---
title: "UnitedHealthcare / Optum ABA coverage in Maryland: the intake guide."
url: "https://carelu.com/payers/unitedhealthcare-maryland"
markdown_url: "https://carelu.com/payers/unitedhealthcare-maryland.md"
state: MD (Maryland)
payer: UnitedHealthcare / Optum in Maryland
kind: Commercial insurance
description: "How UnitedHealthcare / Optum covers ABA for Maryland families — the national clinical policy, prior authorization, Optum's published Maryland state-mandate criteria (COMAR 31.10.39.03 with 25/10 hour floors), Maryland LBA licensure, and what intake should verify."
last_reviewed: October 2026
vob_data_updated: 2026-10-15
---

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

_Payer Guide · UnitedHealthcare · Maryland · Last updated October 2026 · 17 primary sources_

> Optum BH803ABASCC + a published Maryland State Mandates entry adopting the COMAR 25/10-hr floors.

For an intake team in Maryland, a UnitedHealthcare card means three layers at once: the carrier's national clinical policy, Maryland's habilitative-services mandate (Md. Code Ann., Insurance § 15-835, implemented by COMAR 31.10.39.03), and the plan's funding type deciding which of the two actually binds. UnitedHealthcare is the carrier that makes the Maryland layer easiest to enforce: Optum publishes a Maryland entry in its ABA State Mandates criteria that adopts the COMAR rules — hour floors included — for fully-insured plans. This guide stacks the layers 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][6]
- **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) [8][1][6]
- **Autism diagnosis required?**: Yes — DSM-5-TR ASD confirmed with a validated tool (ADI-R, ADOS-2, etc.) [1][6]

## At a glance

- **Covers ABA?:** Yes — for ASD, per the national UnitedHealthcare policy
- **State mandate:** Md. Ins. § 15-835 + COMAR 31.10.39.03 (habilitative services)
- **Mandate age:** Through at least the month the enrollee turns 19; hour floors span 18 months–18 years
- **Mandate floors:** No denial solely on hours up to 25 hrs/wk (18 mo–5 yrs) or 10 hrs/wk (6–18); no dollar cap
- **Optum MD criteria:** Published — BH803ABA State Mandates applies COMAR 31.10.39.03 to MD fully-insured plans
- **Licensure:** MD Licensed Behavior Analyst (Board of Professional Counselors & Therapists)
- **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 Maryland

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. That clinical policy is national — what changes in Maryland is the legal floor underneath it: the state mandate 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 Maryland. [1]

## Optum's Maryland-specific criteria: COMAR, in the carrier's own document

Maryland has its own entry in Optum's ABA State Mandates supplemental criteria (BH803ABA): for fully-insured policies in Maryland, Optum directs reviewers to use the COMAR 31.10.39.03 criteria (April 3, 2014) in place of its standard medical-necessity rules. The document reproduces the Maryland requirements — comprehensive evaluation, physician prescription with treatment goals and annual prescriber review, the no-denial floors of 25 hours/week for ages 18 months–5 years and 10 hours/week for ages 6–18 (with more when medically necessary), school allowed as a service location (though not as an IEP/IDEA obligation), licensed delivery, and the rule that ABA may not be denied as experimental. Once the mandated benefits are exhausted, Optum reverts to its standard medical-necessity policy. For intake, this is leverage: on a fully-insured UHC plan, an hours reduction below the floors contradicts the carrier's own published criteria — cite the state-mandates document, not just the regulation. [2]

## The Maryland mandate underneath

The legal base: Maryland has no standalone autism mandate — ABA rides on the habilitative-services mandate, Insurance § 15-835, which requires Maryland-regulated insurers, nonprofit health service plans, and HMOs to cover habilitative services until at least the end of the month the enrollee turns 19, with the ABA-specific medical-necessity rules delegated to the Insurance Commissioner's regulation, COMAR 31.10.39.03. Carriers aren't required to reimburse services delivered through early intervention or the schools, and self-funded ERISA plans are exempt — for those members the Optum Maryland entry doesn't apply either, and MHPAEA parity is the fallback lever. [3]

## UnitedHealthcare Medicaid in Maryland: the card that doesn't matter for ABA

A family saying "we have UnitedHealthcare" in Maryland may be on UnitedHealthcare Community Plan, a HealthChoice MCO — but that changes nothing for ABA. Maryland carves ABA out of the MCOs entirely: authorizations and claims go to Carelon Behavioral Health, the state's BHASO, under the Medicaid fee-for-service rules — use our Maryland Medicaid guide. One historical wrinkle worth knowing: Optum Maryland was the state's previous behavioral-health ASO before Carelon took over, so legacy Optum-branded Maryland ABA manuals still circulate — they are stale; Carelon's ProviderConnect is the current pipeline. [4][7]

## Licensure & rates in Maryland

Maryland has required licensure to practice behavior analysis since January 2015: the Licensed Behavior Analyst (LBA) credential, administered by the Behavior Analyst Advisory Committee of the State Board of Professional Counselors and Therapists (Health Occupations Title 17, Subtitle 6A; COMAR 10.58.16), built on current BACB certification, a qualifying master's degree, and a criminal-history check. On rates: UnitedHealthcare does not publish commercial ABA fee schedules for Maryland (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement. Maryland's Medicaid fee schedule (effective February 1, 2026 — e.g., 97153 at $24.41/15-min BCBA tier) is the public benchmark to negotiate against. [5]

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

UnitedHealthcare publishes no ABA rate table; its behavioral health network, 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 06/2026) makes the credential level part of every claim line: HM for an RBT, HN for a BCaBA, HO for a master’s-level BCBA or licensed clinician, HP for a BCBA-D or doctoral-level licensed provider. It also says indirect work has no separate code and is bundled into the direct-service codes. Ask Optum network management for your rate sheet. For a public benchmark, Maryland Medicaid's fee schedule (eff. 2/1/2026, unchanged for FY27) pays 97153 at $24.41 per 15 minutes at the BCBA tier, $20.91 BCaBA and $19.17 RBT/BT. [13][9][14]

## Can an out-of-state BCBA treat a Maryland member, including by telehealth?

Maryland licenses the practice: “an individual shall be licensed by the Board before the individual may practice behavior analysis in the State” (Health Occupations § 17-6A-10(a)). Section 17-6A-10 itself exempts only students in a qualifying unpaid clinical educational experience, so plan on a Maryland license before treating a child located in Maryland remotely. [15][13]

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 Maryland, that means a Maryland license before the first remote session. [15][13]

## UnitedHealthcare / Optum claims in Maryland: filing, payment, taxonomy and appeals

Who goes on the claim: Optum’s commercial ABA reimbursement policy (updated June 2026) requires a credential modifier on each ABA line: HM when the rendering provider is an RBT, HN for a BCaBA, HO for a BCBA (or licensed mental health provider), HP for a BCBA-D. 0362T and 0373T take none. UnitedHealthcare’s 2026 Administrative Guide: “you must submit a valid billing NPI, rendering NPI and relevant taxonomy code(s) on all claims and encounters,” and “we encourage you to submit the referring health care provider’s NPI.” So taxonomy is required on UnitedHealthcare claims. The referring provider’s NPI is encouraged rather than required. [9][16][13][17]

Timely filing and payment: Optum’s network manual (effective September 1, 2026) says “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 that clean claims with any required authorization “will be paid within 45 calendar days after Optum receives the claim, or as required by state and federal laws.” For a fully insured Maryland plan, state law is the stricter rule. Insurance § 15-1005 guarantees at least 180 days to file. It also requires payment, or a notice of what is denied, disputed or missing, within 30 days of receipt, and interest on a clean claim still unpaid after 30 days (1.5% a month for days 31–60, 2% for days 61–120, 2.5% after). [9][16][13][17]

Appeals: Optum runs two steps for commercial claims, a reconsideration first and then an appeal, with “a total of 12 months for submission for both steps” unless state law or your agreement sets a different deadline. A late-filing denial needs proof that Optum received and accepted the original claim. Maryland law also guarantees at least 90 working days after a denial to appeal. No Optum or UnitedHealthcare document we read requires electronic visit verification (EVV) for ABA. [9][16][13][17]

## Does UnitedHealthcare (Maryland) 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.” [13][16]

## Which codes does UnitedHealthcare / Optum pay for ABA? (H0031/H0032 and other H-codes)

Optum’s commercial ABA reimbursement policy (2022RP501A) “describes the correct coding methodology and reimbursement for reporting behavior assessment/intervention services (ABA) for the assessment and treatment of Autism Spectrum Disorders with CPT codes 97151-97158 along with the appropriate modifier,” and its code tables cover 97151–97158, 0362T and 0373T. It lists no HCPCS H-code (H0031, H0032, H2014, H2019) for commercial ABA. The same policy says “97151 and 97152 are the only codes eligible for reimbursement for assessment or reassessment activities,” so 97153 or 97155 cannot be billed for assessment work. [9]

## What must a UnitedHealthcare / Optum ABA reauthorization contain? Are graphs required?

Optum’s Supplemental Clinical Criteria (“Continued Service Criteria”) say that “With each clinical review for continued ABA treatment, the provider must submit updated documentation.” Progress must be “assessed and documented for each targeted symptom and behavior … including the same modes of measurement that were utilized for baseline measurement.” It “should include 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,” with movement from baseline shown on validated, norm-referenced assessments and caregiver progress where applicable. Inadequate progress within a six-month period calls for an assessment of the reasons and modified interventions, and utilization below 80% of authorized hours over a two-week period is reviewed. The criteria do not require graphs; they require the measures above. [1]

## Intake gates

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

- **Who may diagnose**: A DSM-5-TR autism spectrum diagnosis from a state-licensed physician, psychologist, or other qualified clinician. Optum asks for the diagnosing clinician and the instrument at the assessment-authorization step, so both are intake fields. [1]
- **Diagnostic tools required**: The diagnosis must be confirmed with at least one clinically validated tool. Optum names first-level instruments — the ADI-R, the ADOS-2 and the DISCO — and accepts second-level tools including the CARS-2, the RITA-T and the STAT. Capture which instrument was used, by whom and when; “diagnosed by Dr. X” without a named tool is the most common reason an Optum assessment request stalls. [1]
- **Referral required?**: Yes on fully insured Maryland plans, written into Optum’s own criteria. Optum’s ABA State Mandates document, “For fully insured policies in Maryland,” says “The following are required for the initiation and continuation of ABA services: A comprehensive evaluation of a child by the child’s primary care provider or specialty physician identifying the need for treatment of autism spectrum disorder. A prescription from a child’s primary care provider or specialty physician that includes specific treatment goals. Annual review by the prescribing primary care provider or specialty physician, in consultation with the ABA provider.” Self-funded plans follow Optum’s standard Supplemental Clinical Criteria, which require prior authorization but no referral or order. COMAR 31.10.39.03 is where that comes from; it lets carriers require “A comprehensive evaluation of a child by the child’s primary care provider or specialty physician,” “A prescription from a child’s primary care provider or specialty physician that includes specific treatment goals,” and an annual review by the prescriber “in consultation with the habilitative services provider” documenting benefit, new or continuing goals and a new or continuing treatment plan. So the order has to come from the child’s primary care provider or a specialty physician, not the BCBA, and it must state treatment goals; no carrier form is published, and no validity period is set other than the annual review. Self-funded ERISA plans are outside the Maryland rule. [2][18][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.” For a fully insured Maryland policy, Insurance § 15-139 requires coverage "for health care services appropriately delivered through telehealth regardless of the location of the patient," bars excluding a service "solely because it is provided through telehealth," requires reimbursement "on the same basis and at the same rate" as in person, and allows preauthorization only if appropriateness is judged "in the same manner" for both. Self-funded employer plans are outside the statute. [12][10][8][1]
- **Age limit** _(plan-dependent)_: Two answers, and plan funding type picks between them. The carrier's national ABA policy states no age limit. Maryland's habilitative-services mandate does: for Maryland-regulated insurers, nonprofit health service plans and HMOs, habilitative services must be covered “until at least the end of the month the enrollee turns 19,” and COMAR 31.10.39.03 pins its no-denial hour floors to age bands — up to 25 hours/week for ages 18 months through 5 years and up to 10 hours/week for ages 6 through 18, with more when medically necessary. Self-funded ERISA plans are exempt from all of it, so establish funding type before quoting either bound. [3][2]
  - Ask the plan: Benefits verification on the specific plan, via the payer portal or the number on the member’s card — ask whether the plan is Maryland-regulated (an insurer, nonprofit health service plan or HMO, which the habilitative-services mandate and COMAR 31.10.39.03 age bands reach) or a self-funded ERISA plan (exempt). If it is self-funded, ask what age limit and weekly hour limit the plan document sets for ABA before you quote either bound to the family.
- **Prior-auth decision time** _(plan-dependent)_: UHC notifies coverage decisions “within the time required by law,” so the clock depends on how the plan is funded. If the child’s plan is fully insured in Maryland, Insurance §15-10B-06 sets the clock: an initial request is decided “within 2 working days after receipt of the information necessary to make the determination,” “additional visits or days of care submitted as part of an existing course of treatment or treatment plan within 1 working day,” emergency requests within 24 hours, and a reviewer missing information must say so within 3 calendar days. Maryland’s teeth: “If a private review agent fails to make a determination within the time limits required under this section, the request shall be deemed approved.” Mental-health treatment plans must be accepted on the MIA uniform treatment plan form. If the employer self-funds, ERISA’s floor applies instead: pre-service decisions “not later than 15 days after receipt of the claim” (one 15-day extension allowed), urgent claims within 72 hours. Optum (UHC’s behavioral arm) sets the reauth window: call the ABA/Autism queue “no more than 30 days prior to the current approvals on file expiring,” with all clinical information ready; retrospective reviews take up to 30 calendar days. [16][19][20][6][13]
  - Ask the plan: the member services or behavioral health number on the ID card — ask whether the plan is fully insured (and in which state) or self-funded, and for its UM decision timeframes
- **Other insurance (who pays first)** _(plan-dependent)_: UHC administers COB “according to the member’s benefit plan and in accordance with law.” Optum: “You are responsible for determining if the member has other insurance coverage. If so, you should bill the primary insurance carrier first, then notify Optum of your findings”; as secondary, payment goes up to Optum’s contracted rate and you may not balance-bill. Maryland has not yet adopted a COB regulation: the Insurance Administration says contract COB provisions “have historically been reviewed for consistency with the NAIC Model, but the Model has not been formally adopted to date,” and its draft COMAR 31.10.53 (comments closed August 2026) would codify the NAIC birthday rule (“The plan of the parent whose birthday falls earlier in the calendar year is the primary plan”) and exclude Medicaid from the definition of a plan — so Maryland Medicaid always pays after the commercial plan. [16][13][21][22]
  - Ask the plan: the carrier’s eligibility response (Availity or the ID-card number) for an other-insurance record, and both parents’ birth dates and custody arrangements at intake; a self-funded plan follows its own plan document
- **Diagnosis recency** _(ask the plan)_: Optum publishes no recency rule for the ASD diagnosis in its Supplemental Clinical Criteria as cited here; what it does set is a review cadence downstream — continued-service reviews every 4–6 months requiring updated standardized adaptive measures and progress measured the same way as baseline. [1]
  - Ask the plan: Optum provider services or the assessment-authorization request on Provider Express — ask whether an evaluation of this age will be accepted before scheduling.

## Delivery and billing rules

Coverage decides whether UnitedHealthcare / Optum in Maryland 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 Supplemental Clinical Criteria set supervision at 1–2 hours per 10 hours of direct treatment, with a floor of at least one hour of 97155 per case per month. In Maryland the supervising analyst must additionally hold the state Licensed Behavior Analyst credential, required to practice behavior analysis since January 2015. Neither the Supplemental Clinical Criteria nor Optum’s commercial ABA reimbursement policy caps how many technicians one BCBA may supervise. [9][1][5]
- **Concurrent billing (97153 + 97155)**: Yes, with a single-provider exclusion. Optum’s commercial ABA reimbursement policy: “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 has to be two people — a technician on 97153 and an analyst on 97155 directing them with the patient present. Optum’s ABA CPT FAQ adds that 97153 and 97156 “may be billed concurrently” as separate services to different family members by different providers. 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.” Team meetings bill only as supervision with the member, supervisor and technician present, and “CPT codes 97153 and 97155 may not be billed for technician training.” [9][8]
- **Daily limits / MUEs**: Optum’s commercial ABA reimbursement policy (2022RP501A, updated June 2026) sets a maximum frequency per day for every code: 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) — and “If a provider bills in excess of 32 units per day, claims may be subject to non-reimbursement or recovery.” The ABA CPT FAQ confirms “For our commercial ABA program MUE’s apply.” There is no weekly hour cap: hours are authorized on documented clinical need, approved units can be shifted among codes within a cluster, and utilization below 80% of authorized hours over a two-week period is addressed at review. [9][8][1]
- **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. [8][11][9]
- **Place of service**: Optum's exclusions are the operative setting rule: team meetings without the member, 1:1 classroom aides, and any service owed under IDEA are not covered, which makes the school and IEP picture a coverage question rather than a background one. Optum's Maryland State Mandates entry goes further in the member's favour for fully-insured plans — it reproduces COMAR's allowance of school as a service location, while keeping IDEA/IEP obligations outside the benefit. [1][2]
- **Bill as provider**: The person who delivered the service is the rendering provider, and a credential modifier on every line says who that was. Optum’s commercial ABA reimbursement policy (2022RP501A, updated June 2026): “The appropriate modifier must be billed to reflect the appropriate credentials of the provider delivering the services.” HM is for when “The approved rendering provider … is … a Registered Behavior Technician (RBT)”; HN for a BCaBA; HO for a BCBA or licensed mental health provider; HP for a BCBA-D. 0362T and 0373T need no modifier. A technician’s 97153 therefore goes out with HM, and the BCBA’s concurrent 97155 with HO. Optum’s network manual (effective September 1, 2026) sets who can appear: behavior analysts apply for the network individually, technicians must be an RBT, a Board-Certified Autism Technician (BCAT) or a certified ABA Technician (ABAT), an agency’s affiliated clinicians “are considered participating under the agency’s Participation Agreement,” and “Any claims submission for a rendering clinician who has not been added to the network is subject to denial.” UnitedHealthcare’s 2026 Administrative Guide requires “a valid billing NPI, rendering NPI and relevant taxonomy code(s) on all claims.” [9][13][16][1]

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

- **Plan funding type:** Fully insured (COMAR floors + Optum's MD criteria apply) vs. self-funded ERISA (exempt) — it decides which rulebook governs.
- **Line of business:** Commercial UHC vs. UnitedHealthcare Community Plan (Medicaid) — Medicaid ABA goes to Carelon, not UHC/Optum at all.
- **ABA prescription + goals:** COMAR requires a prescription with treatment goals from the PCP or a specialty physician, reviewed annually — capture the prescriber and date.
- **Member ID + card photo:** Enough to run a live benefits verification — the only reliable answer on limits and cost-sharing.
- **Diagnosis report + testing:** DSM-5-TR ASD diagnosis confirmed with a validated tool (ADI-R, ADOS-2, etc.) — Optum asks for the instrument.

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

## Verification of benefits (VOB) data

How UnitedHealthcare / Optum in Maryland ABA benefits route and read on an eligibility check. Data last updated 2026-10-15.

### EDI routing

- **Payer ID (Availity):** 87726
- **Payer ID (Change Healthcare / Optum):** 87726 — One UHC row in the Optum/UHC payer list carried an unexplained 'MD / MAMP' annotation alongside the shared 87726 ID — meaning and effect on routing not confirmed this pass.
- **Supports 270/271 eligibility:** Yes
- **Real-time eligibility:** Yes
- **Behavioral health administrator:** Optum Behavioral Health
- **BH administrator payer ID:** 87726

### 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 — step 1 of Optum's two-step authorization (assessment, then treatment); reviews every 4–6 months | 32 units/day (≤8 hrs) per day | — | — | HN, HO, HP |
| 97152 | Yes | Required — step 1 of Optum's two-step authorization (assessment, then treatment); reviews every 4–6 months | 16 units/day (≤4 hrs) per day | — | — | HN, HM, HO, HP |
| 97153 | Yes | Required — step 1 of Optum's two-step authorization (assessment, then treatment); reviews every 4–6 months | 32 units/day (≤8 hrs) per day | — | — | HN, HM, HO, HP |
| 97154 | Yes | Required — step 1 of Optum's two-step authorization (assessment, then treatment); reviews every 4–6 months | 18 units/day (≤4.5 hrs) per day | — | — | HN, HM, HO, HP |
| 97155 | Yes | Required — step 1 of Optum's two-step authorization (assessment, then treatment); reviews every 4–6 months | 24 units/day (≤6 hrs) per day | — | — | HN, HO, HP |
| 97156 | Yes | Required — step 1 of Optum's two-step authorization (assessment, then treatment); reviews every 4–6 months | 16 units/day (≤4 hrs) per day | — | — | HN, HO, HP |
| 97157 | Yes | Required — step 1 of Optum's two-step authorization (assessment, then treatment); reviews every 4–6 months | 16 units/day (≤4 hrs) per day | — | — | HN, HO, HP |
| 97158 | Yes | Required — step 1 of Optum's two-step authorization (assessment, then treatment); reviews every 4–6 months | 16 units/day (≤4 hrs) per day | — | — | HN, HO, HP |
| 0362T | Yes | Required — step 1 of Optum's two-step authorization (assessment, then treatment); reviews every 4–6 months | 16 units/day (≤4 hrs) per day | — | — | — |
| 0373T | Yes | Required — step 1 of Optum's two-step authorization (assessment, then treatment); reviews every 4–6 months | 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 Supplemental Clinical Criteria contains no CPT codes at all; applied here as 'inferred' absent a confirmed Maryland-specific override. Optum's BH803ABA State Mandates supplement reproduces the COMAR 31.10.39.03 hour floors for fully-insured Maryland plans (25 hrs/wk ages 18mo–5, 10 hrs/wk 6–18) — a mandate floor, not a per-code cap, so it doesn't resolve this field. Verify via: Provider Express / UHC provider services.

### Contacts

- **Benefits by phone:** Yes
- **Portal:** [Provider Express](https://www.providerexpress.com)

Questions to ask on a verification call:

- Which places of service (home, office, school, telehealth) are authorized for ABA under this plan?
- Is telehealth allowed for any ABA codes, and which modifier (GT or 95) applies?
- Since UHC medical claims and Optum Behavioral Health share the same payer ID (87726), how should our clearinghouse distinguish ABA/behavioral claims from medical claims for routing?
- Is a two-hop authorization/eligibility process required between UHC and Optum Behavioral Health for ABA, or is it handled directly on one system?
- Can you confirm the current daily unit caps per code (97151–97158, 0362T, 0373T) for this specific plan, since Optum's national reimbursement policy is being used as a proxy?
- What is the direct phone number for ABA benefits and prior-authorization verification, since none is published on Provider Express?

### VOB data sources

- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.uhcprovider.com/content/dam/provider/docs/public/resources/edi/Payer-List-UHC-Affiliates-Strategic-Alliances.pdf (accessed 2026-07-23)
- https://pverify.com/payer-list/ (accessed 2026-07-23; source document older than 18 months)
- 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/autismABA/abaSCC.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/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/scc/ABA_SCC_SM.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/ope-provexpr/us/en/admin-resources/prior-auth-info.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 (Maryland) 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 Maryland?

Yes — under Optum's national two-step authorization policy for ASD, and for fully-insured Maryland plans Optum's own State Mandates document applies the COMAR 31.10.39.03 criteria, including the 25 and 10 hour/week no-denial floors. Self-funded employer plans follow the standard national policy instead.

### What does the Maryland mandate require for ABA?

For fully-insured plans: habilitative-services coverage through at least the month the enrollee turns 19, no denial of ABA solely on prescribed hours up to 25 hrs/week (ages 18 months–5) or 10 hrs/week (ages 6–18), no experimental/investigational denials, and no dollar cap — entered via a comprehensive evaluation plus a physician prescription reviewed annually. Optum reproduces these criteria in its own published document.

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

UnitedHealthcare/Optum publishes no ABA rates. You are paid up to the Fee Maximum in your Optum agreement, and each line carries a credential modifier (HM RBT, HN BCaBA, HO BCBA, HP BCBA-D) under Optum’s ABA reimbursement policy. Ask Optum network management for your rate sheet. Maryland Medicaid's published schedule (97153 $19.17–$24.41 per 15 minutes by credential tier) is the public benchmark.

### 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.

### Does UnitedHealthcare require RBT certification for ABA technicians?

For commercial plans, Optum's ABA reimbursement policy defines the technician line: the approved rendering provider for the HM modifier (less than a bachelor's degree) is "a Registered Behavior Technician (RBT)," and a BCaBA bills HN. The policy notes that state regulatory requirements "may supplement, modify or supersede" it. So plan on RBT-certified technicians for UHC commercial members.

### Who do ABA services get billed under for UnitedHealthcare in Maryland, supervising or rendering provider?

The person who delivered the service is the rendering provider, and a credential modifier identifies them. Optum’s ABA reimbursement policy: HM for an RBT, HN for a BCaBA, HO for a BCBA, HP for a BCBA-D. So a technician’s 97153 goes out with HM and the BCBA’s 97155 with HO. The rendering clinician must be in the network, either credentialed or participating under the agency’s agreement, or the claim is subject to denial.

### What is UnitedHealthcare’s timely filing limit for ABA in Maryland?

Optum’s default is 90 calendar days from the date of service “or as allowed by state or federal law.” On a fully insured Maryland plan, Insurance § 15-1005 guarantees at least 180 days, plus payment or a status notice within 30 days of receipt. Disputes take two steps, reconsideration and then appeal, with 12 months in total for both.

### Does UnitedHealthcare require taxonomy on ABA claims in Maryland?

Yes. UnitedHealthcare’s 2026 Administrative Guide: “you must submit a valid billing NPI, rendering NPI and relevant taxonomy code(s) on all claims and encounters.” The referring provider’s NPI is encouraged, not required.

### Can an out-of-state BCBA treat UnitedHealthcare members in Maryland, including by telehealth?

Maryland requires a Maryland license to practice behavior analysis (Health Occupations § 17-6A-10). Optum (UnitedHealthcare): “Providers offering telehealth visits must be licensed in the state where the member is located at the time of service.”

### Does UnitedHealthcare accept H0031 or H0032 for ABA?

Not on commercial plans. Optum’s commercial ABA reimbursement policy codes ABA on CPT 97151–97158, 0362T and 0373T and lists no H-codes; only 97151 and 97152 may be billed for assessment or reassessment.

### Does UnitedHealthcare require graphs for ABA reauthorization?

Optum’s criteria do not require graphs. They require updated progress for each target measured the same way as baseline: mastery rates, change scores, updated standardized adaptive measures and caregiver progress, plus an explanation and changed plan if progress lagged over six 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. [Optum BH803ABA — ABA State Mandates supplemental criteria (Maryland entry)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/scc/ABA_SCC_SM.pdf)
3. [Md. Insurance Article § 15-835 (Maryland General Assembly)](https://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gin&section=15-835&enactments=false)
4. [MDH HealthChoice — Behavioral Health Coverage (carve-out)](https://health.maryland.gov/mmcp/healthchoice/Pages/BehavioralHealthCoverage.aspx)
5. [MDH Board of Professional Counselors & Therapists — Behavior Analyst License](https://health.maryland.gov/bopc/pages/analysts.aspx)
6. [Optum ABA FAQ (Provider Express)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/abaFAQ.pdf)
7. [MDH HealthChoice MCO Comparison Chart (UHC Community Plan roster entry)](https://health.maryland.gov/mmcp/healthchoice/Documents/hc-mco-comparison-chart.pdf)
8. [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)
9. [Optum — ABA Reimbursement Policy, Commercial (2022RP501A, updated 06/2026)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/reimbPolicies/abaReimburs2020s.pdf)
10. [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)
11. [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)
12. [Md. Code, Insurance § 15-139 — coverage for telehealth](https://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gin&section=15-139&enactments=false)
13. [Optum National Network Manual (BH02330, effective Sept. 1, 2026)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/adminResourcesMain/netwmanual/NNManual.pdf)
14. [MDH ABA Provider Manual — fee schedule pp. 15–16 (eff. Feb 1, 2026)](https://health.maryland.gov/mmcp/epsdt/ABA/Documents/ABA%20Provider%20Manual%202_1_26%20(2).pdf)
15. [Md. Code, Health Occupations § 17-6A-10 — license required to practice behavior analysis](https://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gho&section=17-6A-10&enactments=false)
16. [UnitedHealthcare 2026 Administrative Guide — Chapter 10, NPI](https://www.uhcprovider.com/content/dam/provider/docs/public/admin-guides/2026-UHC-Administrative-Guide.pdf)
17. [Md. Insurance Article § 15-1005 — claims payment, filing and appeal minimums, interest](https://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gin&section=15-1005&enactments=false)
18. [COMAR 31.10.39.03 — Utilization Review Criteria for Treatment of Autism and Autism Spectrum Disorders](https://regs.maryland.gov/us/md/exec/comar/31.10.39.03)
19. [Md. Code, Insurance §15-10B-06 — private review agent determinations](https://mgaleg.maryland.gov/mgawebsite/Laws/StatuteText?article=gin&section=15-10B-06&enactments=false)
20. [eCFR — 29 CFR 2560.503-1(f)(2), ERISA claims procedure timeframes](https://www.ecfr.gov/current/title-29/subtitle-B/chapter-XXV/subchapter-F/part-2560/section-2560.503-1)
21. [Maryland Insurance Administration — Regulatory Activity (NAIC COB model not yet adopted)](https://insurance.maryland.gov/Pages/newscenter/RegulatoryActivity.aspx)
22. [MIA draft COMAR 31.10.53 Coordination of Benefits (posted July 2026)](https://insurance.maryland.gov/Documents/newscenter/legislativeinformation/3.10.53-Draft-712026.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.