For an intake team in Delaware, a UnitedHealthcare card means three layers. First is Optum Behavioral Health’s national ABA criteria. Second is Delaware’s autism mandate. Third is the plan’s funding type, which decides whether the mandate applies. UnitedHealthcare is not one of Delaware’s three Medicaid MCOs, so a UHC card here is commercial (or Medicare).
UnitedHealthcare administers ABA through Optum Behavioral Health under the ABA Supplemental Clinical Criteria (annual review 04/2026). Prior authorization is required, and continued-service review asks why use fell below 80% of authorized hours. Optum’s ABA State Mandates supplement (July 2026) has entries for Arizona, California, Connecticut, Florida, Kentucky, Maryland, Massachusetts, New Jersey, New York, Ohio, Pennsylvania and Virginia (some for Medicaid only). Delaware is not there, so no Delaware-specific criteria modify the commercial policy beyond the statute itself. DHSS’s Medicaid MCOs are AmeriHealth Caritas, Delaware First Health and Highmark Health Options.[1][2][6]
Delaware’s autism mandate is two parallel sections: 18 Del. C. § 3366 for individual plans and § 3570A for group and blanket plans. Each requires coverage "for the screening and diagnosis of autism spectrum disorders and the treatment of autism spectrum disorders in individuals less than 21 years of age," for plans delivered, issued or renewed in Delaware after December 11, 2012, and says coverage "shall not be denied on the basis that the treatment is habilitative or nonrestorative in nature." ABA is subject to "a maximum benefit of $36,000 per 12-month period per person," adjusted each April 1 by CPI-U, "but shall not be subject to any limits on the number of visits an individual may make to an autism services provider … regardless of the locations in which services are provided." The Insurance Commissioner’s 2026 notice sets that maximum at $38,601.65 per person from April 1, 2026 to March 31, 2027; payments for non-ABA autism treatment do not count toward it. Treatment must be "prescribed or ordered" by "a licensed physician or licensed psychologist who determines the care to be medically necessary." Except for inpatient care, the insurer may review ongoing treatment "not more than once every 12 months" unless it and the physician or psychologist agree to more, at the insurer’s cost. Payment is only required to autism services providers who meet DHSS’s certification standards, and a BCBA is deemed to meet them. The mandate does not change school or early-intervention obligations under an IEP, IFSP or 504 plan. It reaches fully insured plans; self-funded employer plans answer to ERISA and federal parity instead.[7][8][9]
Delaware does not license behavior analysts: the BACB’s state licensure table (2026) lists no Delaware law or board. The Board of Mental Health and Chemical Dependency Professionals (24 Del. C. ch. 30) licenses counselors, chemical dependency professionals, marriage and family therapists and art therapists, with no behavior-analyst subchapter. The credential rules that do exist come from the insurance mandate. Under 16 Del. Admin. Code 2102, a provider "currently certified as a BCBA or BCBA-D" is deemed qualified to provide ABA, and "Only people certified as a BCBA or BCBA-D or behavioral technicians who work under the supervision of a BCBA or BCBA-D" qualify. A BCaBA works under supervision. Technicians need a high school diploma or GED, background and abuse-registry checks, annual CPR, an ASD course, an ABA-principles course, competency-based training verified by the supervising BCBA (a current BCaBA meets this), and at least 10 hours of observed training before working one-on-one. BCBA supervision "shall not be less than 1.5:10 per week," with at least 1 hour a week when fewer than 10 hours of ABA are delivered. One open question: Delaware’s psychology act defines the practice of psychology to include "behavior analysis and therapy" (24 Del. C. § 3502), and § 3531(b) exempts "a qualified member of other recognized professions" who does not use a psychologist title. The statute does not name BCBAs, so ask the Division of Professional Regulation if this matters to you. On rates: commercial ABA rates are negotiated and mostly unpublished. The public benchmark is Delaware Medicaid’s ABA schedule (97153 $15.68 per 15 minutes base, $21.34–$31.82 with a modifier).[14][15][11][16][17][19]
UnitedHealthcare publishes no ABA rate table; Optum pays from the contract. Optum’s National Network Manual defines the "Fee Maximum" as "The maximum amount a participating provider may be paid for a specific health care service provided to a member," and says "Reimbursement to clinicians is based upon licensure rather than degree." Optum’s commercial ABA Reimbursement Policy (2022RP501A) puts the credential on every line: HM for an RBT, HN for a BCaBA, HO for a master’s-level BCBA or clinician, and HP for a doctoral-level provider. It notes state requirements "may supplement, modify or supersede" it. For a public benchmark, Delaware Medicaid pays 97153 at $15.68 per 15 minutes without a modifier.[4][5][19]
Two Delaware rules govern commercial claims. 18 Del. C. § 3571V says a carrier "shall permit a provider a minimum of 180 days from the date a covered service is rendered to submit a claim," whether or not the provider is in network (a contract may allow longer). Under 18 Del. Admin. Code 1310, "No more than 30 days after receipt of a clean claim" the carrier must pay it, pay part and explain the rest, deny it in writing, or make one written request for specific information; once that information arrives it has 15 days to act. The Commissioner can order interest on late payments. Both reach state-regulated plans and their administrators, not self-funded ERISA plans.[8][13][4]
Optum’s National Network Manual: claims must be received "no more than 90 calendar days from the date of service, or as allowed by state or federal law or the member’s specific benefit plan," and "Any corrections or additions to a claim should be made within 90 days of initial claim receipt." Complete, authorized claims "will be paid within 45 calendar days after Optum receives the claim, or as required by state and federal laws," which may exclude claims that need coordination-of-benefits decisions; the manual sets no separate secondary-claim deadline and publishes no check-run schedule.[8][13][4]
Optum’s ABA Supplemental Clinical Criteria (review 04/2026) set what each continued-service review needs: progress "assessed and documented for each targeted symptom and behavior … including the same modes of measurement that were utilized for baseline measurement"; progress that includes "rate and percentage of mastered programs, rates of mastered targets, change scores for any outcome measures, updated standardized adaptive measures, and change scores for skills-based assessments"; an assessment of the reasons and modified interventions when there is inadequate progress "within a 6-month period"; and an explanation when use of authorized hours falls below 80% over a two-week period. Treatment plans "are usually reviewed/updated twice annually." The criteria do not require graphs.[1]
The questions that decide whether a family can start with UnitedHealthcare / Optum in Delaware, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the diagnosis; it must be confirmed with validated tools. Progress is reassessed over 6-month periods, and use below 80% of authorized hours triggers review.[1]
A state-licensed physician, psychologist or other licensed clinician qualified to diagnose under DSM-5-TR.[1]
At least one clinically validated tool, such as ADI-R or ADOS/ADOS-2 (the criteria list screening and diagnostic instruments, non-exhaustively).[1]
No separate physician referral; the criteria require prior authorization. For a fully insured Delaware plan, the mandate covers treatment "prescribed or ordered" by a licensed physician or licensed psychologist who determines it is medically necessary, so keep that order on file. Self-funded ERISA plans sit outside the statute.[1][8]
Optum’s criteria carry no age criterion; the benefit plan governs. For fully insured Delaware plans, 18 Del. C. §§ 3366 and 3570A require autism coverage "in individuals less than 21 years of age," and ABA may be capped at a CPI-adjusted maximum ($38,601.65 per person from April 1, 2026), with no visit limits. Self-funded ERISA plans are outside the statute.[1][7][8][9]
Ask the plan: Provider Express benefits check: establish fully insured vs. self-funded ERISA first.
Optum’s telehealth guide (updated September 2025) allows only three ABA codes by telehealth: 97155, 97156 and 97157, "the virtual supervision of ABA Behavior Technicians and Family Training and Guidance." Bill POS 10 (home) or 02 (elsewhere). So 97151 and 97153 are not on Optum’s list. For a fully insured Delaware plan, 18 Del. C. § 3571R requires coverage for services delivered by telemedicine, bars excluding a service "solely because the service is provided through telemedicine," and requires reimbursement "on the same basis and at least at the rate" paid in person. The originating site is the patient’s Delaware location, and insurers and providers "may agree to alternative siting arrangements." Self-funded employer plans are outside the statute. Ask Optum how it applies the three-code list to a fully insured Delaware plan.[3][8]
Ask the plan: Optum Provider Express: confirm funding type and whether a fully insured Delaware plan pays ABA codes beyond 97155–97157 by telehealth.
Depends on how the plan is funded. Delaware’s pre-authorization statute (18 Del. C. §§ 3581–3587, as amended by 85 Del. Laws c. 176) applies to state-regulated plans. A utilization review entity must decide a clean health-care-service request within 5 business days, or 3 business days if submitted electronically, and an urgent one within 48 hours (24 hours electronically). An approval "shall be valid for a period of time that is reasonable and customary for the specific service, but no less than 90 days," and a carrier "may not require more than 1 pre-authorization for an episode of care." It may not revoke an approval on medical-necessity grounds after the provider receives it. Members get at least 30 days to appeal, and the appeal is decided within 15 days. Read with the autism mandate, ongoing ABA may be reviewed "not more than once every 12 months" unless the insurer and the physician or psychologist agree otherwise. Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1 instead: pre-service decisions "not later than 15 days after receipt of the claim," one 15-day extension, urgent care within 72 hours. UnitedHealthcare/Optum publishes no Delaware-specific ABA turnaround.[10][8][18]
Ask the plan: At benefits verification ask whether the plan is fully insured (Delaware-regulated) or self-funded (ERISA).
For a child on two group plans, Delaware follows the birthday rule: "The benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later" (18 Del. Admin. Code 1307, 5.2.1); "birthday" means month and day only, and a tie goes to the plan that covered the parent longer. For separated or divorced parents, a court decree that makes one parent responsible controls; otherwise the custodial parent’s plan pays first, then the custodial parent’s spouse’s plan, then the non-custodial parent’s plan. That rule binds state-regulated group plans; a self-funded plan sets its own order. If the child also has Delaware Medicaid, this plan pays first: Medicaid is payer of last resort and pays "the lesser of patient responsibility or DMAP allowed amount minus TPL paid amount." TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[12][20][21][22]
Ask the plan: Ask UnitedHealthcare/Optum at benefits verification for the coordination-of-benefits order (and whether a self-funded plan uses the birthday rule).
Coverage decides whether UnitedHealthcare / Optum in Delaware 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 criteria require direct case supervision of 1–2 hours for every 10 hours of direct treatment a week; technicians work under a BCBA or licensed clinician and should be RBTs or otherwise certified, and Optum does not recommend parents as RBTs for their own child. For fully insured Delaware plans the DHSS floor applies: not less than 1.5 hours of BCBA supervision per 10 hours a week (16 Del. Admin. Code 2102).[1][11]
Yes for two people, never for one. Optum’s commercial ABA reimbursement policy (2022RP501A, updated June 2026): “Can I report 97153 or 97154 with 97155 concurrently? A. Yes, as long as the criteria in the descriptors of both codes are met. A single QHP may not report 97153 or 97154 with 97155 concurrently.” So the overlap must be a technician on 97153 and an analyst on 97155 directing them with the patient present. 97155 and 97156 on the same date pay only if “separate, distinct, and clearly documented in the progress notes”; “A single provider can’t bill for both simultaneously (e.g., in the same 15-minute block).” 97155 is not payable for treatment planning while the technician works, and neither 97153 nor 97155 may be billed for technician training. Overlap with speech or OT is not addressed as a billing rule; the ABA criteria say ABA services “do not duplicate the services provided to or available to the individual by other medical or behavioral services” and ask for documented coordination with OT, speech and PT providers.[5][1]
No numeric cap; hours must be justified by documented need, and use below 80% of authorized hours must be explained at review. Fully insured Delaware plans may apply the mandate’s ABA dollar maximum ($38,601.65 per person from April 1, 2026) but no visit limits.[1][8][9]
ABA is provided at the least restrictive appropriate level. Not covered: services that are not ABA, "such as 1:1 aid delivered simultaneously during classroom instruction," or services covered under IDEA; school coordination is covered.[1]
Every line carries the rendering credential: HM (RBT), HN (BCaBA), HO (master’s-level BCBA or licensed clinician), HP (doctoral level), under Optum’s commercial ABA Reimbursement Policy.[5]
Not addressed. The criteria set what must be documented for coverage, not who signs a session note or when.[1]
Ask the plan: Optum National Network Manual (documentation standards) and the participating-provider agreement.
No. Optum’s criteria ask for progress on every target using the baseline measurement method, mastery rates and change scores, updated standardized adaptive measures, and an explanation of low hour use, but they do not require graphs.
90 calendar days from the date of service (or longer where state law or the plan allows), corrections within 90 days of the original claim’s receipt, and payment of complete claims within 45 days or the state’s shorter clock. No check-run schedule is published.
Yes, under Optum’s ABA criteria for ASD, with Delaware’s mandate layered on for fully insured plans. Self-funded employer plans follow their own documents.
No. Optum’s ABA State Mandates supplement (July 2026) does not list Delaware.
No. Delaware’s Medicaid MCOs are AmeriHealth Caritas Delaware, Delaware First Health and Highmark Health Options.
Optum’s guide allows only 97155, 97156 and 97157 by telehealth, billed POS 10 or 02. Fully insured Delaware plans are also subject to 18 Del. C. § 3571R, which bars excluding a service solely because it is delivered by telemedicine, so ask Optum how it applies the list to your plan.
UnitedHealthcare/Optum publishes no ABA rates. You are paid up to the Fee Maximum in your Optum agreement, with a credential modifier on each line (HM RBT, HN BCaBA, HO BCBA, HP doctoral). Delaware Medicaid’s 97153 base rate ($15.68 per 15 minutes) is the public benchmark.
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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