---
title: "UnitedHealthcare / Optum ABA coverage in the District of Columbia: the intake guide."
url: "https://carelu.com/payers/unitedhealthcare-district-of-columbia"
markdown_url: "https://carelu.com/payers/unitedhealthcare-district-of-columbia.md"
state: DC (District of Columbia)
payer: UnitedHealthcare / Optum in the District of Columbia
kind: Commercial insurance
description: "How UnitedHealthcare / Optum covers ABA for District of Columbia families: Optum’s ABA criteria, three-code telehealth list, credential modifiers, D.C. Code § 31-3272 (habilitative coverage under 21), DC licensure, prompt pay and what intake should verify."
last_reviewed: October 2026
---

# UnitedHealthcare / Optum ABA coverage in the District of Columbia: the intake guide.

_Payer Guide · UnitedHealthcare · District of Columbia · Last updated October 2026 · 18 primary sources_

> Optum criteria (BH803ABASCC) + D.C. Code § 31-3272 habilitative mandate; no DC entry in Optum’s state mandates supplement.

For an intake team in Washington, a UnitedHealthcare card means Optum Behavioral Health’s national ABA criteria, the District’s habilitative-services mandate in D.C. Code § 31-3272, and the plan’s funding type. UnitedHealthcare is not one of the District’s Medicaid plans, so a UHC card here is commercial (or Medicare).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required: Optum’s ABA Supplemental Clinical Criteria say "Prior authorization is required for ABA" unless "otherwise specified or mandated by contract or law"; they do not exempt the assessment [1]
- **Prior auth for treatment** _(plan-dependent)_: Required; continued-service review examines use of authorized hours below 80% over a two-week period. The review interval is set per authorization [1]
  - Ask the plan: Optum Provider Express or the behavioral health number on the card: ask what review interval applies to this authorization.
- **Autism diagnosis required?**: Yes: a DSM-5-TR ASD diagnosis by a state-licensed physician, psychologist or other qualified licensed clinician, confirmed with at least one clinically validated tool [1]

## At a glance

- **Covers ABA?:** Yes, for ASD, per Optum’s ABA Supplemental Clinical Criteria
- **State mandate:** D.C. Code §§ 31-3271–31-3272 (habilitative services incl. autism; D.C. Law 16-198) + DC EHB benchmark naming ABA
- **Mandate age:** Under 21
- **Mandate caps:** None allowed beyond those for other conditions (parity on deductibles, dollar, visit and durational limits)
- **Exempt from mandate:** Federal employee health plans, Medicare, and self-funded ERISA employer plans
- **Licensure:** DC Board of Psychology licenses behavior analysts (D.C. Law 25-191, 2024); confirm licenses are being issued
- **Fee schedule:** Not public — Optum pays up to the “Fee Maximum” in your agreement, by credential (HM/HN/HO/HP modifiers)

## The national policy, applied in the District

UnitedHealthcare administers ABA through Optum Behavioral Health under the ABA Supplemental Clinical Criteria (interim review April 2026): prior authorization, a diagnosis confirmed with a validated tool, direct case supervision of 1–2 hours per 10 hours of treatment, and continued-service review that looks hard at use below 80% of authorized hours. Optum’s ABA State Mandates supplement (effective July 2026) has entries for Arizona, California, Connecticut, Florida, Maryland, Massachusetts, Ohio, Pennsylvania and Virginia, plus New Jersey and New York Medicaid, but none for the District, so no DC-specific criteria modify the commercial policy. DHCF lists no UnitedHealthcare Medicaid plan in the District. [1][2][18]

## The District mandate: what it guarantees

The District’s autism coverage rule is a habilitative-services statute, not a stand-alone ABA law. D.C. Code § 31-3272 (D.C. Law 16-198, 2007) requires a health insurer to "Provide coverage of habilitative services for children under the age of 21 years and may do so through a managed care system." Section 31-3271 defines habilitative services as "services, including occupational therapy, physical therapy, and speech therapy, for the treatment of a child with a congenital or genetic birth defect to enhance the child’s ability to function," and says a congenital or genetic birth defect "includes: (A) Autism or an autism spectrum disorder." Denying a habilitative request because the condition is not a birth defect is, by statute, an adverse decision. The coverage "shall not be more restrictive than coverage provided for any other illness, condition, or disorder" for deductibles, durational or dollar limits, visit or treatment limits, and cost sharing. An insurer does not have to pay for habilitative services "actually delivered through early intervention or school services." The statute itself never names applied behavior analysis. ABA is named in the District’s essential-health-benefit standard: the DC Health Benefit Exchange Authority’s March 22, 2013 resolution defines the habilitative category as services that help a person "keep, learn or improve skills and functioning for daily living, including, but not limited, to applied behavioral analysis (ABA) for the treatment of autism spectrum disorder." CareFirst’s own ASD policy (3.01.015, updated for March 1, 2026) points DC members to § 31-3272 for mandated coverage. Two exclusions matter in Washington especially: the statute’s definition of a health benefit plan excludes "federal employee health plans, pursuant to contracts with the United States government" and Medicare coverage, and self-funded employer plans answer to ERISA rather than District insurance law. [6][7][8][19][17]

## Licensure, out-of-state BCBAs and rates

The District now licenses behavior analysts, but recently. D.C. Law 25-191 (effective July 19, 2024) gave the Board of Psychology the job of regulating "the practice of behavior analysis" and added a licensed behavior analyst seat to the Board (D.C. Code § 3-1202.11). Under § 3-1207.71 the Board licenses a person who completes a criminal background check, holds "a current certification issued by the Behavior Analyst Certification Board," and has a master’s or higher from a BACB-accredited program, with the education requirement waived for anyone certified by the BACB on or before July 19, 2024. The Mayor was to issue licensure rules (ethics code, education and clinical training, exam, continuing education) within one year. The BACB’s licensure table lists the District (2024, DC Board of Psychology). As of October 2026, though, DC Health’s Board of Psychology page links regulations for psychologists and psychology associates only and shows no behavior-analyst rule or application, so confirm with DC Health whether licenses are being issued before you tell a BCBA they need one. Carriers have not caught up either: CareFirst’s credentialing list still names "Licensed Board-Certified Behavior Analyst (Maryland and Virginia only)" and requires a practitioner to be "licensed in the state where the member receives the service." For telehealth or a BCBA based outside the District, plan on meeting the licensure rule of the place where the child is: DHCF’s telemedicine guidance applies that rule to Medicaid, and ask each commercial plan how it applies it. On rates: commercial ABA rates are negotiated and unpublished. DC Medicaid publishes its ASD fees on the dc-medicaid.com portal, which we could not open. [14][15][16][20][21][22]

## Claims and the credential modifiers

Optum’s National Network Manual (effective Sept. 1, 2026) 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." Its 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, HP for a doctoral-level provider, with indirect work bundled into the direct codes. For fully insured District plans, D.C. Code § 31-3132 requires payment of clean claims within 30 days (interest after) and at least 180 days to file. [5][4][9]

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. [5][4][9]

## Does UnitedHealthcare (DC) require a referring provider on ABA claims?

Not for ABA. Optum’s National Network Manual (effective September 1, 2026), which governs UnitedHealthcare behavioral health claims including ABA, lists what a Form 1500 claim should carry: member and subscriber names and dates of birth, member ID, ICD diagnosis, dates of service, length of session, type and duration of service, and the clinician’s name, credentials, tax ID and NPI. A referring provider is not on the list. UnitedHealthcare’s 2026 Administrative Guide asks for a valid billing NPI, rendering NPI and taxonomy on all claims and adds “we encourage you to submit the referring health care provider’s NPI”; it makes the referring provider’s name and NPI mandatory only on “laboratory, DME, imaging and home health claims.” [5][23]

## What a reauthorization must show

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]

## Intake gates

The questions that decide whether a family can start with UnitedHealthcare / Optum in the District of Columbia, and what they have to bring.

- **Diagnosis recency**: No expiry on the diagnosis; the DSM-5 diagnosis and severity level must be confirmed with a validated tool, and progress is reviewed during continued-service review. [1]
- **Who may diagnose**: A "state licensed physician, psychologist, or other state licensed clinician qualified to make such diagnosis" under DSM-5-TR. [1]
- **Diagnostic tools required**: At least one clinically validated tool from a non-exhaustive list: screens (M-CHAT and others), second-level screens (CARS/CARS-2, RITA-T, STAT), and formal tools (ADI-R, ADOS/ADOS-2, DISCO). [1]
- **Referral required?**: No separate physician referral; the SCC require prior authorization. For a fully insured District plan, D.C. Code § 31-3272 sets no referral or treatment-plan requirement of its own; it lets the insurer deliver habilitative coverage "through a managed care system," which § 31-3271 defines as review and preauthorization of the treatment plan. Federal employee plans and self-funded ERISA plans sit outside the statute. [1][7][6]
- **Telehealth**: Optum’s Telehealth Billing guide (September 2025), commercial: "For ABA services, telehealth is only allowed for these 3 CPT codes: 97155, 97156 or 97157," with POS 02 or 10 required. The SCC say telehealth is "not intended to supplant in-person service." Ask Optum how it applies the three-code list to a District-regulated plan. For a District-regulated plan, D.C. Code § 31-3862 says an insurer "may not deny coverage for a healthcare service on the basis that the service is provided through telehealth if the same service would be covered when delivered in person," must reimburse it, and may review telehealth appropriateness only "in the same manner" as in-person care; cost sharing cannot exceed the in-person amount. The statute names no ABA codes, POS or modifiers, and self-funded and federal employee plans are outside it. [3][1][11]
- **Age limit** _(plan-dependent)_: The SCC carry no age criterion; the benefit plan governs. For fully insured District plans, D.C. Code § 31-3272 requires habilitative coverage (autism included) for children under 21, with no dollar or visit cap allowed beyond what applies to other conditions. Federal employee plans and self-funded ERISA plans are outside the statute, so funding type decides whether that binds. [1][7][6]
  - Ask the plan: Provider Express benefits check: establish fully insured DC, federal employee or self-funded first.
- **Prior-auth decision time** _(plan-dependent)_: Depends on how the plan is funded. Plans regulated by the District fall under the Prior Authorization Reform Amendment Act of 2023 (D.C. Code ch. 38F). Once it has all required information, a utilization review entity must decide and notify "within … 3 business days of receiving the request via electronic portal or 5 business days of receiving the request via mail, telephone, or facsimile" (24 hours for urgent services), and a request not answered in time "shall be deemed approved." Before an adverse determination it must tell the provider that medical necessity is being questioned and offer a chance to add information. An approval is valid "for at least one year," an approval for a chronic condition stays valid "for as long as medically reasonable and necessary," and it may not be revoked if care is provided within 45 business days. The family gets at least 15 calendar days to appeal. 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," with one 15-day extension. UnitedHealthcare/Optum publishes no District-specific ABA turnaround or reauthorization lead time. [12][24][25][17]
  - Ask the plan: At benefits verification ask whether the plan is regulated by the District or self-funded (ERISA), and what reauthorization lead time Optum expects.
- **Other insurance (who pays first)** _(plan-dependent)_: For a child on two plans, the order of benefits comes from the plans’ coordination-of-benefits provisions; we did not read a District COB regulation, so ask UnitedHealthcare/Optum which plan is primary. When a child changes plans mid-treatment, D.C. Code § 31-3875.07 makes a District-regulated plan "honor an approval granted by a previous utilization review entity for at least the initial 60 days" of new coverage. If the child also has DC Medicaid, UnitedHealthcare/Optum pays first: Medicaid pays after other coverage (42 CFR 433.139), and DC’s Medicaid plans require the primary’s EOB with the claim. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270). If a payer later retracts payment because another carrier was primary, § 31-3133 limits that clawback to 18 months and gives you 180 days to bill the right carrier. [13][10][26][27][28]
  - Ask the plan: Ask UnitedHealthcare/Optum at benefits verification for the coordination-of-benefits order and record every other coverage the child has.

## Delivery and billing rules

Coverage decides whether UnitedHealthcare / Optum in the District of Columbia 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**: "Consistent with CASP standards of care, direct case supervision is required 1–2 hours for every 10 hours of direct treatment per week." Optum does not recommend parents serving as their own child’s RBT. [1]
- **Daily limits / MUEs**: No numeric cap; hours must match documented need. Use below 80% of authorized hours over two weeks must be explained at review. [1]
- **Place of service**: Not covered: services that are not ABA, "such as 1:1 aid delivered simultaneously during classroom instruction," or services covered under IDEA. D.C. Code § 31-3272 likewise excludes habilitative services delivered through early intervention or school. [1][7]
- **Bill as provider**: Each claim line carries the rendering credential: HM (RBT), HN (BCaBA), HO (master’s-level BCBA or licensed clinician), HP (doctoral level); indirect services are bundled into direct codes (2022RP501A). [4]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not addressed in the SCC or the reimbursement policy. [1][4]
  - Ask the plan: Optum Provider Express support or your participating-provider agreement.
- **Session-note signature** _(ask the plan)_: Not addressed in the SCC. [1]
  - Ask the plan: Optum National Network Manual documentation standards and your participating-provider agreement.

## What intake should collect for UnitedHealthcare / Optum in the District of Columbia

- **Plan funding type:** Fully insured DC plan (§ 31-3272 applies), federal employee plan, or self-funded ERISA.
- **Member ID + card photo:** Enough to run a live benefits verification on Provider Express.
- **Diagnosis with a validated tool:** DSM-5-TR ASD and severity level, confirmed with a validated tool (ADI-R, ADOS-2 and others).
- **Staff credentials:** Each line carries HM (RBT), HN (BCaBA), HO (BCBA) or HP (BCBA-D).

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

## Common questions

### Does UnitedHealthcare (Optum) require graphs for ABA continued-service reviews?

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.

### What are UnitedHealthcare (Optum)’s claim filing deadlines for District of Columbia ABA claims?

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.

### Does UnitedHealthcare (DC) require a referring provider on ABA claims?

No. Optum’s National Network Manual lists the required claim fields for behavioral health claims without a referring provider, and UnitedHealthcare’s 2026 Administrative Guide only encourages the referring NPI. It is mandatory there only on lab, DME, imaging and home health claims.

### Does UnitedHealthcare cover ABA therapy in Washington, DC?

Yes, under Optum’s national ABA criteria for ASD. Fully insured DC plans must also cover habilitative services for autism for children under 21 under D.C. Code § 31-3272.

### Does Optum have DC-specific ABA criteria?

No. Optum’s ABA State Mandates supplement (July 2026) has no District of Columbia entry.

### Can ABA be delivered by telehealth with UnitedHealthcare in DC?

Optum’s commercial telehealth guide allows only 97155, 97156 and 97157, billed POS 02 or 10. DC law bars denying a covered service only because it is delivered by telehealth for District-regulated plans, so ask Optum how it applies the list.

### Is UnitedHealthcare a DC Medicaid plan?

No. DC Medicaid’s plans are AmeriHealth Caritas DC and MedStar Family Choice DC, plus HSCSN for CASSIP.

## Primary sources

1. [Optum ABA Supplemental Clinical Criteria (BH803ABASCC; annual review 8/2025, interim review 4/2026)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/abaSCC.pdf)
2. [Optum — ABA State Mandates (BH 803ABA STM72026, effective July 2026)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/scc/ABA_SCC_SM.pdf)
3. [Optum — Telehealth Billing Quick Reference Guide (updated September 2025)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/home/Telehealth_Billing_Guide_Updates.pdf)
4. [Optum — ABA Reimbursement Policy, Commercial (2022RP501A)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/reimbPolicies/abaReimburs2020s.pdf)
5. [Optum National Network Manual (effective Sept. 1, 2026)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/adminResourcesMain/netwmanual/NNManual.pdf)
6. [D.C. Code § 31-3271 — Definitions (habilitative services; "congenital or genetic birth defect" includes autism)](https://code.dccouncil.gov/us/dc/council/code/sections/31-3271)
7. [D.C. Code § 31-3272 — Coverage of habilitative services for children under 21 (D.C. Law 16-198)](https://code.dccouncil.gov/us/dc/council/code/sections/31-3272)
8. [DC Health Benefit Exchange Authority — Executive Board Resolution on EHB standards (Mar. 22, 2013): habilitative category includes ABA for ASD](https://hbx.dc.gov/sites/default/files/dc/sites/Health%20Benefit%20Exchange%20Authority/publication/attachments/Resolution-EHBandPlanOfferingStandardsmk_0.pdf)
9. [D.C. Code § 31-3132 — Prompt payment (30-day clean claim; 180-day minimum filing window)](https://code.dccouncil.gov/us/dc/council/code/sections/31-3132)
10. [D.C. Code § 31-3133 — Retroactive denial of reimbursement](https://code.dccouncil.gov/us/dc/council/code/sections/31-3133)
11. [D.C. Code § 31-3862 — Telehealth: private reimbursement](https://code.dccouncil.gov/us/dc/council/code/sections/31-3862)
12. [D.C. Code § 31-3875.03 — Prior authorization decision timeframes (Prior Authorization Reform Amendment Act of 2023)](https://code.dccouncil.gov/us/dc/council/code/sections/31-3875.03)
13. [D.C. Code § 31-3875.07 — Continuity of care (honor a prior plan’s approval for 60 days)](https://code.dccouncil.gov/us/dc/council/code/sections/31-3875.07)
14. [D.C. Code § 3-1202.11 — Board of Psychology (regulates the practice of behavior analysis; D.C. Law 25-191)](https://code.dccouncil.gov/us/dc/council/code/sections/3-1202.11)
15. [D.C. Code § 3-1207.71 — Behavior analyst licensure: eligibility and education](https://code.dccouncil.gov/us/dc/council/code/sections/3-1207.71)
16. [BACB — U.S. Licensure of Behavior Analysts (District of Columbia: 2024, DC Board of Psychology)](https://www.bacb.com/u-s-licensure-of-behavior-analysts/)
17. [29 CFR 2560.503-1 — ERISA claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
18. [DHCF — Medicaid Managed Care Plans (MCPs): AmeriHealth Caritas DC, MedStar Family Choice DC, HSCSN (CASSIP)](https://dhcf.dc.gov/page/medicaid-managed-care-plans-mcps)
19. [CareFirst — Medical Policy Update, January 2026 (3.01.015 Autism Spectrum Disorder, eff. 3/1/2026; DC § 31-3272 pointer)](https://provider.carefirst.com/carefirst-resources/provider/pdf/medical-policy-update-january-2026.pdf)
20. [DC Health — Psychology Licensing (Board of Psychology page)](https://dchealth.dc.gov/service/psychology-licensing)
21. [CareFirst Provider Manual, Chapter 3: Provider Network Requirements / Administrative Functions (credentialing; payment policy index)](https://provider.carefirst.com/carefirst-resources/provider/pdf/provider-manual-chapter-3-administrative-functions.pdf)
22. [DHCF — Telemedicine Provider Guidance (January 2023, Transmittal 23-11)](https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/page_content/attachments/Telemedicine%20Provider%20Guidance_January%202023%20-%20Transmittal%2023-11.pdf)
23. [2026 UnitedHealthcare Care Provider Administrative Guide — Chapter 10, claims and NPI](https://www.uhcprovider.com/content/dam/provider/docs/public/admin-guides/2026-UHC-Administrative-Guide.pdf)
24. [D.C. Code § 31-3875.04 — Length of prior authorization](https://code.dccouncil.gov/us/dc/council/code/sections/31-3875.04)
25. [D.C. Code § 31-3875.05 — Prior authorization appeals](https://code.dccouncil.gov/us/dc/council/code/sections/31-3875.05)
26. [42 CFR 433.139 — Medicaid third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
27. [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)
28. [38 CFR 17.270 — CHAMPVA is the last payer](https://www.ecfr.gov/current/title-38/section-17.270)

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.