For an intake team in New Hampshire, a UnitedHealthcare card means three layers: Optum Behavioral Health’s national ABA criteria, New Hampshire’s autism mandate in RSA 417-E, and the plan’s funding type, which decides whether the mandate applies. UnitedHealthcare is not one of New Hampshire’s three Medicaid 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): prior authorization for ABA, assessment first and treatment second on Provider Express, with continued-service review looking hard at use below 80% of authorized hours. Optum’s ABA State Mandates supplement lists Arizona, California, Connecticut, Florida, Massachusetts, New Jersey, New York, Ohio and Pennsylvania; New Hampshire is not there, so no New Hampshire-specific criteria modify the commercial policy. UnitedHealthcare does not hold a New Hampshire Medicaid contract (DHHS lists AmeriHealth Caritas, NH Healthy Families and WellSense).[4][5][6]
New Hampshire’s autism mandate sits inside its mental-illness parity statute. RSA 417-E:1 requires every insurer, nonprofit health service corporation and HMO issuing or renewing accident or health coverage in the state to cover "pervasive developmental disorder or autism" on terms "no less extensive than the coverage provided for any other type of health care for physical illness." RSA 417-E:2 then defines the treatment: "applied behavioral analysis, necessary to produce socially significant improvements in human behavior or to prevent loss of attained skill or function," plus pharmaceuticals, psychiatric, APRN, psychologist and social-work services, and speech, occupational and physical therapy. Two conditions bind ABA specifically. It "must be provided by a person professionally certified by the national Behavior Analyst Certification Board or performed under the supervision of" one. And the insurer "may require submission of a treatment plan, including the frequency and duration of treatment," signed by the primary care provider or a listed specialist (child psychiatrist, developmental-behavioral pediatrician, child neurologist, or a psychologist trained in child psychology), updated "no more frequently than on a semi-annual basis." Coverage "shall not be denied on the basis that services are habilitative in nature." The age and dollar question has changed since enactment: HB 569 as passed in 2010 let a policy "limit coverage for applied behavior analysis to $36,000 per year for children 0 to 12 years of age, and $27,000 from ages 13 to 21." That paragraph does not appear in the current RSA 417-E:2, whose source note lists amendments in 2011 and 2022, and no other age or dollar limit appears in the section. Autism Speaks’ New Hampshire summary (last updated December 2019) still describes the caps, so expect some plan documents and benefit summaries to lag. The mandate reaches fully insured plans only; self-funded employer plans answer to ERISA and federal parity.[7][8]
New Hampshire does not license behavior analysts. The BACB’s state licensure table (updated 2026) lists no New Hampshire law or board, and the practical credential is therefore BACB certification, which the mandate itself requires. That shapes credentialing in two ways. First, carriers credential BCBAs on certification rather than a state license number, even where a form asks for one (WellSense’s New Hampshire ABA form has a "BCBA license #" field). Second, the state credentialing clock in RSA 420-J:4 does help: a carrier must tell you an application is incomplete within 15 business days and must "act upon and finalize the credentialing process within 30 calendar days" of a clean and complete application for primary care physicians and mental health providers (45 days for specialists). The statute does not say which bucket a BCBA falls in, so ask. The provisional-pay rule in RSA 420-J:8-c is keyed to "a valid license from the respective state licensing board," which New Hampshire BCBAs do not hold, so do not plan on being paid before credentialing completes. On rates: commercial ABA rates are negotiated and unpublished. RSA 417-E:1, V-b requires carriers’ contracts to pay mental health and substance use treatment services, on average, at least as favorably as non-hospital primary care, measured against relative Medicare reimbursement; the statute does not say whether ABA codes are in that comparison. The public benchmark is the NH Medicaid fee-for-service schedule, which is low (97153 $17.79 and 97155 $16.43 per 15-minute unit).[11][9][7][17][20]
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, NH Medicaid’s 2026 fee-for-service schedule pays 97153 at $17.79 per 15 minutes; commercial contracts are negotiated separately.[15][16][17]
New Hampshire’s RSA 420-J:8-a makes health carriers pay clean claims for services rendered in New Hampshire "within 30 calendar days upon receipt of a clean non-electronic claim or 15 calendar days upon receipt of a clean electronic claim," with 1.5% interest per month on overdue claims. A carrier is not in violation for a claim submitted more than 90 days after the service.[18][19]
UnitedHealthcare’s 2026 administrative guide publishes no single timely-filing number ("Timely filing limits vary based on state requirements and contracts"; check your agreement). 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.[18][19]
Optum’s National Network Manual (effective September 1, 2026), which governs the behavioral health claims Optum administers for UnitedHealthcare, sets the filing clock: “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 “Any corrections or additions to a claim should be made within 90 days of initial claim receipt.” Claims with all required information and any required authorization are generally paid “within 45 calendar days after Optum receives the claim, or as required by state and federal laws.” If Optum is secondary you are paid up to the Optum contracted rate; the manual sets no separate secondary-claim deadline and does not mention electronic visit verification.[15][16][4]
Optum’s commercial ABA reimbursement policy (2022RP501A, updated June 2026) lists CPT 97151–97158, each with a credential modifier (HM for an RBT, HN for a BCaBA, HO for a BCBA or licensed clinician, HP for a BCBA-D), plus 0362T and 0373T without modifiers. It lists no HCPCS H-codes such as H0031 or H0032, and says “97151 and 97152 are the only codes eligible for reimbursement for assessment or reassessment activities.” At each continued-treatment review, Optum’s ABA criteria ask for updated documentation showing progress “for each targeted symptom and behavior, including progress toward defined goals, including the same modes of measurement that were utilized for baseline measurement.” They do not require graphs as such.[15][16][4]
UnitedHealthcare says that when the member chooses an out-of-network provider, the No Surprises Act and state surprise-billing laws generally do not apply, and “United will look to the member’s benefit plan to determine if it is covered and how it should be paid.” Reimbursement may use a percentage of CMS rates, FAIR Health, Viant, a “Negotiated Rate” agreed “after the service was provided,” or other methods, and “Which option is used depends on various factors, including but not limited to the terms of the healthcare benefit plan.” On commercial HMO plans, “If the needed health care provider is not available in-network, not available within the needed time frame or too far away, the PCP needs to request an out-of-network prior authorization”; if approved, “the member is not responsible for costs over their applicable in-network cost-sharing.” For disputes, Optum's Provider Express portal “is available to network clinicians and group practices, as well as out-of-network individual clinicians,” and Optum asks for “member-specific treatment plans, clinical records, payment appendices or other items that support why you believe our decision was incorrect.”[3][19][15]
The questions that decide whether a family can start with UnitedHealthcare / Optum in New Hampshire, 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. Progress is reassessed over 6-month periods, and use below 80% of authorized hours triggers review.[4]
A state-licensed physician, psychologist, or other state-licensed clinician qualified to diagnose under DSM-5-TR. LCSW: not named. The test turns on licensure and diagnostic scope, so an LCSW's diagnosis is accepted only if the plan agrees it is within the LCSW's licensed scope; confirm with the plan before relying on one.[4]
At least one clinically validated tool, from a non-exhaustive three-tier 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). Treatment intensity is set from a baseline measure such as VB-MAPP, ABLLS-R, Vineland or SRS.[4]
No separate physician referral; the SCC require prior authorization, run as a two-step Optum flow on Provider Express. For a fully insured New Hampshire plan, RSA 417-E:2, II lets the insurer require a treatment plan, with frequency and duration, signed by the primary care provider or a listed specialist, updated no more than every six months. Self-funded ERISA plans sit outside the statute.[4][7]
Three codes, after an attestation. Optum’s Telehealth Billing guide (updated September 2025) says for commercial plans: “For ABA services, telehealth is only allowed for these 3 CPT codes: 97155, 97156 or 97157. These are the procedure codes that identify the virtual supervision of ABA Behavior Technicians and Family Training and Guidance.” So the 97151 assessment and technician 97153 are not on Optum’s telehealth list. Bill POS 10 (home) or 02 (elsewhere). The SCC add that telehealth options “are not intended to supplant in-person service; rather, they are intended to supplement” it. For a fully insured New Hampshire plan, RSA 415-J:3 says an insurer “may not deny coverage on the sole basis that the coverage is provided through telemedicine” and must cover and reimburse it “on the same basis” as in person, with “no restriction on eligible originating or distant sites,” for “all modes of telehealth.” Its list of providers who may use all modes includes “Professionals certified by the national behavior analyst certification board or persons performing services under the supervision of” a BACB certificant “as required by RSA 417-E:2.” Self-funded employer plans are outside the state statute. Ask Optum how it applies the three-code list to a fully insured New Hampshire plan. The same guide lists telehealth modifiers 93, 95, FQ, GT and GQ as optional on commercial claims; the POS code is what is mandatory.[13][4][14]
The SCC carry no age criterion; the member’s benefit plan governs. For fully insured New Hampshire plans, the current RSA 417-E:2 carries no age or dollar limit on ABA (the 2010 caps of $36,000 a year for ages 0–12 and $27,000 for 13–21 are no longer in the text). Self-funded ERISA plans are outside the statute, so plan funding type decides whether that binds.[4][7][8]
Ask the plan: Provider Express benefits check or the behavioral health number on the card: establish fully insured vs. self-funded ERISA first.
Depends on how the plan is funded. Fully insured New Hampshire plans fall under RSA 420-J:6. For requests sent through the carrier’s electronic prior-authorization process, a non-urgent decision is due "within 7 calendar days of obtaining all information necessary to make the determination"; for paper or fax requests the limit is 14 calendar days; urgent requests are decided within 72 hours. Any request for more information must come within 7 calendar days of the request date, and information supplied in a peer-to-peer counts. A missed deadline means the request "shall be considered approved." Once approved, the carrier may not revoke or limit it "if care is provided within 60 business days" of the approval, and a peer-to-peer must be offered within 2 business days of a request. Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1 instead: pre-service decisions "not later than 15 days after receipt of the claim," one 15-day extension, urgent care within 72 hours. UnitedHealthcare/Optum publishes no New Hampshire-specific ABA turnaround or reauthorization lead time.[9][12]
Ask the plan: At benefits verification ask whether the plan is fully insured (New Hampshire-regulated) or self-funded (ERISA), whether you are submitting electronically, and what reauthorization lead time UnitedHealthcare/Optum expects.
For a child on two group plans, New Hampshire follows the birthday rule: when parents are married or living together, "the plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (Ins 1904.05(d)(2)); for separated parents a court decree controls, and otherwise the custodial parent’s plan pays first. That rule binds group plans regulated by the state; a self-funded plan sets its own order. When both plans require precertification, RSA 420-J:3-b says the member "shall obtain pre-certification from the primary plan," and the secondary plan "shall not refuse payment for such services solely on the basis that the services were not pre-certified by the secondary plan" (it can still apply its own criteria). If the child also has NH Medicaid, UnitedHealthcare/Optum pays first: Medicaid is payer of last resort (42 CFR 433.139), and NH Medicaid will not pay a balance the primary denied for "incorrect billing, non-eligible provider, or lack of medical necessity." TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[10][9][21][22][23][24]
Ask the plan: Ask UnitedHealthcare/Optum at benefits verification for the member’s coordination-of-benefits order (and whether a self-funded plan uses the birthday rule), and record every other coverage the child has.
Coverage decides whether UnitedHealthcare / Optum in New Hampshire 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, direct case supervision is required at 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 certified. Optum does not recommend parents serving as their own child’s RBT.[4]
Yes for two people, never for one. Optum’s commercial ABA reimbursement policy (2022RP501A, updated June 2026): “Can I report 97153 or 97154 with 97155 concurrently? A. Yes, as long as the criteria in the descriptors of both codes are met. A single QHP may not report 97153 or 97154 with 97155 concurrently.” So the overlap must be a technician on 97153 and an analyst on 97155 directing them with the patient present. 97155 and 97156 on the same date pay only if “separate, distinct, and clearly documented in the progress notes”; “A single provider can’t bill for both simultaneously (e.g., in the same 15-minute block).” 97155 is not payable for treatment planning while the technician works, and neither 97153 nor 97155 may be billed for technician training. Overlap with speech or OT is not addressed as a billing rule; the ABA criteria say ABA services “do not duplicate the services provided to or available to the individual by other medical or behavioral services” and ask for documented coordination with OT, speech and PT providers.[16][4]
Per-day maximums, enforced on the claim. Optum’s commercial ABA reimbursement policy (2022RP501A, updated June 2026) sets a maximum frequency per day for every code: 97151 32 units (8 hours), 97152 16 (4 hours), 97153 32 (8 hours), 97154 18 (4.5 hours), 97155 24 (6 hours), 97156 16, 97157 16, 97158 16, 0362T 16 and 0373T 32. It says “For commercial ABA program MUE’s apply, per CMS guidelines” and “If a provider bills in excess of 32 units per day, claims may be subject to non-reimbursement or recovery.” There is no weekly hour cap: requested hours must be justified by documented clinical need, and at continued-service review use below 80% of authorized hours over a two-week period must be explained with barriers and a plan.[16][4]
Optum (UnitedHealthcare's behavioral health administrator) publishes the rule. Its ABA CPT FAQ: “Provider signature is required on progress notes. Parent/guardian signatures are not required on progress notes.” Its ABA documentation protocol (BH02325, June 1, 2026) asks for daily progress notes showing the place of service, the specific service, who attended and the “signature of the rendering provider,” with “Legible identity of the rendering provider with credentials.” On amendments: “All addendums, late entries and corrections should follow CMS guidelines,” “The date of signature must reflect the date the note is finalized,” and a note signed after the date of service must meet late-entry requirements and “clearly indicate the date the note was signed.” A 97155 note names the technician present (with credentials) and records any protocol modification and the direction given to the technician. The protocol says state law, Medicaid requirements or the member's benefit plan control where they set different standards, so a self-funded plan may add its own.[25][26]
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 (teacher training, meetings, observations) is covered.[4]
A credentialed ABA provider is a master’s- or doctoral-level BCBA or a licensed behavioral health clinician credentialed for ABA; a BCaBA or non-licensed staff member works under that provider’s direct supervision, implementing the plan the provider wrote.[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.
Only under the member's out-of-network benefits, priced by a method the plan sets (a percentage of CMS rates, FAIR Health, Viant or a negotiated rate). On commercial HMO plans an out-of-network provider can be approved when no network provider is available in time or nearby; the PCP requests an out-of-network prior authorization, and the member then pays only in-network cost-sharing.
Optum, which administers UnitedHealthcare’s behavioral health claims, needs all claim information within 90 calendar days of the date of service unless state law, federal law or the benefit plan allows longer; corrections are due within 90 days of initial claim receipt.
Optum’s commercial ABA reimbursement policy lists only CPT 97151–97158 (with an HM, HN, HO or HP credential modifier), 0362T and 0373T. No H-codes are listed.
Thirty-two units (8 hours). Optum’s commercial ABA reimbursement policy caps each code per day, and units over the maximum may be denied or recovered.
Yes, under Optum’s national ABA criteria for ASD, with New Hampshire’s RSA 417-E mandate layered on for fully insured plans. Self-funded employer plans follow their own documents.
No. Optum’s ABA State Mandates supplement does not list New Hampshire, so the standard national criteria and two-step authorization apply.
No. New Hampshire’s Medicaid plans are AmeriHealth Caritas New Hampshire, NH Healthy Families and WellSense.
Optum’s commercial telehealth guide allows only 97155, 97156 and 97157 by telehealth (supervision and family training), billed POS 10 or 02. The 97151 assessment and 97153 are not on that list. Fully insured NH plans are also subject to RSA 415-J, which bars denying a covered service only because it is delivered by telemedicine, so ask Optum how it applies the list to your plan.
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. NH Medicaid’s fee-for-service rate for 97153 ($17.79 per 15 minutes) is the only public benchmark.
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.
Fifteen calendar days for a clean electronic claim and 30 for paper (RSA 420-J:8-a), on plans subject to the Managed Care Law. Claims filed more than 90 days after service lose that protection.
Yes. The 2026 administrative guide requires a valid billing NPI, rendering NPI and relevant taxonomy code on all claims and encounters.
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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