UnitedHealthcare ABA coverage in Michigan: the intake guide.

"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.^[1][5]

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.^[1]

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.^[1][5]

Supervision and family training may be delivered virtually by an approved Optum virtual-visits provider who has attested to the requirements: bill 97155 or 97156 with POS 02 (Optum’s FAQ also lists POS 10 for a member at home), and tell the ABA care advocate at authorization. Optum points to the CASP telehealth practice parameters for best practice.^[2][1]

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.^[1][5][6]

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.^[1][5]

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.^[10][11]

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).^{[12][5][13][14][15]}

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.

"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.^[1][2]

Allowed: "When supervision is provided, you may bill concurrently for both Supervisors and Behavior Technicians, billing with 97153 and 97155," the same for 97154 group services, and 97153 with 97156 "may be billed concurrently" because they are distinct services to different family members by different providers. Team meetings count only as supervision when the member, supervisor and technician are present.^[2]

Optum publishes no per-day unit ceiling; approvals are given as unit clusters that can be shifted among codes within the cluster, and clinical review addresses utilization below 80% of authorized hours over a two-week period. For fully insured Michigan plans the mandate bars visit limits but allows annual dollar maximums by age band.^[2][1][5]

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.^[2][1]

Credentialed ABA providers are BCBAs and attested licensed behavioral health clinicians; BCaBAs and technicians work under their supervision. Claims identify the rendering level by modifier: HN for a BCaBA (bachelor’s level) and HM for a behavior technician.^[1][2]

Optum’s criteria require daily progress notes with place of service, start and stop time, who rendered the service, the specific service, who attended, interventions, and the licensure or credentials of those in the session, but do not state who must sign or by when.^[1]

Ask the plan: The UnitedHealthcare / Optum provider agreement and administrative guide documentation standards.