then dated, and initialed by the person." Its medical-record review also scores "Entries dated and the author identified" and "Legible entries." The Level of Care Guidelines and the shared program description add no session-note rule of their own (the program description requires a treatment plan within 30 days of admission, reviewed every 6 months). No signing deadline is published.[10][2][1]
Follows the TennCare rule — Clinic, Home, Community, School, Telehealth and Other are all requestable on the universal form, and medically necessary school-based behavioral health services need not sit in an IEP to be reimbursable. UHC adds two conditions of its own: services “must be located in TN,” and “the rationale for services and schedule of treatment with location should be a part of the treatment plan” — so setting is a documented clinical choice, not a scheduling convenience. Treatment protocols are expected to be “implemented repeatedly, frequently, and consistently across environments until the client can function independently in multiple situations.”[2][1][4]
Follows the TennCare rule: the claim rides on the group or servicing provider identified on the universal form, with the practitioner level carried as a modifier — HO on analyst-delivered codes, HM on technician-delivered, and 97153 split between the two. UHC’s guidelines describe who may perform which component rather than whose NPI the claim carries, and no separate UHC rendering-versus-supervising convention is published for TennCare ABA.[4][2]
Not answered for 97153 with 97155. The Level of Care Guidelines address intensity and medical necessity rather than claim edits, and the shared program description bars only two overlaps — more than one licensed analyst serving a member during a specific time interval, and ABA delivered simultaneously with OT, speech, PT or psychotherapy.[2][1]
Ask the plan: UnitedHealthcare’s TN ABA line (800) 690-1606 or tn_medicaid_aba@uhc.com, and the UHC Community Plan of Tennessee reimbursement policies on uhcprovider.com.
TennCare requires each plan to run at least one provider payment cycle a week, on the same day each week, as the plan sets and TennCare approves. The contract and the plan's manual do not publish the day or a submission cutoff time, so ask provider services which day the check run closes. Clean claims must be paid within 30 days (90% of them) and almost all claims processed within 60 days.
Yes. The universal ABA request form asks for cumulative graphs or charts of baseline data and current progress, with the current behavior support and treatment plans and the goals met during the authorization period. Functioning should be re-measured with standardized tools at least every two years.
No H-codes are published for ABA. The universal ABA request form is built on CPT 97151–97158, and the shared program description lists no HCPCS codes.
Yes — it administers the TennCare ABA benefit (EPSDT, under 21) under the shared tri-MCO program description, plus UHC's own Level of Care Guidelines with additional requirements like an explicit physician order.
It's the only one with a distinct clinical overlay: physician-order requirement, extra scrutiny above 20 hours/week of comprehensive ABA, a device-attention test for telehealth, and a 3-month no-measurable-progress discharge rule.
The universal tri-MCO ABA request form via Provider Express, fax (877) 217-6068, or secure email tn_medicaid_aba@uhc.com; ABA line (800) 690-1606.
It can be requested. The universal TennCare ABA request form has an "Indicate if Hours are telehealth" checkbox on every code row, including the 97151/97152 assessment and 97155 supervision, so telehealth hours are authorized code by code. The shared program description asks providers to judge clinical appropriateness and use HIPAA-compliant technology.
The shared TennCare program description sets credential expectations for "RBT paraprofessionals": RBTs and their supervising BCBAs "must comply with ALL of the current Behavior Analyst Certification Board (BACB) requirements for credentialing, ethics, competency, supervision, and maintenance of the RBT credential." Direct ABA must be delivered or supervised by a TN Licensed Behavior Analyst. Technicians do not bill under their own NPI: the universal form collects the group (or solo servicing) NPI, and technician codes carry the HM modifier.
120 days from the date of service (from the primary carrier’s EOB when other coverage pays first), per the TennCare contract and UnitedHealthcare’s TennCare manual.
Not in any published source. The shared TennCare MCO ABA Program Description and Tennessee’s licensing rules (1180-05) name no CPR or first-aid training for ABA staff; the TennCare MCO contract requires it only for consumer-directed CHOICES and ECF CHOICES workers. Your employer may still require it.
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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