--- title: "UnitedHealthcare / Optum ABA coverage in Georgia: the intake guide." url: "https://carelu.com/payers/unitedhealthcare-georgia" markdown_url: "https://carelu.com/payers/unitedhealthcare-georgia.md" state: GA (Georgia) payer: UnitedHealthcare / Optum in Georgia kind: Commercial insurance description: "How UnitedHealthcare / Optum covers ABA for Georgia families — the national clinical policy, prior authorization, the O.C.G.A. § 33-24-59.10 (Ava’s Law) mandate (ages, caps, exemptions), Georgia behavior-analyst licensure, and what intake should verify." last_reviewed: October 2026 vob_data_updated: 2026-10-15 --- # UnitedHealthcare / Optum ABA coverage in Georgia: the intake guide. _Payer Guide · UnitedHealthcare · Georgia · Last updated October 2026 · 12 primary sources_ > Optum Supplemental Clinical Criteria (BH803ABASCC) + the O.C.G.A. § 33-24-59.10 (Ava’s Law) mandate layer. For an intake team in Georgia, a UnitedHealthcare card means three layers at once: the carrier's national clinical policy, Georgia's autism insurance mandate (O.C.G.A. § 33-24-59.10 (Ava’s Law)), and the plan's funding type deciding which of the two actually binds. This guide stacks them in order. ## Prior authorization and diagnosis at a glance - **Prior auth for the assessment**: Required — step 1 of Optum's two-step authorization (assessment auth via Provider Express) [1] - **Prior auth for treatment**: Required — a separate treatment authorization after the assessment. “At a minimum, most treatment reviews are required every 4-6 months depending on the account/state law,” and continued-care requests go in “no more than 30 days prior to the current approvals on file expiring” (Optum ABA CPT FAQ) [7][1] - **Autism diagnosis required?**: Yes — DSM-5-TR ASD confirmed with a validated tool (ADI-R, ADOS-2, etc.) [1] ## At a glance - **Covers ABA?:** Yes — for ASD, per the national UnitedHealthcare policy - **State mandate:** O.C.G.A. § 33-24-59.10 (Ava’s Law) - **Mandate age:** Age 20 and under (mandate); parity may extend in practice - **Mandate caps:** $35,000/yr nominal ABA cap; no visit limits allowed - **Exempt from mandate:** ≤10-employee groups; self-funded ERISA plans - **Licensure:** Licensed Behavior Analyst (GA Behavior Analyst Licensing Board) - **Fee schedule:** Not public — participating providers bill from the fee schedule in their Optum agreement ## The national policy, applied in Georgia UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months and an operational flag when utilization falls below 80% of authorized hours. That clinical policy is national — what changes in Georgia is the legal floor underneath it: the state mandate below governs what fully-insured plans must cover, while self-funded employer plans answer to ERISA and federal parity instead. Plan funding type is therefore the first fact to establish on every benefits check. The full national policy breakdown lives in our UnitedHealthcare / Optum guide; this page covers what changes in Georgia. [1] ## The Georgia mandate: what it guarantees (and doesn't) Ava’s Law requires state-regulated accident and sickness plans (including the state employee health plan) to cover ASD treatment for individuals 20 years of age or under, with ABA nominally cappable at $35,000 per year — and no limits allowed on the number of visits. The statute exempts employers with 10 or fewer employees, and insurers can seek a one-year opt-out if an actuary certifies the mandate raises average premiums more than 1%. Self-funded ERISA plans are exempt by federal preemption. Federal mental-health parity (MHPAEA) generally makes the dollar and age caps hard to enforce against covered large-group plans — a payer applying the $35K cap to a large-group member is a red flag to escalate, not accept. [2][3] ## No Georgia-specific UnitedHealthcare policy exists We checked: UnitedHealthcare / Optum publishes no Georgia-specific ABA policy, form, or supplement — the national policy plus the state mandate is the whole picture. That’s worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where Georgia-specific answers come from, not a carrier document. [1] ## Licensure & rates in Georgia Georgia now licenses behavior analysts: HB 412 (2022) created the Georgia Behavior Analyst Licensing Board under the Secretary of State, with licensure built on BCBA certification. Confirm your supervising analysts hold the Georgia license when credentialing with any commercial plan. On rates: UnitedHealthcare does not publish commercial ABA fee schedules for Georgia (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement, so treat rate expectations as a contracting conversation, not a lookup. [4] ## What is UnitedHealthcare’s fee schedule for ABA in Georgia? UnitedHealthcare does not publish a commercial ABA rate table; Optum administers the behavioral health benefit and pays under your participation agreement. Optum’s Telehealth Billing guide (September 2025) tells providers that “participating (contracted) network providers should use the applicable CPT code(s) listed on their fee schedule,” and that payment “may also be subject to benefit plan provisions and prior authorization requirements.” Optum’s commercial ABA reimbursement policy (2022RP501A) sets how the claim is built rather than the price: 97151–97158 with a credential modifier (HM for an RBT, HN for a BCaBA, and so on), 15-minute units counted the CMS way, and indirect work “bundled with direct services for consideration of reimbursement.” For rates, ask Optum network management or check your agreement. [8][5] ## Can an out-of-state BCBA treat a Georgia member, including by telehealth? Georgia licenses the practice: “The unlicensed practice of applied behavior analysis is prohibited in this state,” at a fine of $1,000 per violation (O.C.G.A. 43-7A-6, added by HB 412, effective July 1, 2023). A BCBA “residing and practicing in another state who temporarily provides applied behavior analysis services in this state to a resident of this state” may apply for a temporary license covering “not more than a total of 30 days within a calendar year” (43-7A-8), and the board licenses by reciprocity someone actively licensed in a state with comparable requirements that reciprocates with Georgia (43-7A-9). As enacted, Chapter 7A contains no telehealth exception. [10][11] Optum, which runs UnitedHealthcare’s commercial behavioral network, is explicit. Its National Network Manual (effective September 1, 2026): “Providers offering telehealth visits must be licensed in the state where the member is located at the time of service. In addition, providers must comply with all licensing laws and telehealth regulations in the jurisdiction(s) where the provider is licensed and where the member is receiving treatment.” For a child located in Georgia, that means a Georgia license before the first remote session. [10][11] ## Does a doctor’s referral meet UnitedHealthcare’s diagnosis requirement in Georgia? Not by itself. Optum’s criteria require “a valid diagnosis of ASD… issued by a state licensed physician, psychologist, or other state licensed clinician qualified to make such diagnosis,” with the DSM-5 diagnosis and severity level “confirmed and documented by the diagnosing clinician using at least one clinically validated tool,” and the ABA record must hold the “comprehensive assessment establishing the autism diagnosis.” Optum’s ABA FAQ adds that the diagnostic evaluation “must be comprehensive,” while “updated evaluations may target specific skill deficits and are not required to be comprehensive unless there is a question about an individual’s autism spectrum disorder diagnosis.” A physician who made the diagnosis with a validated tool and documented it meets the rule; a referral that only asks for ABA or an evaluation does not. [1][7] How old the diagnosis may be: Optum sets no maximum age. The FAQ says members need “an updated DSM-5 diagnosis of Autism Spectrum Disorder” (an older DSM-IV label such as Asperger’s or PDD-NOS must be updated), and “there is no required frequency at which an assessment must take place.” [1][7] ## UnitedHealthcare (Optum) ABA claims in Georgia: filing deadline, payment and appeals Optum, which runs UnitedHealthcare’s commercial behavioral network, sets the claim rules in its National Network Manual (effective September 1, 2026): “All information necessary to process claims must be received by Optum 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 corrections should be made within 90 days of initial receipt. The manual sets no separate deadline for a secondary (COB) claim: “if Optum is a secondary plan, you will be paid up to the Optum contracted rate,” and the 45-day payment guideline “may exclude claims that require coordination of benefits determinations.” Codes: Optum's commercial ABA reimbursement policy lists CPT 97151–97158, 0362T and 0373T as the reimbursable ABA codes, each with the credential modifier of whoever delivered the service; it lists no HCPCS H-codes for ABA. Clean claims with any required authorization are “generally” paid within 45 calendar days, or as state law requires. To contest a claim or authorization decision on a commercial plan, request a reconsideration first and then an appeal; the two steps together allow 12 months unless state law or the participation agreement says otherwise. A non-urgent prior-authorization appeal can be filed within 180 days. [5][11][12] Payment clock: Georgia’s prompt-pay statute (O.C.G.A. 33-24-59.14) gives an insurer or administrator 15 working days for an electronic claim and 30 calendar days for a paper claim to pay it, or to send written notice of why it is denied and what is needed, with interest of 12 percent a year on late payments; any undisputed part of a claim must be paid on that clock. A self-funded employer plan may sit outside Georgia insurance law, so confirm the funding type first. [5][11][12] ## What an ABA reauthorization request must contain (and whether graphs are required) Optum asks for progress measured the same way as the baseline, not specifically for graphs. With each review for continued ABA the provider must show progress “for each targeted symptom and behavior, including progress toward defined goals, including the same modes of measurement that were utilized for baseline measurement,” with “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,” movement from baseline on validated, norm-referenced measures, caregiver progress where applicable, and an analysis when progress stalls over 6 months; reviews also look at authorized hours used below 80% over a 2-week period. The criteria do not require graphs or set a data-recency window. [1] ## Intake gates The questions that decide whether a family can start with UnitedHealthcare / Optum in Georgia, and what they have to bring. - **Diagnosis recency**: No maximum age on the diagnosis, but it must be current in form. The Supplemental Clinical Criteria (interim review April 2026) require a valid DSM-5-TR ASD diagnosis from a state-licensed physician, psychologist or other qualified clinician, confirmed with at least one clinically validated tool, and set no re-diagnosis interval. Optum’s ABA FAQ adds that “members need to have an updated DSM-5 diagnosis of Autism Spectrum Disorder to be eligible for ABA services unless state-specific mandates allow different diagnoses,” so an Asperger’s or PDD-NOS label from the DSM-IV era must be updated; that the diagnostic evaluation “must be comprehensive,” while “updated evaluations may target specific skill deficits and are not required to be comprehensive unless there is a question about an individual’s autism spectrum disorder diagnosis”; and that “there is no required frequency at which an assessment must take place.” What Optum does clock is the review cycle: continued-service reviews every 4–6 months. [1][7] - **Who may diagnose**: State-licensed and scope-qualified: “a valid diagnosis of ASD (or other applicable diagnosis as required by governing laws) must be issued by a state licensed physician, psychologist, or other state licensed clinician qualified to make such diagnosis according to the diagnostic criteria based on the DSM-5-TR.” The diagnosing clinician — not the ABA provider — confirms and documents both the diagnosis and the severity level. On the treating side Optum requires a master’s- or doctoral-level BCBA, a credentialed licensed behavioral health clinician with attested ABA expertise, or a BCaBA or non-licensed individual under the direct supervision of one of those; in Georgia the analyst must additionally hold a Georgia Behavior Analyst Licensing Board licence under HB 412. [1] - **Diagnostic tools required**: Optum publishes the fullest instrument taxonomy of the national carriers, in two stages. For the diagnosis, “the DSM-5 diagnosis and severity level are confirmed and documented by the diagnosing clinician using at least one clinically validated tool (not an all-inclusive list),” across first-level screening tools (ABC, CHAT/M-CHAT, CSBS-DP-IT-Checklist, ASQ, AQ, CAST), second-level screening tools (CARS/CARS-2, RITA-T, STAT) and formal diagnostic tools (ADI-R, ADOS/ADOS-2, DISCO). For treatment intensity, the plan must be set from baseline measurement “with the use of at least one of the following validated measurement tools”: ATEC, VB-MAPP, ABLLS/ABLLS-R, AFLS, PEAK, SSIS, RBS-R, SRS, Vineland (VABS) or CFQL-2 — with the caveat that “measurement tools should be individualized and will not be the same for all individuals or programs.” The ABA provider separately completes a standard or functional behavioral assessment, caregiver interviews, direct observation, record review, a baseline skills assessment and norm-referenced instruments against age-matched peers. [1] - **Telehealth**: Three codes, after an attestation. Optum’s Telehealth Billing guide (updated September 2025) is explicit for commercial plans: “For ABA services, telehealth is only allowed for these 3 CPT codes: 97155, 97156 or 97157” — virtual supervision of technicians and family training — so technician-delivered 97153 is not payable by telehealth. The provider must first be “an approved Optum virtual visits provider who has attested” (the virtual-visits attestation on Provider Express) and must tell the ABA Care Advocate at authorization. Bill the in-person code with the member’s location as the place of service: POS 10 when the member is at home, POS 02 anywhere else (the older ABA CPT FAQ says POS 02; the 2025 guide requires one of the two on every behavioral-health telehealth claim, and POS 11 or a telehealth modifier alone is not paid). Optum’s criteria add that telehealth is “not intended to supplant in-person service.” Because only 97155, 97156 and 97157 are allowed by telehealth on commercial plans, the 97151 assessment and 97152 supporting assessment must be done in person, while remote BCBA direction of the technician (97155) is allowed. [8][7][1] - **Age limit** _(plan-dependent)_: Optum’s ABA Supplemental Clinical Criteria publish no age limit — coverage turns on a valid ASD diagnosis and medical necessity. The age term in Georgia comes from Ava’s Law (individuals 20 years of age or under on state-regulated plans, with ≤10-employee groups exempt and self-funded ERISA plans preempted), and there is no Georgia entry in Optum’s ABA State Mandates criteria to add anything on top. Federal parity generally makes the mandate’s age cap hard to enforce against covered large-group plans. [1][6][2] - Ask the plan: Plan funding type and employer size, then a live benefits verification — the mandate, not the carrier criteria, is what carries the age term. - **Referral required?** _(plan-dependent)_: No referral requirement is published; the gate is authorization. “Prior authorization is required for ABA (unless otherwise specified or mandated by contract or law),” run as Optum’s two-step structure on Provider Express — assessment authorized first, then treatment — with continued-service reviews every 4–6 months. Whether a specific plan also requires a PCP referral is a benefit-design question. State law adds no order requirement either: Ava's Law (O.C.G.A. § 33-24-59.10) defines covered treatment as care "prescribed, provided, or ordered" for an individual diagnosed with ASD without naming a required prescriber; what it does allow a fully insured plan to require is that a licensed physician or licensed psychologist demonstrate ongoing medical necessity for applied behavior analysis at least annually. Self-funded plans sit outside it. So: no statutory service order, but expect the plan to want an annual physician or psychologist medical-necessity statement — ask at benefits verification whether this plan requires one, and whether a PCP referral is needed on top of authorization. [1][2] - Ask the plan: A live benefits verification plus Provider Express — confirm whether the plan layers a referral requirement on top of the two-step authorization. - **Prior-auth decision time** _(plan-dependent)_: It depends on how the plan is funded. A fully insured UnitedHealthcare plan sold in Georgia follows the Ensuring Transparency in Prior Authorization Act. A standard request gets notice "within 7 calendar days of obtaining all necessary information to make such authorization or adverse determination" (O.C.G.A. 33-46-26). Urgent requests get notice "no later than 72 hours after receiving all information needed" (33-46-27). A missed deadline means "automatic authorization" of the service (33-46-29), with a narrow de minimis exception. Both clocks start only once the plan has everything it needs, so send a complete packet. The Act also binds DCH contracts under the State Health Benefit Plan. A self-funded employer plan is governed by ERISA instead: "not later than 15 days after receipt of the claim," with one 15-day extension, and 72 hours for urgent care. No reauthorization lead time is published for UnitedHealthcare ABA in Georgia. [13][14][15] - Ask the plan: Benefits verification with UnitedHealthcare: ask whether the plan is fully insured (Georgia prior-authorization law), self-funded (ERISA), or the State Health Benefit Plan, and the plan's reauthorization lead time. - **Other insurance (who pays first)** _(plan-dependent)_: Between two parents' group plans, Georgia's coordination-of-benefits rule uses 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 in that year." "Birthday" means month and day only. If the birthdays match, the plan that has covered the parent longer pays first. For separated or divorced parents, the order is the custodial parent's plan, then the step-parent's, then the non-custodial parent's, unless a court decree assigns health costs to one parent. That rule governs fully insured group plans. A self-funded employer plan sets its own order in its plan document. The UnitedHealthcare plan pays before Georgia Medicaid, which is payer of last resort and still wants its own ABS PA when secondary. It also pays before TRICARE, which pays only after other coverage. When the child also has CHAMPVA, the UnitedHealthcare plan pays first: "If you have any other type of other health insurance, CHAMPVA will pay secondary." [16][17][18][19] - Ask the plan: UnitedHealthcare member services / benefits verification: confirm funding type and the COB order in the plan document, and collect the other parent's plan, each parent's date of birth and any custody decree at intake. ## Delivery and billing rules Coverage decides whether UnitedHealthcare / Optum in Georgia 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**: Optum’s commercial reimbursement policy publishes no supervision percentage or caseload cap — it refers providers to the ABA Coding Coalition for supervision requirements. What it does police is the boundary: “CPT codes 97153 and 97155 may not be billed for technician training,” including training a technician new to the organization on a client’s programming or on reassessment-driven goal changes. And 97155 “should be reported only for services where the QHP is either engaged directly with the patient or is directing a technician in implementing a modified protocol with the patient” — treatment planning is an indirect service and not separately reimbursable. [5] - **Concurrent billing (97153 + 97155)**: Yes, with a single-provider exclusion. “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 concurrency has to be two people — technician on 97153, analyst on 97155 directing them with the patient present. Separately, 97155 and 97156 may both pay on the same date of service only if the services are separate, distinct and clearly documented; “a single provider can’t bill for both simultaneously (e.g., in the same 15-minute block).” ABA alongside speech, OT or PT: Optum publishes no same-clock-time rule for ABA with another therapy. Its supplemental clinical criteria say "ABA services do not duplicate the services provided to or available to the individual by other medical or behavioral services," and require documented coordination with other allied health providers ("occupational therapy, speech therapy, physical therapy and any other applicable providers") "to reduce the likelihood of unnecessary duplication of services"; Optum's ABA CPT FAQ adds that ABA providers should know the child's other therapies, how often they occur and their goals, with ongoing communication documented. [5][1][7] - **Daily limits / MUEs**: Optum publishes its own per-day table on top of CMS MUEs — maximum frequency per day: 97151 32 units (8 hrs), 97152 16 (4 hrs), 97153 32 (8 hrs), 97154 18 (4.5 hrs), 97155 24 (6 hrs), 97156 16 (4 hrs), 97157 16 (4 hrs), 97158 16 (4 hrs), 0362T 16 (4 hrs), 0373T 32 (8 hrs). MUEs otherwise apply per CMS guidance, and billing above 32 units/day of 97153 “may be subject to non-reimbursement or recovery.” Time is counted on the CMS 15-minute rule (1 unit at ≥ 8 minutes, 2 at ≥ 23, and so on). [5] - **Session-note signature**: “Provider signature is required on progress notes. Parent/guardian signatures are not required on progress notes” (Optum ABA CPT FAQ). Each daily session note records place of service, start and stop time, who rendered the service, the specific service, who attended and the interventions. Optum’s ABA documentation protocol (June 1, 2026) requires the “signature of the rendering provider” and “Legible identity of the rendering provider with credentials,” and “The date of signature must reflect the date the note is finalized” — a note signed after the date of service must follow late-entry rules and show the date it was signed. Same-date services must be “separate, distinct, and clearly documented in the progress notes,” or the claim may be denied. [7][9][5] - **Bill as provider**: One provider-level modifier per line, matching whoever actually rendered the service: HM = Registered Behavior Technician (less than bachelor’s level), HN = BCaBA (bachelor’s level), HO = BCBA or master’s-level licensed clinician, HP = BCBA-D or doctoral-level licensed clinician. A billable ABA-supervisor service is billed with the applicable CPT code plus HO. Stacking level modifiers is a denial risk: “Billing multiple provider-level modifiers (HN, HM, HO, HP) on the same service line same service and same DOS is not appropriate and may result in claim denial.” Indirect work has no code of its own — it is bundled into the direct-service code. [5] - **Place of service** _(plan-dependent)_: No place-of-service code list is published: the commercial ABA reimbursement policy sets codes, modifiers, units and concurrency but no setting rule. School: Optum’s clinical criteria exclude “services that are not ABA therapy, such as 1:1 aid delivered simultaneously during classroom instruction, or services covered under the Individuals with Disabilities Education Act (IDEA),” but “school ABA services do allow for coordination of services and would cover services such as teacher training, meetings with school personnel, and observations in the school setting.” [1] - Ask the plan: UnitedHealthcare/Optum provider services and the member’s benefit document; Optum’s published ABA State Mandates document carries no Georgia entry, so nothing state-specific applies on top. ## What intake should collect for UnitedHealthcare / Optum in Georgia - **Plan funding type:** Fully insured (mandate applies) vs. self-funded ERISA (exempt) — it decides which rulebook governs. Ask for the employer and check the card. - **Member ID + card photo:** Enough to run a live benefits verification — the only reliable answer on limits and cost-sharing. - **Diagnosis report:** DSM-5 ASD diagnosis, diagnosing provider and credentials, evaluation date. - **Age:** Where the mandate carries age terms, flag edge cases for the parity analysis rather than turning families away. Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf ## Verification of benefits (VOB) data How UnitedHealthcare / Optum in Georgia ABA benefits route and read on an eligibility check. Data last updated 2026-10-15. ### EDI routing - **Payer ID (pVerify):** 00192 - **Payer ID (Change Healthcare / Optum):** 87726 — QA re-check (2026-07-23): neither cited source (pVerify list, Optum ABA Supplemental Clinical Criteria) actually contains this payer ID — pVerify's own list has no "87726" line at all, only a distinct "UHG007 United Healthcare - Optum Behavioral Solutions" entry, and the Optum SCC document contains zero payer IDs. Confirm directly via Provider Express / UHC provider services before automating on 87726. - **Supports 270/271 eligibility:** Yes - **Behavioral health administrator:** Optum Behavioral Health ### How the 271 reports ABA benefits - **ABA benefit bucket (service type code):** MH — UHC's own EDI feed (87726) formally supports MH/A4-A8 with financial detail, but whether members whose ABA benefit is carved to Optum Behavioral Health actually receive populated MH-flavor detail through this SAME feed — versus a referral/vendor-lookup stub via the guide's own documented EB*U 'vendor' segment mechanism — is not resolved by any source found this pass. Confirm via Provider Express / UHC provider services for the specific plan. - **Deductible applies to ABA:** yes — Same open question as abaBenefitBucket — confirm whether the carved-out BH benefit populates deductible detail on this feed. - **Cost-share type:** plan-dependent — Both copay and coinsurance are structurally supported per plan; which applies to a given member is plan-document-specific. - **271 response quality for ABA:** high ### Code-level coverage | Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers | | --- | --- | --- | --- | --- | --- | --- | | 97151 | Yes | Required — Optum ABA prior authorization (specific process/review cadence not confirmed in either cited source) | 32 units/day (≤8 hrs) per day | — | — | HN, HO, HP | | 97152 | Yes | Required — Optum ABA prior authorization (specific process/review cadence not confirmed in either cited source) | 16 units/day (≤4 hrs) per day | — | — | HN, HM, HO, HP | | 97153 | Yes | Required — Optum ABA prior authorization (specific process/review cadence not confirmed in either cited source) | 32 units/day (≤8 hrs) per day | — | — | HN, HM, HO, HP | | 97154 | Yes | Required — Optum ABA prior authorization (specific process/review cadence not confirmed in either cited source) | 18 units/day (≤4.5 hrs) per day | — | — | HN, HM, HO, HP | | 97155 | Yes | Required — Optum ABA prior authorization (specific process/review cadence not confirmed in either cited source) | 24 units/day (≤6 hrs) per day | — | — | HN, HO, HP | | 97156 | Yes | Required — Optum ABA prior authorization (specific process/review cadence not confirmed in either cited source) | 16 units/day (≤4 hrs) per day | — | — | HN, HO, HP | | 97157 | Yes | Required — Optum ABA prior authorization (specific process/review cadence not confirmed in either cited source) | 16 units/day (≤4 hrs) per day | — | — | HN, HO, HP | | 97158 | Yes | Required — Optum ABA prior authorization (specific process/review cadence not confirmed in either cited source) | 16 units/day (≤4 hrs) per day | — | — | HN, HO, HP | | 0362T | Yes | Required — Optum ABA prior authorization (specific process/review cadence not confirmed in either cited source) | 16 units/day (≤4 hrs) per day | — | — | — | | 0373T | Yes | Required — Optum ABA prior authorization (specific process/review cadence not confirmed in either cited source) | 32 units/day (≤8 hrs) per day | — | — | — | Code notes: - **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** Unit caps and modifiers sourced from Optum's national ABA Reimbursement Policy (2022RP501A) — the GA-specific Supplemental Clinical Criteria contains no CPT codes at all; applied here absent a confirmed GA-specific override. QA re-check (2026-07-23): the previously shipped "two-step authorization (assessment, then treatment); continued-service review every 4-6 months" language does not appear in either OPTUM_SCC or the Reimbursement Policy — removed pending a source that actually states it. Verify via: Provider Express / UHC provider services. ### Contacts - **Benefits by phone:** Yes - **Provider services phone:** 1-877-614-0484 - **Hours:** Monday–Friday, 7 a.m.–7 p.m. CT - **Portal:** [Provider Express](https://public.providerexpress.com) Questions to ask on a verification call: - Does ABA route to Optum Behavioral Health or stay on UHC's medical payer ID (87726) — and what payer ID do you use for eligibility checks? - What Availity and Change Healthcare payer IDs should we use for UnitedHealthcare Georgia — no UHC entry appears in the Availity list we have, and neither cited source actually confirms 87726 for Change Healthcare? - Is the ABA cost share a copay or coinsurance, and is it charged per visit or per day? - Does the member's out-of-pocket maximum apply to ABA cost share? - What POS codes and telehealth modifiers do you accept for ABA billing? - What's the Optum ABA prior-authorization process and review cadence for continued services? - Does eligibility checking return real-time or batch-only 271 responses? ### VOB data sources - https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23) - https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/abaSCC.pdf (accessed 2026-07-23) - https://www.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23) - https://www.uhcprovider.com/content/dam/provider/docs/public/resources/edi/EDI-270-271-Companion-Guide-005010X279A1.pdf (accessed 2026-07-23) - https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/reimbPolicies/abaReimburs2020s.pdf (accessed 2026-07-23) - https://public.providerexpress.com/content/ope-provexpr/us/en/contact-us.html (accessed 2026-07-23) - https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/adminResourcesMain/netwmanual/NNManual.pdf (accessed 2026-10-14) ## Common questions ### Does UnitedHealthcare (Optum) require graphs for ABA reauthorization? Optum's criteria do not require graphs; they require progress measured the same way as the baseline, mastery rates, change scores and updated standardized adaptive measures at each continued-treatment review. ### Does UnitedHealthcare (Optum) accept H0031 or H0032 for ABA in Georgia? Not on commercial plans: Optum's commercial ABA reimbursement policy lists CPT 97151–97158, 0362T and 0373T as the reimbursable ABA codes, with the credential modifier of the person who delivered the service. ### How long do I have to file a UnitedHealthcare (Optum) ABA claim in Georgia, including as secondary? Optum's National Network Manual requires everything needed to process the claim within 90 calendar days of the date of service (or longer where state or federal law or the member's plan allows), with corrections within 90 days of initial receipt. It sets no separate secondary-claim deadline; as secondary, Optum pays up to its contracted rate. ### Does UnitedHealthcare cover ABA therapy in Georgia? Yes — under the carrier's national policy for ASD, layered on Georgia's mandate (O.C.G.A. § 33-24-59.10 (Ava’s Law)) for fully-insured plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first. ### What does the Georgia autism mandate require? Ava’s Law requires state-regulated accident and sickness plans (including the state employee health plan) to cover ASD treatment for individuals 20 years of age or under, with ABA nominally cappable at $35,000 per year — and no limits allowed on the number of visits. See the mandate section above for ages, caps, and exemptions — and remember federal parity limits how hard the numeric caps can be enforced against group plans. ### What is UnitedHealthcare’s fee schedule for ABA in Georgia? There is no public one. Optum tells participating providers to bill “the applicable CPT code(s) listed on their fee schedule,” meaning the schedule in your Optum agreement, with payment subject to the member’s benefits and prior authorization. Ask Optum network management for rates. ### How often does UnitedHealthcare (Optum) reauthorize ABA? Optum, which manages UnitedHealthcare’s behavioral health benefits, says “At a minimum, most treatment reviews are required every 4-6 months depending on the account/state law.” Call in the continued-care request “no more than 30 days prior to the current approvals on file expiring,” with updated progress data measured the same way as baseline and updated standardized measures. There is no fixed reassessment frequency (“There is no required frequency at which an assessment must take place”) — ask for reassessment hours inside the treatment request. If more hours are needed mid-authorization, call the ABA team with a clinical rationale. ### Can an out-of-state BCBA treat UnitedHealthcare members in Georgia, including by telehealth? Georgia prohibits unlicensed ABA practice (O.C.G.A. 43-7A-6); a temporary license of up to 30 days a year and reciprocity exist. Optum (UnitedHealthcare): “Providers offering telehealth visits must be licensed in the state where the member is located at the time of service.” ### How old can a diagnosis report be for UnitedHealthcare (Optum) ABA in Georgia? Optum publishes no age limit on the diagnosis. It must be a DSM-5 ASD diagnosis (an older Asperger’s or PDD-NOS label needs updating) from a licensed clinician who confirmed it with at least one validated tool; a later evaluation does not have to be comprehensive unless the diagnosis is in question (Optum ABA FAQ and Supplemental Clinical Criteria). ### Does a doctor’s referral count as the diagnosis for UnitedHealthcare ABA in Georgia, or is a new evaluation needed? A referral alone is not enough. Optum needs the comprehensive diagnostic evaluation from a licensed physician, psychologist or other qualified clinician, with the diagnosis and severity confirmed by a validated tool. If the referring doctor did that evaluation, send it; if not, a diagnostic evaluation is needed. ### What is UnitedHealthcare’s timely filing limit for ABA in Georgia? Optum’s National Network Manual: 90 calendar days from the date of service, unless state law, the benefit plan or your agreement allows longer. Reconsideration and appeal together must be filed within 12 months. ## Primary sources 1. [Optum ABA Supplemental Clinical Criteria (BH803ABASCC)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/abaSCC.pdf) 2. [Georgia Code § 33-24-59.10 (Ava's Law)](https://codes.findlaw.com/ga/title-33-insurance/ga-code-sect-33-24-59-10/) 3. [Autism Speaks — Georgia state-regulated coverage](https://www.autismspeaks.org/georgia-state-regulated-insurance-coverage) 4. [Georgia Association for Behavior Analysis — licensure (HB 412)](https://www.georgia-aba.org/licensure) 5. [Optum — Applied Behavior Analysis (ABA) Reimbursement Policy, Commercial (2022RP501A)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/reimbPolicies/abaReimburs2020s.pdf) 6. [Optum — ABA State Mandates supplemental criteria (BH 803ABA STM12026)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/scc/ABA_SCC_SM.pdf) 7. [Optum — FAQ: Autism/ABA Using CPT Codes (BH00083-24-FAQ, 01/2024)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/abaCPT-FAQs.pdf) 8. [Optum — Telehealth Billing Quick Reference Guide (BH01511, updated September 2025)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/home/Telehealth_Billing_Guide_Updates.pdf) 9. [Optum — Medical Records Documentation for Reviews of ABA Services (BH02325, 6/1/2026)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/OBHS_ABA_Services_Documentation_Protocols.pdf) 10. [Georgia HB 412 (2022) — O.C.G.A. Title 43, Ch. 7A behavior analyst licensure (effective July 1, 2023)](https://gov.georgia.gov/document/2022-signed-legislation/hb-412/download) 11. [Optum Behavioral Health — National Network Manual (published July 1, 2026; effective Sept. 1, 2026)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/adminResourcesMain/netwmanual/NNManual.pdf) 12. [O.C.G.A. § 33-24-59.14 — claim payment deadlines and interest (FindLaw)](https://codes.findlaw.com/ga/title-33-insurance/ga-code-sect-33-24-59-14/) 13. [Georgia SB 80 (2021) — O.C.G.A. 33-46-26, -27, -29, -30 (Ensuring Transparency in Prior Authorization Act)](https://gov.georgia.gov/document/2021-signed-legislation/sb-80/download) 14. [O.C.G.A. 33-46-26 — prior authorization notice within 7 calendar days (FindLaw)](https://codes.findlaw.com/ga/title-33-insurance/ga-code-sect-33-46-26/) 15. [29 CFR 2560.503-1 — ERISA claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1) 16. [Ga. Comp. R. & Regs. 120-2-48-.05 — Group Coordination of Benefits, order of benefits](https://www.law.cornell.edu/regulations/georgia/Ga-Comp-R-Regs-R-120-2-48-.05) 17. [GA DCH — Part I Policies and Procedures for Medicaid/PeachCare for Kids (version date July 1, 2026), 104.3 and 303 (GAMMIS copy retrieved via web.archive.org)](https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Part%201%20Policies%20and%20Procedures%20for%20Medicaid%20PeachCare%20for%20Kids%20Q3%20July%202026%2020260706155614.pdf) 18. [10 U.S.C. 1079(i)(1) — TRICARE pays after other coverage, Medicaid excepted](https://www.govinfo.gov/content/pkg/USCODE-2023-title10/html/USCODE-2023-title10-subtitleA-partII-chap55-sec1079.htm) 19. [CHAMPVA Guidebook (updated Jan. 1, 2025) — Other Health Insurance](https://www.va.gov/COMMUNITYCARE/docs/pubfiles/programguides/CHAMPVA-Guide.pdf) 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.