UnitedHealthcare commercial plans manage ABA through Optum Behavioral Health. In Michigan that means Optum’s national ABA supplemental clinical criteria and its CPT-code FAQ, Michigan’s autism mandate for fully insured plans, and the plan’s funding type. Optum publishes no Michigan ABA program page, and its July 2026 state-mandates supplement carries no Michigan entry, so the national criteria plus the statute are the whole picture.
Optum’s ABA Supplemental Clinical Criteria (annual review August 2025, interim review April 2026) require prior authorization for ABA "unless otherwise specified or mandated by contract or law," a valid DSM-5-TR ASD diagnosis from a state-licensed physician, psychologist or other qualified clinician confirmed with at least one validated tool, a credentialed provider (BCBA or attested licensed clinician), and direct case supervision of 1–2 hours per 10 hours of treatment. Classroom 1:1 aide work and IDEA services are excluded. Optum’s FAQ allows concurrent billing of 97153 with 97155 and 97156, virtual supervision and family training for approved virtual-visit providers (POS 02), and uses HN/HM modifiers for BCaBAs and technicians.[4][5][6][7]
Optum’s state-mandates supplement (July 2026) lists special rules for other states but none for Michigan, and Optum’s Provider Express has no Michigan ABA program page; Michigan’s requirements come from the statute below.[4][5][6][7]
Michigan’s autism mandate has two parallel statutes: MCL 500.3406s for insurers (added by 2012 PA 100, amended by 2016 PA 276, applying to policies delivered, issued or renewed beginning 180 days after its April 18, 2012 enactment) and MCL 550.1416e for health care corporation group and nongroup certificates. Both require coverage "for the diagnosis of autism spectrum disorders and treatment of autism spectrum disorders," including behavioral health treatment such as applied behavior analysis, and bar the carrier from limiting the number of visits, from denying coverage because treatment "is educational or habilitative in nature," and from applying dollar limits, copays, deductibles or coinsurance that do not apply to physical illness generally.[8][9]
Unlike newer mandates, Michigan’s still carries age and dollar ceilings the carrier may choose to apply: coverage for treatment may be limited "through 18 years of age" and to a maximum annual benefit of $50,000 through age 6, $40,000 from 7 through 12, and $30,000 from 13 through 18. Treatment must be "prescribed or ordered" by a licensed physician or licensed psychologist who finds it medically necessary, behavioral health treatment must be "provided or supervised by a board certified behavior analyst or a licensed psychologist," and the diagnosis means assessments "including the autism diagnostic observation schedule, performed by a licensed physician or a licensed psychologist." While a member is in treatment the carrier may require a treatment plan and treatment review, request the ADOS results, request that the ADOS be repeated no more than once every three years, and request an annual development evaluation. Utilization review, medical-necessity review, network requirements and coordination of benefits still apply. Exempt: self-funded ERISA employer plans (outside state insurance law), exchange qualified health plans to the extent the coverage exceeds essential health benefits, and, under 500.3406s, short-term policies of six months or less.[8][9]
Michigan licenses behavior analysts through LARA’s Board of Behavior Analysts under Part 182A of the Public Health Code (Michigan’s licensure law dates from 2016). A license requires current BACB certification in good standing sent directly from the BACB, a criminal background check, human-trafficking and implicit-bias training, and renews every four years; assistant behavior analysts have their own LARA license and supervision verification. Technicians are not licensed by the state. UnitedHealthcare does not publish commercial ABA rates; they are contract terms.[10][11][12]
Michigan’s prompt-pay statute, MCL 500.2006(8), governs insured health plans (it excludes administrative-services-only arrangements): "A clean claim must be paid within 45 days after receipt of the claim by the health plan," with 12% simple annual interest after that; the plan must flag defects within 30 days, and the provider gets 45 days to fix them. A provider "must bill a health plan within 1 year after the date of service" for the claim to be a clean claim.[3][25][22]
UnitedHealthcare’s 2026 administrative guide publishes no single timely-filing number ("Timely filing limits vary based on state requirements and contracts"; check your agreement). For ABA, which Optum Behavioral Health administers, Optum’s National Network Manual (effective September 1, 2026) does give one: all claim information must be received “no more than 90 calendar days from the date of service, or as allowed by state or federal law or the member’s specific benefit plan,” corrections “within 90 days of initial claim receipt,” and claims with all required information and any required authorization are generally paid “within 45 calendar days” after Optum receives them, “or as required by state and federal laws.” Michigan’s prompt-pay statute treats a claim billed within one year of the date of service as eligible to be a clean claim, so ask Optum which limit your agreement applies. It requires "a valid billing NPI, rendering NPI and relevant taxonomy code(s) on all claims," and encourages, but does not require, the referring provider’s NPI. Most claims are adjudicated within 15 days, up to 45. Claim reconsiderations and appeals are due within 12 months of the original EOB or PRA.[3][25][22]
Single case agreements and out-of-network care. Optum’s ABA FAQ answers whether a provider can get a single case agreement while credentialing: “Not automatically. In exception cases, based on clinical need, new business implementations, or other gaps in the network, a SCA may be approved after review with the clinical team.” Once the provider is contracted, send Optum network management your member list “who will coordinate with the clinical team to update your authorizations.” UnitedHealthcare’s administrative guide gives the general gap rule: when no network provider is available, a network provider may request an exception, and “If approved, we apply the network benefits to the services done by the out-of-network care provider.” Some cards carry a W500 Emergent Wrap for “network gap exception services.”[5][22][23][3][19][24]
Out-of-network payment. Where the No Surprises Act or a state surprise-billing law does not apply, “United will look to the member’s benefit plan.” The amount may come from a percentage of CMS rates, a FAIR Health percentile, Viant, a rate “negotiate[d] with an out-of-network provider after the service was provided,” or a third-party network discount. “Which option is used depends on … the terms of the healthcare benefit plan.” No public document gives a UnitedHealthcare out-of-network ABA rate, so the plan document (SPD or certificate) is the answer.[5][22][23][3][19][24]
Reconsideration and appeal packet. Optum’s network manual runs a two-step process for commercial and Medicare Advantage plans (“This process does not apply to Medicaid plans”): reconsideration, then appeal, with “a total of 12 months for submission for both steps” unless state law or your agreement says otherwise. Include “member-specific treatment plans, clinical records, payment appendices or other items that support why you believe our decision was incorrect,” plus proof of timely filing: “confirmation we received and accepted your claim within your timely filing requirement.” Optum decides “based on the materials available at the time of the review.” Mail the reconsideration form and documents to Optum Behavioral Health Solutions, P.O. Box 30757, Salt Lake City, UT 84123, or use Provider Express > Appeals > Submit Claim Appeal, stating “the factual or legal basis for appeal.” UnitedHealthcare’s guide adds: “Please be detailed in why you feel the payment is not the adjudication outcome you expected.” At the appeal step, attach only new material: “Please do not include any materials that you sent to us as part of the reconsideration request.”[5][22][23][3][19][24]
Whose authorization is it? Optum’s manual lists ABA among non-routine outpatient services and says “Authorizations for non-routine outpatient services are specific to the requesting clinician. The clinician will receive a copy of the authorization approval.” Inside a contracted group, “Any ABA Supervisor who is credentialed under the group or facility contract can see a member, billing with the applicable CPT code(s).” Optum publishes no rule that moves an authorization to a different agency or TIN, so a new agency requests its own.[5][22][23][3][19][24]
What the request must contain. Optum publishes no mandatory assessment-report template. Its ABA Request for Services Checklist (BH00853) lists what the portal asks for: the supervisor, “Agency name and Tax ID,” service address, the diagnosing clinician and date of diagnosis, the service location (with IEP and school details for school-based hours), other services, current symptoms, “Assessments used and applicable scores (if completed i.e., Vineland, VB-MAPP, ABLLS),” the severity of deficits, the goals per domain, and “Progress made in this area including number of goals mastered.”[5][22][23][3][19][24]
Credential modifiers and who may bill each code. Optum’s commercial ABA reimbursement policy (2022RP501A) applies to network and non-network providers. HM = RBT (“less than a bachelor’s degree level”; “State regulatory requirements may supplement, modify or supersede this policy”), HN = BCaBA (bachelor’s level), HO = BCBA or licensed mental health provider (master’s level), HP = BCBA-D or licensed mental health provider (doctorate). Allowed modifiers by code: 97151 HN, HO or HP; 97152, 97153 and 97154 HN, HM, HO or HP; 97155, 97156, 97157 and 97158 HN, HO or HP. 0362T and 0373T take no modifier. Bill “only one provider-level modifier per ABA service line.”[5][22][23][3][19][24]
What changes on Jan. 1, 2027. CMS records that at its September 2025 meeting the AMA CPT Editorial Panel "deleted CPT codes 0362T" and "0373T," "revised eight existing CPT codes" (97151 through 97158) and "created six new CPT codes" for adaptive behavior services; the AMA released the CPT 2027 code set on Sept. 9, 2026, with changes in effect on January 1. The ABA Coding Coalition’s 2027 guidance gives the final numbers: 97148 and add-on +97149 (behavior identification supporting assessment of harmful behavior, delivered by two technicians, additional technicians on the add-on), 97159 and add-on +97160 (adaptive behavior treatment of harmful behavior, same two-technician structure), 97173 (adaptive behavior treatment with analysis by a physician or other QHP, face-to-face with one patient) and 97180 (non-face-to-face services personally performed by the QHP, such as data review and modifying protocols). "Protocol modification" becomes "analysis" in the descriptors, and "since there is no grace period, 0362T and 0373T are invalid for dates of service on or after January 1, 2027." No state "approves" the codes themselves: they are Category I CPT codes that HIPAA requires on electronic claims, but, as the Coalition notes, HIPAA "does not, however, govern whether a payer covers a code / service, what a payer pays for a code / service, or what a payer requires to authorize" it, so each payer has to load them, price them and say how authorizations that list 0362T or 0373T carry over.[26][27][28][19][7]
UnitedHealthcare (Optum Behavioral Health) had published no 2027 adaptive-behavior code guidance as of Nov. 1, 2026: Optum’s commercial ABA reimbursement policy (updated February 2026) still lists the current code set, including 0373T, and its ABA clinical resources page lists no 2027 code document. Ask UnitedHealthcare how it will load and price the new codes and whether authorizations that list 0362T or 0373T carry over.[26][27][28][19][7]
The questions that decide whether a family can start with UnitedHealthcare (Optum Behavioral Health) in Michigan, and what they have to bring. Each maps onto something intake should ask on the first call.
"A valid diagnosis of ASD … must be issued by a state licensed physician, psychologist, or other state licensed clinician qualified to make such diagnosis" under DSM-5-TR. For fully insured Michigan plans the mandate names a licensed physician or licensed psychologist.[4][8]
The DSM-5 diagnosis and severity level must be confirmed using at least one clinically validated tool; Optum lists screening tools (e.g., M-CHAT, CARS/CARS-2, STAT) and formal diagnostic tools (ADI-R, ADOS/ADOS-2, DISCO), and norm-referenced functional instruments (e.g., ABLLS, VB-MAPP) for treatment planning.[4]
Optum’s criteria require no physician referral; prior authorization is required for ABA "unless otherwise specified or mandated by contract or law." For a fully insured Michigan policy the mandate adds an order requirement: covered treatment is care "prescribed or ordered for an individual diagnosed with 1 of the autism spectrum disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary," and the treatment plan is developed "when the treatment of an autism spectrum disorder is first prescribed or ordered." Self-funded ERISA plans sit outside the statute.[4][8]
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.”[20][5][4]
Optum’s ABA criteria set no age cap. Michigan’s mandate lets a fully insured carrier limit autism treatment coverage to members "through 18 years of age" and cap it at $50,000 a year through age 6, $40,000 for ages 7–12 and $30,000 for ages 13–18; whether a given plan uses those limits is in its certificate. Self-funded ERISA plans set their own terms.[4][8][9]
Ask the plan: Live benefits verification (UnitedHealthcare / Optum): fully insured vs. self-funded, and whether the certificate applies the mandate’s age-18 and annual-dollar limits.
Optum’s criteria set no recency window for the diagnosis; they require it be confirmed and documented with at least one clinically validated tool. On fully insured Michigan plans the mandate lets the carrier request a repeat ADOS no more than once every three years and an annual development evaluation.[4][8]
Ask the plan: Optum Behavioral Health at the authorization request — ask whether an older diagnostic report will be accepted for this member.
Turns on how the plan is funded. Fully insured Michigan insurance and HMO plans follow MCL 500.2212e: after May 31, 2024 a non-urgent prior authorization request "is considered granted" if the insurer does not grant it, deny it, or ask for more information "within 7 calendar days after the date and time of submission," and again within 7 calendar days after additional information is submitted; a request the provider certifies as urgent is considered granted if not acted on within 72 hours. An approved authorization "is valid for not less than 60 calendar days or for a duration that is clinically appropriate, whichever is later." The statute’s "health benefit plan" covers individual and group insurance, HMO contracts, and self-funded plans of the state or local governments, not private self-funded employer plans, which follow ERISA: pre-service decisions "not later than 15 days after receipt of the claim," one 15-day extension, urgent claims within 72 hours.[13][14]
Ask the plan: At benefits verification ask whether the plan is fully insured (Michigan-regulated) or self-funded (ERISA), then confirm the UnitedHealthcare / Optum turnaround and reauthorization lead time (Optum Behavioral Health via the number on the member ID card or Provider Express).
Which plan pays first is set by Michigan’s Coordination of Benefits Act for state-regulated plans: for a dependent child whose parents are married or living together, "The plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (same birthday: the plan covering the parent longer); for divorced or separated parents a court order assigning health coverage controls, then the order in MCL 550.253. The autism mandate adds that a member with two policies covering autism gets benefits "subject to the limits of this section when coordinating benefits." If the child also has Michigan Medicaid, UnitedHealthcare pays first: Medicaid is payer of last resort and "is not liable for payment of services denied because coverage rules of the primary health insurance were not followed," so get UnitedHealthcare’s authorization even when Medicaid (the PIHP) will pay secondary. TRICARE pays after other coverage except Medicaid (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[15][8][16][17][18]
Ask the plan: Ask UnitedHealthcare at benefits verification for the member’s coordination-of-benefits order (Optum Behavioral Health via the number on the member ID card or Provider Express); self-funded plans set their own COB terms in the plan document. Record every other coverage the child has.
Coverage decides whether UnitedHealthcare (Optum Behavioral Health) in Michigan pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
"Consistent with CASP standards of care, direct case supervision is required 1–2 hours for every 10 hours of direct treatment per week." Technicians work under a BCBA or licensed behavioral health clinician and should be RBTs or otherwise appropriately certified; parents should not serve as RBTs for their own child. Optum’s ABA FAQ adds that it generally sees 2 hours per 10 hours of technician time and asks for a clinical rationale above that.[4][5]
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.”[19][5]
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. For fully insured Michigan plans the mandate bars visit limits but allows annual dollar maximums by age band.[19][5][4][8]
“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.[5][21][19]
Home (POS 12), clinic (11), community (99) and school (03) are the common places of service, with telehealth reported as POS 10 (member at home) or 02 (member elsewhere). Not covered: services that are not ABA therapy, such as a "1:1 aid delivered simultaneously during classroom instruction," or services covered under IDEA; school-related coordination (teacher training, meetings with school personnel, observations in school) is allowed.[5][4]
Only two ABA codes change. From Dec. 1, 2026, UnitedHealthcare no longer requires prior authorization for 0362T and 0373T when provided to members younger than 18 on its commercial plans (commercial code list revised Nov. 6, 2026). 97151–97158 are not on the list and still need authorization, and the Individual Exchange and Community Plan lists name no ABA code. UHC says to check plan-specific exceptions in the Prior Authorization and Advance Notification tool. 0362T and 0373T are deleted from CPT on Jan. 1, 2027, so the change covers December 2026 dates of service.
Yes, for ASD, managed by Optum Behavioral Health with prior authorization. Fully insured plans also follow Michigan’s mandate; self-funded plans are exempt.
Yes. Optum allows 97153 and 97155 (and 97154 with supervision) to be billed concurrently when supervision is provided.
Optum publishes no Michigan ABA program page and its state-mandates supplement has no Michigan entry; the national criteria and Michigan’s statute apply.
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.
Within 45 days of receipt for a clean claim on an insured plan (MCL 500.2006(8)), with 12% interest after that. Self-funded plans are not covered.
Yes. The 2026 administrative guide requires a valid billing NPI, rendering NPI and relevant taxonomy code on all claims and encounters.
Optum's ABA Supplemental Clinical Criteria require a valid DSM-5-TR ASD diagnosis from a state-licensed physician, psychologist or other qualified licensed clinician. The diagnosing clinician confirms the diagnosis and severity level "using at least one clinically validated tool," such as the ADOS-2, ADI-R or CARS-2. The ABA provider then completes its own behavioral assessment with baseline measurement on at least one validated tool (for example the VB-MAPP, ABLLS-R, AFLS or Vineland) and builds the treatment plan from it. "Prior authorization is required for ABA (unless otherwise specified or mandated by contract or law)." The criteria set no expiry on the diagnosis.
Not automatically. Optum approves an SCA only “in exception cases, based on clinical need, new business implementations, or other gaps in the network,” after clinical review. UnitedHealthcare can also apply network benefits to an out-of-network provider when no network provider is available.
Member-specific treatment plans, clinical records, payment appendices or anything else showing why the decision was wrong, plus proof the claim was filed on time. Both steps must be filed within 12 months in total. At the appeal step, send only new material.
Optum says non-routine outpatient authorizations, ABA included, are “specific to the requesting clinician,” but any ABA supervisor credentialed under the same group contract can see the member. A different agency requests its own authorization.
HM = RBT, HN = BCaBA, HO = BCBA or master’s-level licensed provider, HP = BCBA-D or doctoral-level licensed provider. 97151 and 97155–97158 cannot carry HM; 0362T and 0373T take no modifier.
Not as of Nov. 1, 2026. Optum’s commercial ABA reimbursement policy (updated February 2026) still lists the current codes, including 0373T. CPT 2027 deletes 0362T and 0373T and adds 97148/97149, 97159/97160, 97173 and 97180 from Jan. 1, 2027, so ask UnitedHealthcare how it will price them and handle existing authorizations.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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