---
title: "UnitedHealthcare / Optum ABA coverage in New Hampshire: the intake guide."
url: "https://carelu.com/payers/unitedhealthcare-new-hampshire"
markdown_url: "https://carelu.com/payers/unitedhealthcare-new-hampshire.md"
state: NH (New Hampshire)
payer: UnitedHealthcare / Optum in New Hampshire
kind: Commercial insurance
description: "How UnitedHealthcare / Optum covers ABA for New Hampshire families: Optum’s ABA criteria and two-step authorization, New Hampshire’s RSA 417-E autism mandate (no current age or dollar caps), credentialing without a state license, and what intake should verify."
last_reviewed: September 2026
---

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

_Payer Guide · UnitedHealthcare · New Hampshire · Last updated September 2026 · 9 primary sources_

> Optum criteria (BH803ABASCC) + New Hampshire’s RSA 417-E mandate; no NH state supplement, no NH Medicaid plan.

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).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required: the ABA Supplemental Clinical Criteria require prior authorization for ABA "unless otherwise specified or mandated by contract or law"; UnitedHealthcare runs it as a two-step Optum flow, assessment first [1]
- **Prior auth for treatment** _(plan-dependent)_: Required: second step (treatment authorization); the review interval is set per authorization [1]
  - Ask the plan: Optum Provider Express support at (866) 209-9320: ask what review interval will be set on this member’s ABA treatment authorization.
- **Autism diagnosis required?**: Yes: DSM-5-TR ASD confirmed by the diagnosing clinician with at least one validated tool [1]

## At a glance

- **Covers ABA?:** Yes, for ASD, per Optum’s ABA Supplemental Clinical Criteria
- **State mandate:** RSA 417-E:1, III(h) + RSA 417-E:2 (HB 569, Laws 2010 ch. 363)
- **Mandate age:** No age limit in the current statute (the 2010 law let plans cap ABA by age band, 0–12 and 13–21; that paragraph is gone)
- **Mandate caps:** None in the current text; the 2010 caps ($36,000/yr ages 0–12, $27,000/yr ages 13–21) no longer appear in RSA 417-E:2
- **Exempt from mandate:** Self-funded ERISA employer plans (outside state insurance law)
- **Licensure:** None: NH does not license behavior analysts; the mandate requires BACB certification or BACB-certificant supervision

## The national policy, applied in New Hampshire

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). [1][2][3]

## The New Hampshire mandate: what it guarantees

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. [4][5]

## Credentialing, licensure and rates

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). [8][6][4][10][11]

## Intake gates

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

- **Diagnosis recency**: 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. [1]
- **Who may diagnose**: A state-licensed physician, psychologist, or other state-licensed clinician qualified to diagnose under DSM-5-TR. [1]
- **Diagnostic tools required**: 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. [1]
- **Referral required?**: 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. [1][4]
- **Age limit** _(plan-dependent)_: 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. [1][4][5]
  - Ask the plan: Provider Express benefits check or the behavioral health number on the card: establish fully insured vs. self-funded ERISA first.
- **Prior-auth decision time** _(plan-dependent)_: 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. [6][9]
  - 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.
- **Other insurance (who pays first)** _(plan-dependent)_: 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). [7][6][12][13][14][15]
  - 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.
- **Telehealth** _(ask the plan)_: The SCC now point to CASP’s telehealth practice parameters and say telehealth options "are not intended to supplant in-person service; rather, they are intended to supplement" it. They publish no code list or POS rule. [1]
  - Ask the plan: Provider Express or the behavioral health number on the card: ask which ABA codes are payable by telehealth on this plan and with which POS code.

## Delivery and billing rules

Coverage decides whether UnitedHealthcare / Optum in New Hampshire 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**: 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. [1]
- **Daily limits / MUEs**: No numeric cap. Requested hours must be justified by documented clinical need at the least restrictive appropriate level. At continued-service review, use below 80% of authorized hours over a two-week period must be explained with barriers and a plan. [1]
- **Place of service**: 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. [1]
- **Bill as provider**: 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. [1]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not addressed. The SCC define direct case supervision as happening during direct treatment but do not state the billing consequence. [1]
  - Ask the plan: Optum Provider Express National Network Manual and the participating-provider agreement, or a written coding determination from Optum.
- **Session-note signature** _(ask the plan)_: Not addressed. The SCC set what must be documented for coverage, not who signs a session note or when. [1]
  - Ask the plan: Optum Provider Express National Network Manual (documentation standards) and the participating-provider agreement.

## What intake should collect for UnitedHealthcare / Optum in New Hampshire

- **Plan funding type:** Fully insured (RSA 417-E applies) vs. self-funded ERISA (plan document governs).
- **Member ID + card photo:** Enough to run a live benefits verification on Provider Express.
- **Diagnosis with a validated tool:** DSM-5-TR ASD and severity level, confirmed with a validated tool (ADI-R, ADOS-2 and others). Optum asks for the instrument.
- **Signed treatment plan:** RSA 417-E:2 lets the insurer require one signed by the PCP or a listed specialist.

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

## Common questions

### Does UnitedHealthcare cover ABA therapy in New Hampshire?

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.

### Does Optum have New Hampshire-specific ABA criteria?

No. Optum’s ABA State Mandates supplement does not list New Hampshire, so the standard national criteria and two-step authorization apply.

### Is UnitedHealthcare a New Hampshire Medicaid plan?

No. New Hampshire’s Medicaid plans are AmeriHealth Caritas New Hampshire, NH Healthy Families and WellSense.

## Primary sources

1. [Optum ABA Supplemental Clinical Criteria (BH803ABASCC; annual review 8/2025, interim review 4/2026)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/abaSCC.pdf)
2. [Optum — ABA State Mandates supplemental criteria (BH 803ABA)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/scc/ABA_SCC_SM.pdf)
3. [NH DHHS — Medicaid Care Management (the three Medicaid health plans)](https://www.dhhs.nh.gov/programs-services/medicaid/medicaid-care-management)
4. [RSA 417-E:1–2 — Coverage for biologically-based mental illnesses; treatment of pervasive developmental disorder or autism](https://www.gencourt.state.nh.us/rsa/html/XXXVII/417-E/417-E-mrg.htm)
5. [HB 569 (2010), Laws 2010 ch. 363 — as enacted, with the original ABA dollar caps](https://gc.nh.gov/legislation/2010/HB0569.html)
6. [RSA 420-J — Managed Care Law (420-J:3-b, 420-J:4 credentialing, 420-J:6 utilization review, 420-J:8-c)](https://www.gencourt.state.nh.us/rsa/html/XXXVII/420-J/420-J-mrg.htm)
7. [N.H. Admin. Rules Ins 1904 — Group Coordination of Benefits (Ins 1904.05 order of benefits)](https://www.gencourt.state.nh.us/rules/state_agencies/ins1900.html)
8. [BACB — U.S. Licensure of Behavior Analysts (New Hampshire not listed)](https://www.bacb.com/u-s-licensure-of-behavior-analysts/)
9. [29 CFR 2560.503-1 — ERISA claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
10. [NH MMIS — 2026 Fee Schedule, Covered Procedures Report with SA Requirements (as of 07-24-2026)](https://nhmmis.nh.gov/portals/wps/wcm/connect/4a6d9e2c-f8af-407e-86f8-6378c7e79ad8/2026+Fee+Schedule+-+Covered+Procedures+Report+with+SA+Requirements+as+of+07-24-2026.pdf?MOD=AJPERES&CVID=p.9ZszB)
11. [WellSense — Applied Behavioral Analysis Prior Authorization Form, New Hampshire (updated 11/14/2025)](https://www.wellsense.org/hubfs/Forms/Provider_Forms/Applied_Behavioral_Analysis_Prior_Authorization_Form_NH.pdf)
12. [42 CFR 433.139 — Medicaid third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
13. [NH Medicaid — Non-Primary Payer Claim Billing Requirements (updated May 23, 2023)](https://nhmmis.nh.gov/portals/wps/wcm/connect/9d07a0a4-82af-46c4-b758-d1a911bd9753/NH+Medicaid+Non-Primary+Claim+Billing+Requirements.pdf?MOD=AJPERES&CVID=oywGTyK)
14. [10 U.S.C. 1079(i)(1) — TRICARE pays after other coverage except Medicaid](https://www.govinfo.gov/content/pkg/USCODE-2023-title10/html/USCODE-2023-title10-subtitleA-partII-chap55-sec1079.htm)
15. [38 CFR 17.270 — CHAMPVA is the last payer](https://www.ecfr.gov/current/title-38/section-17.270)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 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.