UnitedHealthcare Community Plan is one of the five Apple Health managed care plans HCA lists, and its behavioral health benefits are managed by Optum. For ABA, Optum uses a Washington-specific set of criteria, the Washington Medicaid Supplemental Clinical Criteria (policy BH803WA112025, effective November 2025), whose ABA section restates chapter 182-531A WAC almost word for word. UnitedHealthcare’s 2026 Washington provider manual lists the covered services: the COE evaluation and prescription, the LBAT functional assessment and treatment plan, and ABA delivered by an LBAT or a certified behavior technician working with one.
The ABA section of Optum’s Washington Medicaid Supplemental Clinical Criteria (effective November 2025) sets eligibility as "A diagnosis of an ASD, as defined by the DSM, or other developmental disability for which there is evidence ABA is effective" and says plainly: "There is no age requirement to be eligible for ABA services." It then follows the state’s three stages: a Center of Excellence evaluation and prescription (developmental pediatrician, neurologist, pediatric neurologist, pediatric psychiatrist, psychiatrist or psychologist, or an HCA-designated ARNP, physician, PA or naturopath); an LBAT assessment and treatment plan on HCA’s template, signed by the LBAT and applicable to the next six months; and prior authorization before the plan is implemented, received "no more than 60 days from the date of the assessment and ABA therapy treatment plan." Recertification is "granted in three-month increments, or longer at the agency’s discretion," requested 15 calendar days before expiration with a reevaluation showing measurable change. Covered and non-covered services, provider qualifications and inpatient criteria match the WAC.[1][2][3][4]
UnitedHealthcare’s ABA Corner offers an online ABA Treatment Request Form and a roster template for loading non-licensed clinicians; HCA’s February 2025 session added fax 877-217-6068 and said approvals follow the policy posted on Provider Express. The plan’s ABA support line for members and care coordination is 1-866-456-5376.[1][2][3][4]
UnitedHealthcare told providers that the "Rendering provider is required to be loaded under group record prior to submitting claims," with monthly roster updates to waabacaid@uhc.com. Its 2026 manual says "Washington requires claims be filed within 365 days from the date of service," and that claims with ABA procedure codes "follow our Pay & Chase policy" when other coverage exists. Members may file standard and expedited appeals within 60 calendar days; UnitedHealthcare decides expedited appeals within 72 hours and standard appeals within 14 calendar days (up to 28 with an extension). After the plan’s appeal, a member has 120 calendar days to request a state hearing (WAC 182-526-0200).[4][2][9]
The questions that decide whether a family can start with UnitedHealthcare Community Plan of Washington, and what they have to bring. Each maps onto something intake should ask on the first call.
"There is no age requirement to be eligible for ABA services" (Optum Washington Medicaid criteria). COEs need additional training to diagnose and prescribe ABA for adults 21 and over.[1]
No expiry on the COE evaluation is stated; the LBAT plan must correlate with the COE’s current diagnostic evaluation, and the PA request is due within 60 days of the assessment and plan.[1]
A COE: a Title 18 RCW licensee experienced with ASD who is a developmental pediatrician, neurologist, pediatric neurologist, pediatric psychiatrist, psychiatrist or psychologist, or an ARNP, physician, PA or naturopath designated by HCA after COE training (Optum Washington criteria). COEs serving these members must be contracted with the MCO.[1]
The COE documents formal diagnostic procedures (name, dates, results) or the clinical findings used to confirm the diagnosis, plus, if available, the ASD screening tool, a cognitive or developmental assessment and an adaptive behavior assessment with standardized scores (Optum Washington criteria).[1]
Yes: a COE prescription. "Any person may refer a client" to a COE, which must provide "A prescription for ABA services" (Optum Washington criteria).[1]
The Washington criteria and the manual publish no ABA telehealth rule of their own. The state rule applies to Apple Health: HCA’s ABA billing guide (January 1, 2026) lists the ABA codes allowed by telemedicine. Allowed: 97155, 97156 and 97157, plus team conferences 99366 and 99368. Allowed with limits: 97151, but only for indirect work (caregiver interviews and rating scales, treatment plan development, record review, scoring); direct observation and direct assessment of the child may not be done remotely. In the day treatment program (H2020), direct ABA must be in person in the clinic, and CBT supervision may be by audio-visual telemedicine only while an LBAT stays on site. Not allowed by telemedicine: 0362T, 0373T, 97153, 97154 and 97158. For telemedicine the originating site is where the client is (where the caregiver is, for caregiver training). Bill POS 02, or POS 10 when the client is at home, and add modifier 95 when the distant site is a nonfacility; to bill for a client located in Washington the practitioner must be licensed in Washington or hold a compact license Washington recognizes, and no behavior analyst compact is on HCA’s list.[1][2][7][8]
Claims with "ABA procedure codes follow our Pay & Chase policy": UnitedHealthcare pays and pursues the other payer. Where a primary paid, UHC pays the patient responsibility up to its allowable rate, or nothing if the primary paid in full with no patient responsibility; COB adjustments may be made within 30 months of the initial process date (2026 manual).[2][11]
No ABA decision timeframe is published in the criteria or the manual read. Federal managed care rules apply: for rating periods starting on or after January 1, 2026, standard decisions "may not exceed 7 calendar days after receiving the request for service" (42 CFR 438.210(d)).[10][2]
Ask the plan: UnitedHealthcare Community Plan ABA line, 1-866-456-5376.
Coverage decides whether UnitedHealthcare Community Plan of Washington 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.
Optum’s Washington criteria: a CBT must "Be supervised directly by an LBAT for at least five percent of total direct care per week" and review the client’s progress with the supervisor at least every two weeks; when a LABA is the LBAT, the LABA and the supervising LBA or licensed psychologist share the duties.[1]
The criteria repeat the WAC limits: one initial ABA assessment and plan a year, up to four additional assessments and revisions a year, one lifetime day-treatment authorization; requests beyond them are evaluated as limitation extensions (WAC 182-501-0169). Treatment units are set per authorization.[1]
The treatment plan must "Be signed by the LBAT responsible for the plan development and oversight"; a CBT must document each visit (targeted behavior, interventions, response, technique changes, plan for next visit, graphed data). No rule on who signs each session note is stated.[1]
Per the criteria: a day services program, or a community-based program in the home, office, clinic or community (park, restaurant, child care, school, workplace) as required by the plan; community settings "must be included in the ABA therapy treatment plan." School-based health care or early intervention program-based services are not covered unless prior authorized.[1]
Yes. Optum’s Washington Medicaid criteria say "There is no age requirement to be eligible for ABA services." Adults need a COE evaluation from a provider qualified to diagnose and prescribe for adults.
Use the online ABA Treatment Request Form in the ABA Corner on UHCprovider.com, or fax 877-217-6068, within 60 days of the LBAT assessment, with the COE evaluation and prescription.
UnitedHealthcare’s 2026 Washington manual says claims must be filed within 365 days from the date of service.
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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