For an intake team in Montana, a UnitedHealthcare card means three layers: Optum Behavioral Health’s national ABA criteria, Montana’s autism mandate in MCA 33-22-515, and the plan’s funding type. Montana Medicaid has no managed care plans, so a UHC card here is commercial (or Medicare).
UnitedHealthcare administers ABA through Optum Behavioral Health under the ABA Supplemental Clinical Criteria (BH803ABASCC; interim review April 2026), which require prior authorization for ABA and look hard at use below 80% of authorized hours. Optum’s ABA State Mandates supplement (effective July 2026) covers Arizona, California, Connecticut, Florida, Indiana, Kansas Medicaid, Kentucky, Massachusetts Medicaid, New Jersey, New York Medicaid, Ohio and Pennsylvania; Montana is not on it, so no Montana-specific criteria modify the commercial policy. Optum’s National Network Manual (effective Sept. 1, 2026) does list Montana regulatory requirements for provider agreements.[1][2][5]
Montana’s autism mandate is MCA 33-22-515, enacted in 2009. It reaches "each group disability policy, certificate of insurance, or membership contract" delivered, issued, renewed, extended or modified in Montana, and requires "coverage for diagnosis and treatment of autism spectrum disorders for a covered child 18 years of age or younger." Health service corporations (MCA 33-30-102 applies chapter 22 to them) and HMOs (MCA 33-31-111 lists 33-22-515 among the provisions that bind them) are covered too. The covered diagnoses are written in older DSM terms: autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified, "as defined by the most recent edition" of the DSM. Habilitative and rehabilitative care "includes medically necessary interactive therapies derived from evidence-based research, including applied behavior analysis," and it must be "prescribed, provided, or ordered by a licensed physician or licensed psychologist." ABA under the statute "must be provided by an individual who is licensed by the behavior analyst certification board or is certified by the department of public health and human services as a family support specialist with an autism endorsement." The statute lets a plan cap the benefit: coverage "may be limited to a maximum benefit of" $50,000 a year for a child 8 or younger and $20,000 a year from 9 through 18. Ordinary deductibles, coinsurance and copays may apply, but special cost sharing for autism care may not. When treatment is ongoing, the insurer "may request that the treating physician provide a treatment plan" (diagnosis, treatment by type and frequency, anticipated duration and outcomes, and why it is medically necessary) and may ask for an update "every 6 months." The section also binds the state and university employee plans, local-government employee plans and non-ERISA self-funded MEWAs. Two gaps matter at intake: the text speaks only of group coverage, and ERISA self-funded employer plans sit outside state insurance law altogether.[6][7][8]
Montana licenses behavior analysts. Since 2017 (Ch. 425, L. 2017), MCA Title 37, chapter 17, part 4 has the Board of Psychologists license behavior analysts and assistant behavior analysts; the BACB’s licensure table lists Montana (2017, MT Board of Psychologists). "An individual may not represent to the public that the individual is an assistant behavior analyst or a behavior analyst without a license," and a license requires current BACB certification at the matching level (BCBA or BCaBA), a fingerprint background check and the Board’s coursework rules (MCA 37-17-403). A behavior technician supervised by a licensed behavior analyst does not need a license, and neither do school district staff, licensed psychologists and those acting under their authority, licensed clinical professional counselors, licensed social workers and family support specialists with an autism endorsement (MCA 37-17-404). A BCaBA or technician must be supervised by a licensed behavior analyst or by a licensed psychologist board-certified by ABPP in behavioral and cognitive psychology (MCA 37-17-405). For telehealth, MCA 37-2-305 lets "a person licensed under this title" treat by telehealth when it is appropriate and meets the standard of care; it creates no registration for providers licensed only in another state. So a BCBA licensed elsewhere should plan on a Montana license before treating a child located in Montana, including by video. Commercial ABA rates are negotiated and unpublished; the public benchmark is the Montana Medicaid ABA fee schedule (July 1, 2025: 97153 $11.36 and 97155 $20.46 per 15-minute unit).[23][14][15][16][17][18][24][22]
Montana’s prompt-pay statute, MCA 33-18-232, says an insurer "shall pay or deny a claim within 30 days after receipt of a proof of loss" unless it makes a reasonable request for more information, and then within 60 days. A late insurer owes the claim "plus 10% annual interest" from the date it was due (interest under $5 is not payable). The statute governs insurers; a self-funded ERISA plan follows its own plan document and federal claims rules. Timely filing limits are set by each carrier’s contract, not by Montana statute.[10][5][4][22][3][1]
Optum’s National Network Manual 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 a provider may not bill the member for a late claim. Payment is capped at the "Fee Maximum," and "Reimbursement to clinicians is based upon licensure rather than degree." Optum’s commercial ABA reimbursement policy (2022RP501A) makes the credential part of every line: HM for an RBT, HN for a BCaBA, HO for a master’s-level BCBA or licensed clinician, HP for a doctoral-level provider; indirect work has no separate code. For a public benchmark, Montana Medicaid pays 97153 at $11.36 per 15 minutes (July 2025).[10][5][4][22][3][1]
Billing details from Optum’s own documents. Codes: the commercial ABA reimbursement policy (2022RP501A) covers ABA billed "with CPT codes 97151-97158" plus 0362T and 0373T, each line with its credential modifier; it lists no HCPCS H-code. Telehealth: claims "must include either POS 02 or POS 10" (10 when the member is at home), and "Optum will not reimburse for services billed with only telehealth modifiers"; modifiers 93, 95, FQ, GT and GQ are optional, and commercial ABA telehealth covers only 97155, 97156 and 97157. Filing: claims are due "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 "Any corrections or additions to a claim should be made within 90 days of initial claim receipt." Payment: clean claims with any required authorization are generally paid within 45 calendar days of receipt or as state and federal law requires, which may exclude claims needing a coordination-of-benefits determination. Reauthorization (Supplemental Clinical Criteria): each continued-service review needs progress for every target "including the same modes of measurement that were utilized for baseline," with "rate and percentage of mastered programs, rates of mastered targets, change scores for any outcome measures, updated standardized adaptive measures"; inadequate progress over a 6-month period requires an analysis and modified interventions. Graphs are not named. Supervision: "direct case supervision is required 1–2 hours for every 10 hours of direct treatment per week," with no published cap on technicians per BCBA.[10][5][4][22][3][1]
The questions that decide whether a family can start with UnitedHealthcare / Optum in Montana, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the diagnosis; it must be confirmed with severity level using validated tools. Use below 80% of authorized hours triggers review.[1]
A state-licensed physician, psychologist, or other state-licensed clinician qualified to diagnose under DSM-5-TR.[1]
At least one validated tool from a non-exhaustive list: first-level screens (M-CHAT and others), second-level screens (CARS/CARS-2, RITA-T, STAT) and formal diagnostic tools (ADI-R, ADOS/ADOS-2, DISCO).[1]
No separate referral in Optum’s criteria; ABA needs prior authorization. For a fully insured Montana group plan, MCA 33-22-515 covers ABA "prescribed, provided, or ordered by a licensed physician or licensed psychologist," and lets the insurer ask the treating physician for a treatment plan, updated every 6 months. Self-funded ERISA plans sit outside the statute.[1][6]
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 the list. Bill POS 10 (patient at home) or 02 (elsewhere); POS 11 is not a telehealth POS. For state-regulated plans, MCA 33-22-138 requires telehealth coverage of otherwise-covered services "equivalent to the coverage for services that are provided in person," and its provider list includes Title 37, chapter 17 licensees; ask Optum how it applies the three-code list to a fully insured Montana plan. Optum’s guide makes modifiers 93, 95, FQ, GT and GQ optional; the POS is what marks the claim as telehealth, and the authorization does not need a telehealth flag in any Optum document read.[3][1][9]
Optum’s criteria carry no age criterion; the member’s benefit plan governs. For fully insured Montana group plans, MCA 33-22-515 requires coverage "for a covered child 18 years of age or younger" and lets the plan cap the autism benefit at $50,000 a year through age 8 and $20,000 a year from 9 through 18. Self-funded ERISA plans and individual policies are outside the statute’s text, so funding type and plan type decide whether that binds.[1][6]
Ask the plan: Provider Express benefits check or the behavioral health number on the card: establish fully insured group vs. self-funded first.
Depends on how the plan is funded. Fully insured Montana plans fall under MCA 33-32-211: for a prospective (prior-authorization) review the insurer must decide and notify "not later than 7 business days after the date the health insurance issuer receives the request" or after it receives all necessary information, with one extension of up to 7 business days for matters beyond its control; a request that fails the filing procedure must be flagged within 3 days. Urgent care requests are decided within 48 hours (MCA 33-32-212). A reduction or termination of an approved course of treatment before it ends is an adverse determination that must be noticed in advance, and the service continues pending the internal review. Once approved, a certification "is valid for at least 6 months," and 12 months for treatment of a chronic condition (MCA 33-32-107). 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," with one 15-day extension. Optum publishes no Montana-specific ABA turnaround or reauthorization lead time.[12][13][11][19]
Ask the plan: At benefits verification ask whether the plan is fully insured (Montana-regulated) or self-funded (ERISA), and what reauthorization lead time Optum expects.
If the child also has Montana Medicaid, the commercial plan pays first: Montana Healthcare Programs requires providers to "bill other insurance carriers before billing Montana Healthcare Programs" in most cases, and Medicaid is the payer of last resort under 42 CFR 433.139. If the other insurer has not responded in 90 days, Medicaid can be billed with proof the claim was sent. When a child is on two commercial plans, the order of benefits comes from Montana’s coordination-of-benefits rules for state-regulated plans and from the plan document for self-funded plans; we could not open the Montana rule text this run (rules.mt.gov returned a captcha), so get the order from the carrier.[20][21]
Ask the plan: Ask UnitedHealthcare/Optum at benefits verification for the member’s coordination-of-benefits order, and record every other coverage the child has.
Coverage decides whether UnitedHealthcare / Optum in Montana 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.
Optum’s criteria require direct case supervision of 1–2 hours for every 10 hours of direct treatment, consistent with practice standards; technicians work under a BCBA or licensed behavioral health clinician and "should be registered behavior technicians (RBT) or another appropriately certified behavior technician as allowable by state mandate." Optum does not recommend parents serving as their own child’s RBT. Montana law: a licensed behavior analyst or ABPP-certified behavioral psychologist supervises (MCA 37-17-405). Optum’s criteria publish no cap on the number of technicians per BCBA.[1][16]
Allowed for different people. Optum’s commercial ABA reimbursement policy: 97153 or 97154 may be reported with 97155 concurrently "as long as the criteria in the descriptors of both codes are met," but "A single QHP may not report 97153 or 97154 with 97155 concurrently." 97155 and 97156 on the same day must be at different times.[4]
Optum’s commercial maximum units per day: 97151 32; 97152 16; 97153 32; 97154 18; 97155 24; 97156, 97157, 97158 and 0362T 16; 0373T 32. Billing beyond them risks non-payment or recovery. A Montana group plan may also apply the mandate’s annual dollar caps.[4][6]
ABA is provided at the least restrictive, most clinically appropriate level. Not covered: services that are not ABA "such as 1:1 aid delivered simultaneously during classroom instruction," or services covered under IDEA; school coordination is allowed.[1]
A credentialed ABA provider is a master’s- or doctoral-level BCBA or a licensed behavioral health clinician credentialed for ABA; BCaBAs and technicians work under that provider. Each line carries the rendering credential modifier (HM RBT, HN BCaBA, HO master’s-level, HP doctoral).[1][4]
Not addressed. The criteria set what must be documented for coverage, not who signs a session note or when.[1]
Ask the plan: Optum National Network Manual documentation standards and the participating-provider agreement.
No. Optum’s commercial ABA policy uses CPT 97151–97158, 0362T and 0373T with credential modifiers.
The criteria ask for progress measured the same way as baseline, mastery rates, change scores and updated standardized adaptive measures; graphs are not named.
Optum: 90 calendar days from the date of service unless state law or the plan allows longer, with corrections within 90 days of the first claim’s receipt.
Yes, under Optum’s national ABA criteria for ASD. Fully insured Montana group plans must also meet MCA 33-22-515 for children 18 and under; self-funded plans follow their own documents.
No. Optum’s ABA State Mandates supplement (July 2026) does not list Montana.
Optum’s commercial telehealth guide allows only 97155, 97156 and 97157 by telehealth, billed POS 10 or 02. Fully insured Montana plans are also subject to MCA 33-22-138’s telehealth parity rule, so ask Optum how it applies.
Yes, if they are different people: Optum allows 97153 or 97154 with 97155 concurrently when both code descriptors are met, but one QHP cannot bill both.
Optum’s manual says 90 calendar days from the date of service unless state or federal law or the member’s plan allows longer.
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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