---
title: "UnitedHealthcare / Optum ABA coverage in Maine: the intake guide."
url: "https://carelu.com/payers/unitedhealthcare-maine"
markdown_url: "https://carelu.com/payers/unitedhealthcare-maine.md"
state: ME (Maine)
payer: UnitedHealthcare / Optum in Maine
kind: Commercial insurance
description: "How UnitedHealthcare / Optum covers ABA for Maine families: Optum’s ABA criteria and prior authorization, the three-code telehealth rule, Maine’s autism mandate (age 10 and under, $36,000 ABA cap allowed), and what intake should verify."
last_reviewed: October 2026
---

# UnitedHealthcare / Optum ABA coverage in Maine: the intake guide.

_Payer Guide · UnitedHealthcare · Maine · Last updated October 2026 · 19 primary sources_

> Optum criteria (BH803ABASCC) + Maine’s autism mandate (age 10 and under); no Maine state supplement; telehealth limited to 97155–97157.

For an intake team in Maine, a UnitedHealthcare card means three layers: Optum Behavioral Health’s national ABA criteria, Maine’s autism mandate in Title 24-A, and the plan’s funding type. MaineCare has no managed care plans, so a UHC card in Maine is commercial (or Medicare), never Medicaid.

## 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 [1]
- **Prior auth for treatment** _(plan-dependent)_: Required; continued-service review examines use of authorized hours (below 80% over two weeks must be explained). 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 will be set on this member’s ABA authorization.
- **Autism diagnosis required?**: Yes: DSM-5-TR ASD diagnosed by a state-licensed physician, psychologist or other qualified state-licensed clinician, confirmed with a validated tool [1]

## At a glance

- **Covers ABA?:** Yes, for ASD, per Optum’s ABA Supplemental Clinical Criteria
- **State mandate:** 24-A M.R.S. § 2768 (individual), § 2847-T (group), § 4259 (HMO)
- **Mandate age:** 10 years of age or under (raised from 5 by P.L. 2013, c. 597, from 1/1/2015)
- **Mandate caps:** Plans may cap ABA at $36,000 per year; no visit limits allowed
- **Exempt from mandate:** Self-funded ERISA employer plans (outside state insurance law)
- **Licensure:** None: Maine does not license behavior analysts; the mandate requires national-board (BACB) certification or supervision
- **Fee schedule:** Not public — Optum pays up to the “Fee Maximum” in your agreement, by credential level (HM/HN/HO/HP modifiers)

## The national policy, applied in Maine

UnitedHealthcare administers ABA through Optum Behavioral Health under the ABA Supplemental Clinical Criteria (BH803ABASCC; interim review April 2026): "Prior authorization is required for ABA (unless otherwise specified or mandated by contract or law)," and continued-service review addresses use "below 80% over a 2-week period." Optum’s ABA State Mandates supplement (effective July 2026) has entries for Arizona, California, Connecticut, Florida, Indiana, Kansas, Kentucky, Maryland, Massachusetts, New Jersey, New York, Ohio, Pennsylvania and Virginia; Maine is not among them, so no Maine-specific Optum criteria modify the commercial policy. MaineCare is fee-for-service with no health plans. [1][2][19]

## The Maine mandate: what it guarantees

Maine’s autism mandate is written three times, once for each kind of contract: 24-A M.R.S. § 2768 for individual health insurance, § 2847-T for group policies, and § 4259 for individual and group HMO contracts. The operative text is the same in all three. The plan "must provide coverage for autism spectrum disorders for an individual covered under a policy or contract who is 10 years of age or under." It must cover "any assessments, evaluations or tests by a licensed physician or licensed psychologist to diagnose whether an individual has an autism spectrum disorder," and must cover treatment "when it is determined by a licensed physician or licensed psychologist that the treatment is medically necessary," with ongoing medical necessity demonstrable "at least annually." It "may not include any limits on the number of visits," but it "may limit coverage for applied behavior analysis to $36,000 per year" (the group and HMO versions add "to the extent allowed by federal law"), and payments for unrelated care may not count toward that cap. ABA is covered as a habilitative or rehabilitative service, and "To be eligible for coverage, applied behavior analysis must be provided by a person professionally certified by a national board of behavior analysts or performed under the supervision of" such a person. The mandate does not change a school’s obligations under an IEP or IFSP. The age ceiling was 5 until P.L. 2013, c. 597 raised it to 10 for policies issued or renewed from January 1, 2015. Two practical consequences: a child turns out of the mandate at 11, after which ABA depends on the plan’s own terms; and the mandate binds fully insured plans regulated in Maine, not self-funded employer plans, which answer to ERISA and their plan documents. [6][7][8][9]

## Credentialing, licensure and rates

Maine does not license behavior analysts. The BACB’s U.S. licensure table, which lists every state with a behavior-analyst licensure law and its board, does not include Maine, and Title 32 of the Maine Revised Statutes (professions and occupations) has no behavior-analyst chapter (chapter 141, sometimes cited for this, is the professional land surveyors chapter). The working credential is BACB certification, which the mandate itself requires for whoever provides or supervises ABA. Maine’s credentialing statute still helps: under 24-A M.R.S. § 4303(2)(D) a carrier must decide a completed credentialing application "within 60 days," must review a new application within 30 days and return an incomplete one "with a comprehensive list of all corrections needed," and "may not require that a provider have a home address within the State." Under § 4303(2-A), once credentials are granted the carrier pays claims for services rendered "from the date a complete application for credentialing is submitted," though you may not submit those claims until the carrier tells you the credentialing outcome and effective date. Commercial ABA rates are negotiated and unpublished, and the MaineCare ABA rate (Section 28, H2021 U1 HK) sits on a fee schedule we could not retrieve this month. [15][16][12][7][19]

## What is UnitedHealthcare’s fee schedule for ABA?

UnitedHealthcare publishes no ABA rate table; Optum pays from the contract. 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," adding that "Reimbursement to clinicians is based upon licensure rather than degree." Optum’s commercial ABA Reimbursement Policy (2022RP501A, updated June 2026) puts the credential on every line: HM for an RBT, HN for a BCaBA, HO for a master’s-level BCBA or licensed mental health provider, HP for doctoral level, and it bundles indirect work into the direct-service codes. Ask Optum network management for your rate sheet. [4][5]

## Claims in Maine: payment timing, retro denials and appeals

Maine’s prompt-pay law, 24-A M.R.S. § 2436, makes a health claim "payable within 30 days after proof of loss is received"; a claim "neither disputed nor paid within 30 days is overdue" and bears interest at 1½% a month. A provider may submit a claim to every carrier that may be liable, primary and secondary, at the same time, and each must pay or deny "within 30 calendar days after the carrier has received all information needed," whether or not the other carrier has acted. A claim the carrier rejects for not using the standard claim form cannot be billed to the family; fix and resubmit it. After payment, § 4303(10) bars a carrier from retrospectively denying a paid claim more than 12 months after payment unless it gives the reason in writing and the claim falls within narrow exceptions (up to 36 months for duplicate payment, services not delivered, adjustment with another insurer or legal action; beyond that only for fraud or Medicaid/Medicare/CHIP claims). Appeals of an adverse treatment decision must be heard by a clinical peer who was not involved in the first decision (§ 4304(7)). The timely-filing limit itself is a contract term, not a statute. Optum’s own filing limit: claims information "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." Its network manual lists separate Maine Regulatory Requirements. [13][12][10][4]

Optum’s manual adds that "Any corrections or additions to a claim should be made within 90 days of initial claim receipt," and that complete, authorized claims "will be paid within 45 calendar days after Optum receives the claim, or as required by state and federal laws" (claims needing coordination-of-benefits decisions may take longer). It sets no separate secondary-claim deadline and publishes no check-run schedule. [13][12][10][4]

## 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 Maine, and what they have to bring.

- **Diagnosis recency**: No expiry on the diagnosis; it must be confirmed with validated tools. Use below 80% of authorized hours over two weeks triggers review. [1]
- **Who may diagnose**: The diagnosis "must be issued by 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; the SCC list formal diagnostic tools including the ADI-R, ADOS/ADOS-2 and DISCO, alongside screening instruments. [1]
- **Referral required?**: No separate physician referral; the SCC require prior authorization. For a fully insured Maine plan, the mandate covers treatment "when it is determined by a licensed physician or licensed psychologist that the treatment is medically necessary," and the plan may require that physician or psychologist to demonstrate ongoing medical necessity "at least annually." Self-funded ERISA plans sit outside the statute. [1][7]
- **Telehealth**: Three codes. Optum’s Telehealth Billing guide (updated September 2025), commercial: "For ABA services, telehealth is only allowed for these 3 CPT codes: 97155, 97156 or 97157." So the 97151 assessment and technician 97153 are not on Optum’s list. Bill POS 10 (home) or 02 (elsewhere); Optum "will not reimburse for services billed with only telehealth modifiers." The SCC add that telehealth options "are not intended to supplant in-person service; rather, they are intended to supplement" it. For a fully insured Maine plan, 24-A M.R.S. § 4316 says a carrier "may not deny coverage on the basis that the health care service is provided through telehealth if the health care service would be covered if it were provided through in-person consultation," that "Prior authorization is required for telehealth services only if prior authorization is required for the corresponding covered health care service," and that "An in-person consultation prior to the delivery of services through telehealth is not required." Coverage may not be limited "on the basis of geography, location or distance for travel," and the carrier may not add telehealth-only credentialing. Self-funded employer plans are outside the statute. Ask Optum how it applies the three-code list to a fully insured Maine plan. [3][1][11]
- **Age limit** _(plan-dependent)_: The SCC carry no age criterion; the member’s benefit plan governs. For fully insured Maine plans, 24-A M.R.S. §§ 2768, 2847-T and 4259 require autism coverage for a covered person "10 years of age or under" and allow ABA to be capped at $36,000 a year; from age 11 the plan’s own terms decide. Self-funded ERISA plans are outside the statute. [1][6][7][8]
  - Ask the plan: Provider Express benefits check or the behavioral health number on the card: establish fully insured vs. self-funded ERISA first.
- **Prior-auth decision time** _(plan-dependent)_: Depends on how the plan is funded. Fully insured Maine plans fall under 24-A M.R.S. § 4304(2): a provider’s prior-authorization request for a nonemergency service "must be answered by a carrier within 72 hours or 2 business days, whichever is less." The same clock restarts when the carrier asks for more information (from receipt of it) or says outside consultation is needed. "If a carrier does not grant or deny a request for prior authorization within the time frames required under this subsection, the request for prior authorization by the provider is granted." Once approved, the carrier "may not retrospectively deny coverage or payment for the originally approved service" absent fraudulent or materially incorrect information, and may not deny the claim when the service is delivered within 14 days before or after the approved date. 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. UnitedHealthcare/Optum publishes no Maine-specific ABA turnaround or reauthorization lead time. [10][17]
  - Ask the plan: At benefits verification ask whether the plan is fully insured (Maine-regulated) or self-funded (ERISA), and what reauthorization lead time Optum expects.
- **Other insurance (who pays first)** _(plan-dependent)_: Maine lets a provider bill every potentially liable carrier at once: under 24-A M.R.S. § 2436(1-A) each carrier, primary or secondary, must pay or deny "within 30 calendar days after the carrier has received all information needed to pay or deny the claim whether or not another carrier with which it is attempting to coordinate has acted." If two carriers cannot agree on the order of benefits within 30 days of having everything they need, Bureau of Insurance Rule ch. 790 says they "shall immediately pay the claim in equal shares" and settle up afterward, with neither paying more than it would have as primary. We did not find Maine’s order-of-benefit (birthday-rule) text this month, so ask the carriers which plan is primary. If the child also has MaineCare, UnitedHealthcare/Optum pays first: "MaineCare is the payer of last resort," and a medical-necessity denial from the commercial plan must be appealed before MaineCare will consider the claim (MaineCare Benefits Manual Ch. I, § 1.07-3). TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270). [13][14][18][20][21][22]
  - Ask the plan: Ask UnitedHealthcare/Optum at benefits verification for the member’s coordination-of-benefits order (and whether a self-funded plan follows its own order), and record every other coverage the child has, including MaineCare.

## Delivery and billing rules

Coverage decides whether UnitedHealthcare / Optum in Maine 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." Technicians "should be registered behavior technicians (RBT) or another appropriately certified behavior technician as allowable by state mandate," and Optum does not recommend parents serving as their own child’s RBT. [1]
- **Concurrent billing (97153 + 97155)**: 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]
- **Daily limits / MUEs**: No numeric cap in the SCC. At continued-service review, use of authorized hours below 80% over a two-week period must be explained with barriers and a plan. A fully insured Maine plan may cap ABA at $36,000 a year but may not limit visits. [1][7]
- **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. Telehealth claims must carry POS 02 or 10, which "should reflect the location of the member, not the provider." [1][3]
- **Bill as provider**: Each claim line carries the rendering credential: HM (RBT), HN (BCaBA), HO (master’s-level BCBA or licensed mental health provider), HP (doctoral level), per Optum’s commercial ABA Reimbursement Policy; reimbursement "is based upon licensure rather than degree." [5][4]
- **Session-note signature** _(ask the plan)_: Not addressed. The SCC set what must be documented for coverage, not who signs a session note or when. [1]
  - Ask the plan: Optum Provider Express National Network Manual (documentation standards) and the participating-provider agreement.

## What intake should collect for UnitedHealthcare / Optum in Maine

- **Plan funding type:** Fully insured (Maine mandate applies) vs. self-funded ERISA (plan document governs).
- **Child’s age:** The Maine mandate covers children 10 and under; from 11 the plan’s own terms decide.
- **Diagnosis with a validated tool:** DSM-5-TR ASD confirmed with a validated tool (ADI-R, ADOS-2 and others). Optum asks for the instrument.
- **Other coverage:** Second parent’s plan, MaineCare (pays last), TRICARE or CHAMPVA.

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 Maine 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 cover ABA therapy in Maine?

Yes, under Optum’s national ABA criteria for ASD, with Maine’s autism mandate layered on for fully insured plans (children 10 and under). Self-funded employer plans follow their own documents.

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

No. Optum’s ABA State Mandates supplement (July 2026) does not list Maine, so the standard national criteria apply.

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

Optum’s commercial telehealth guide allows only 97155, 97156 and 97157 by telehealth, billed POS 10 or 02. Fully insured Maine plans are also subject to 24-A M.R.S. § 4316, which bars denying a covered service only because it is delivered by telehealth, so ask Optum how it applies the list to your plan.

### What does UnitedHealthcare pay for ABA in Maine?

Optum publishes no ABA rates. You are paid up to the Fee Maximum in your agreement, with a credential modifier on each line (HM RBT, HN BCaBA, HO BCBA, HP doctoral).

### Is UnitedHealthcare a MaineCare plan?

No. MaineCare pays providers directly, fee-for-service; there are no MaineCare health plans for ABA.

## 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 supplemental criteria (BH803ABASTM, effective July 2026; Maine not listed)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/scc/ABA_SCC_SM.pdf)
3. [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)
4. [Optum National Network Manual (BH02330, effective Sept. 1, 2026)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/adminResourcesMain/netwmanual/NNManual.pdf)
5. [Optum — ABA Reimbursement Policy, Commercial (2022RP501A, updated June 2026)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/reimbPolicies/abaReimburs2020s.pdf)
6. [24-A M.R.S. § 2768 — Coverage for the diagnosis and treatment of autism spectrum disorders (individual policies)](https://legislature.maine.gov/statutes/24-A/title24-Asec2768.html)
7. [24-A M.R.S. § 2847-T — Coverage for the diagnosis and treatment of autism spectrum disorders (group policies)](https://legislature.maine.gov/statutes/24-A/title24-Asec2847-T.html)
8. [24-A M.R.S. § 4259 — Coverage for the diagnosis and treatment of autism spectrum disorders (HMO contracts)](https://legislature.maine.gov/statutes/24-A/title24-Asec4259.html)
9. [P.L. 2013, c. 597 — An Act To Amend Insurance Coverage for Diagnosis of Autism Spectrum Disorders (age 5 → 10; applies from Jan. 1, 2015)](https://legislature.maine.gov/legis/bills/bills_126th/chapters/PUBLIC597.asp)
10. [24-A M.R.S. § 4304 — Utilization review (prior authorization timeframes)](https://legislature.maine.gov/statutes/24-A/title24-Asec4304.html)
11. [24-A M.R.S. § 4316 — Coverage for telehealth services](https://legislature.maine.gov/statutes/24-A/title24-Asec4316.html)
12. [24-A M.R.S. § 4303 — Plan requirements (sub-§ 2 credentialing, 2-A payment during credentialing, 10 retrospective denials)](https://legislature.maine.gov/statutes/24-A/title24-Asec4303.html)
13. [24-A M.R.S. § 2436 — Interest on overdue payments (30-day claim payment)](https://legislature.maine.gov/statutes/24-A/title24-Asec2436.html)
14. [Bureau of Insurance Rule 02-031 ch. 790 — Procedures for Resolving Coordination of Benefits Disputes](https://www.maine.gov/sos/sites/maine.gov.sos/files/content/assets/031c790.doc)
15. [BACB — U.S. Licensure of Behavior Analysts (Maine not listed)](https://www.bacb.com/u-s-licensure-of-behavior-analysts/)
16. [Maine Revised Statutes, Title 32 (Professions and Occupations) — chapter list (no behavior-analyst chapter; ch. 141 is Professional Land Surveyors)](https://legislature.maine.gov/statutes/32/title32ch0sec0.html)
17. [29 CFR 2560.503-1 — ERISA claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
18. [MaineCare Benefits Manual, Ch. I, Section 1 — General Administrative Policies and Procedures (1.07 TPL, 1.10 claims, 1.14 prior authorization, 1.23 provider appeals)](https://www.maine.gov/sos/sites/maine.gov.sos/files/inline-files/c1s001.docx)
19. [MaineCare Benefits Manual, Ch. II, Section 28 — Adaptive Behavior Services for Children (eff. April 29, 2026, filing 2026-101)](https://www.maine.gov/sos/sites/maine.gov.sos/files/inline-files/c2s028-2026-101%20NEW.docx)
20. [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)
21. [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)
22. [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.