---
title: "UnitedHealthcare / Optum ABA coverage in North Dakota: the intake guide."
url: "https://carelu.com/payers/unitedhealthcare-north-dakota"
markdown_url: "https://carelu.com/payers/unitedhealthcare-north-dakota.md"
state: ND (North Dakota)
payer: UnitedHealthcare / Optum in North Dakota
kind: Commercial insurance
description: "How UnitedHealthcare / Optum covers ABA for North Dakota families: Optum’s ABA criteria and authorization, telehealth limits, credential modifiers, North Dakota’s Bulletin 2018-1 (no autism statute), behavior-analyst licensure, and what intake should verify."
last_reviewed: October 2026
---

# UnitedHealthcare / Optum ABA coverage in North Dakota: the intake guide.

_Payer Guide · UnitedHealthcare · North Dakota · Last updated October 2026 · 20 primary sources_

> Optum criteria (BH803ABASCC) and two-step authorization; no North Dakota state supplement; Bulletin 2018-1 and ND licensure layer.

For an intake team in North Dakota, a UnitedHealthcare card means three layers: Optum Behavioral Health’s national ABA criteria, North Dakota’s Bulletin 2018-1 (the state has no autism statute), and the plan’s funding type. UnitedHealthcare is not a North Dakota Medicaid plan: children’s Medicaid ABA is fee-for-service.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required: Optum’s ABA Supplemental Clinical Criteria say "Prior authorization is required for ABA" unless "otherwise specified or mandated by contract or law" [1]
- **Prior auth for treatment** _(plan-dependent)_: Required: treatment is authorized after the assessment; the review interval is set per authorization [1]
  - Ask the plan: Optum Provider Express or the behavioral health number on the card: ask what review interval will be set on this member’s ABA treatment authorization.
- **Autism diagnosis required?**: Yes: a DSM-5-TR ASD diagnosis confirmed with clinically validated tools [1]

## At a glance

- **Covers ABA?:** Yes, for ASD, per Optum’s ABA Supplemental Clinical Criteria
- **State mandate:** No autism statute; ND Insurance Department Bulletin 2018-1 (July 10, 2018), applying federal parity
- **Mandate age:** None set; the bulletin carries no age limit (its ABA paragraph refers to children)
- **Mandate caps:** None set; autism benefits may not carry limits stricter than medical/surgical benefits
- **Exempt from mandate:** Self-funded ERISA employer plans (not regulated by the Insurance Department)
- **Licensure:** Yes: licensed behavior analyst / assistant under N.D.C.C. ch. 43-64 (Board of Integrative Health Care)
- **Fee schedule:** Not public — Optum pays up to the “Fee Maximum” in your agreement, by credential level (HM/HN/HO/HP modifiers)

## The national policy, applied in North Dakota

UnitedHealthcare administers ABA through Optum Behavioral Health under the ABA Supplemental Clinical Criteria (BH803ABASCC; annual review August 2025, interim review April 2026): prior authorization for ABA, direct case supervision of "1–2 hours for every 10 hours of direct" treatment consistent with CASP standards, and continued-service review that looks at use of authorized hours below 80%. Optum’s ABA State Mandates supplement carries state-specific entries (among them Arizona, California, Connecticut, Florida, Kentucky, Maryland, New Jersey, Ohio, Pennsylvania and Virginia, some for Medicaid only); North Dakota is not among them, so no North Dakota-specific criteria modify the commercial policy. [1][2]

## The North Dakota coverage rule: Bulletin 2018-1

North Dakota has no autism insurance statute: chapter 26.1-36 of the Century Code, the accident and health insurance chapter, contains no autism or ABA section (§ 26.1-36-09.15, sometimes cited as the autism mandate, is the telehealth coverage section). The rule that binds insured plans is Insurance Department Bulletin 2018-1, issued July 10, 2018 to "all health insurance carriers choosing to cover Autism Spectrum Disorder," which says "treatments for Autism Spectrum Disorder cannot be excluded from an insurance policy." It rests on federal mental health parity: if a carrier covers autism and "seeks to place QTLs or NQTLs on autism spectrum disorder benefits or treatments, it must show that a similar limitation exists regarding substantially all benefits and treatments on the medical/surgical portion of their insurance coverage," and autism benefits "may not be subject to any separate cost-sharing requirements or treatment limitations that only apply to mental health/substance use disorder benefits." On ABA specifically: "exclusion of Applied Behavior Analysis (ABA) therapy to treat children with autism spectrum disorder on the basis that ABA therapy is experimental or investigative treatment will not be allowed by the Department." Carriers may still review medical necessity and periodically review continuing treatment, "as long as the standards for such reviews are comparable to and not more stringent than reviews conducted for substantially all medical/surgical services in the same classification." The bulletin defines treatment as care "prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician or a licensed psychologist who determines the care to be medically necessary," including behavioral health treatment. It applied to grandfathered and transitional individual, small-group and large-group policies from October 1, 2018, and to non-grandfathered policies and Department-regulated self-funded multiple employer welfare arrangements from January 1, 2019. It sets no age or dollar cap of its own. Ordinary self-funded employer plans are not regulated by the Department and answer to ERISA and federal parity instead. [7][8][9]

## Licensure, out-of-state BCBAs and rates

North Dakota licenses behavior analysts. Under N.D.C.C. 43-64-02, "Effective January 1, 2020, an individual may not practice applied behavior analysis without a current license issued by the board," the State Board of Integrative Health Care. There are two licenses: licensed behavior analyst (a master’s or doctorate from an ABAI-accredited or BACB-approved program, the BCBA examination, current BACB certification, and the North Dakota professional responsibility examination "once developed and approved by the board") and licensed assistant behavior analyst (bachelor’s, the BCaBA examination, and proof of supervision by a licensed behavior analyst). Anyone who held a license or registration from the Board of Psychologist Examiners under chapter 43-32 on December 31, 2019 was grandfathered. The board’s exemptions include behavior technicians who "deliver applied behavior analysis services under the extended authority and direction of a licensed behavior analyst or a licensed assistant behavior analyst" (titles such as "registered behavior technician"), licensed psychologists practicing within competence, and people providing ABA in a public school setting. A BCBA licensed in another state can apply for license by endorsement: the board grants it when the applicant holds "a verified current valid license in good standing to practice as a behavior analyst professional in another state," passed the BACB examination, and the other state’s requirements are "substantially similar." We read chapter 43-64, chapter 43-57 and the full rule chapter 112-05-01 and found no exemption for an out-of-state behavior analyst treating a North Dakota child, in person or by telehealth, so plan on a North Dakota license before serving North Dakota members and confirm telehealth questions with the board. On rates: commercial ABA rates are negotiated and unpublished. The public benchmark is ND Medicaid’s professional fee schedule (August 1, 2026): 97153 $10.81 and 97155 $31.76 per unit. [12][13][14][15][20]

## Claims operations in North Dakota

North Dakota’s claim-payment statute, N.D.C.C. 26.1-36-37.1, gives an insurer 15 business days after receiving a proof of loss to "pay the claim or that portion of the claim that is not contested, deny the claim, or make an initial request for additional information," and another 15 business days after receiving the information to pay or deny; a contested claim must be explained in writing. That binds insured policies, not self-funded ERISA plans. Prior authorization for insured plans runs under chapter 26.1-36.12 (seven calendar days after complete information, 72 hours if urgent, missed deadlines deemed approved; see the turnaround field below). Timely-filing limits and the rendering-versus-supervising NPI rule are set by each carrier’s contract, not by state law. [9][10][5]

Optum’s National Network Manual: claims 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," and "Any corrections or additions to a claim should be made within 90 days of initial claim receipt." Complete, authorized claims "will be paid within 45 calendar days after Optum receives the claim, or as required by state and federal laws," which may exclude claims that need coordination-of-benefits decisions; the manual sets no separate secondary-claim deadline and publishes no check-run schedule. [9][10][5]

## What is UnitedHealthcare’s fee schedule for ABA?

UnitedHealthcare publishes no ABA rate table; 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 service, adding that "Reimbursement to clinicians is based upon licensure rather than degree." Optum’s commercial ABA Reimbursement Policy (2022RP501A; history through June 2026) puts the credential level on each 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, and says "There is no CPT code for reporting indirect services separately." Ask Optum network management for your rate sheet. For a public benchmark, ND Medicaid’s August 2026 fee schedule pays 97153 at $10.81 per unit. [5][4][20]

## What a reauthorization must show

Optum’s ABA Supplemental Clinical Criteria (review 04/2026) set what each continued-service review needs: progress "assessed and documented for each targeted symptom and behavior … including the same modes of measurement that were utilized for baseline measurement"; progress that includes "rate and percentage of mastered programs, rates of mastered targets, change scores for any outcome measures, updated standardized adaptive measures, and change scores for skills-based assessments"; an assessment of the reasons and modified interventions when there is inadequate progress "within a 6-month period"; and an explanation when use of authorized hours falls below 80% over a two-week period. Treatment plans "are usually reviewed/updated twice annually." The criteria do not require graphs. [1]

## Intake gates

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

- **Diagnosis recency**: No expiry on the diagnosis; it must be confirmed with validated tools, and treatment intensity is set from a current baseline measure. [1]
- **Who may diagnose**: The diagnosis "must be issued by a state licensed physician, psychologist, or other state licensed clinician qualified to make such diagnosis" under DSM-5-TR criteria. [1]
- **Diagnostic tools required**: At least one clinically validated tool from a non-exhaustive list: second-level screens (CARS/CARS-2, RITA-T, STAT) and formal diagnostic tools (ADI-R, ADOS/ADOS-2, DISCO). [1]
- **Referral required?**: No separate physician referral in the SCC; ABA requires prior authorization through Optum. North Dakota has no autism statute requiring a referral. For insured plans, Bulletin 2018-1 defines treatment as "evidence-based care and related equipment prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician or a licensed psychologist who determines the care to be medically necessary." The bulletin sets no order form, contents or validity period, so the practical route is a written order or recommendation for ABA from the diagnosing physician or psychologist (often inside the diagnostic report), kept on file. Single-employer self-funded ERISA plans sit outside the bulletin. [1][7]
- **Telehealth**: Three codes. 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." So the 97151 assessment and technician 97153 are not on Optum’s telehealth list. Telehealth claims must use POS 02 or POS 10, reflecting where the member is. For an insured North Dakota policy, N.D.C.C. 26.1-36-09.15 requires coverage "for health services delivered by means of telehealth which is the same as the coverage for health services delivered by in-person means," lets payment be negotiated "in the same manner" as in-person rates, and does not require a provider at the originating site. Its definition of "health care provider" lists licensees under named chapters, including psychologists (43-32), but not behavior analysts (43-64), so whether a behavior analyst’s telehealth falls inside the statute is not settled by its text. Self-funded employer plans are outside the statute. [3][9]
- **Age limit** _(plan-dependent)_: The SCC carry no age criterion; the member’s benefit plan governs. North Dakota has no autism statute, and Bulletin 2018-1 sets no age or dollar limit: for insured plans it bars autism-only limits that are more restrictive than those on medical/surgical benefits, and bars excluding ABA as experimental (its ABA paragraph speaks of "children with autism spectrum disorder"). Self-funded ERISA plans are outside the bulletin, so plan funding type decides whether it binds. [1][7]
  - Ask the plan: Provider Express benefits check or the behavioral health number on the card: establish insured vs. self-funded ERISA first.
- **Prior-auth decision time** _(plan-dependent)_: Depends on how the plan is funded. Insured North Dakota plans fall under N.D.C.C. ch. 26.1-36.12: a non-urgent decision is due "within seven calendar days of obtaining all necessary information," an urgent one within 72 hours, and if the provider or family does not supply requested information within 14 calendar days of a written request the carrier "may make an adverse determination." A prior authorization is valid for at least six months (12 months for "a chronic or long-term care condition"), cannot be revoked "if care is provided within forty-five business days" of approval, and a new carrier must honor a prior plan’s authorization for the first 60 days of coverage. If the carrier misses a deadline, "any health care services subject to review automatically are deemed authorized." Requirement changes need 60 days’ written notice to contracted providers. The chapter does not reach Medicaid or the state employees’ PERS plan. 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 North Dakota-specific ABA turnaround or reauthorization lead time. [10][16]
  - Ask the plan: At benefits verification ask whether the plan is insured in North Dakota (ch. 26.1-36.12 applies) or self-funded (ERISA), and what reauthorization lead time UnitedHealthcare/Optum expects.
- **Other insurance (who pays first)** _(plan-dependent)_: For a child on two group plans, North Dakota follows the birthday rule: for parents who are married or living together, "The plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (N.D. Admin. Code 45-08-01.2); a court decree controls for separated parents, and otherwise the custodial parent’s plan pays first. That rule binds plans regulated by the state; a self-funded plan sets its own order. If the child also has ND Medicaid, UnitedHealthcare/Optum pays first: ND Medicaid is "generally the payer of last resort," pays only the member responsibility up to its allowed amount, and expects providers "to follow TPL payer policy and procedures for payment," so be in the commercial network and get its authorization. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270). [11][17][18][19]
  - 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.

## Delivery and billing rules

Coverage decides whether UnitedHealthcare / Optum in North Dakota 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. Technicians work under a BCBA or licensed behavioral health clinician; Optum does not recommend parents serving as their own child’s RBT. In North Dakota the supervisor must hold a ch. 43-64 license (or be a licensed psychologist practicing within competence). [1][13]
- **Daily limits / MUEs**: No numeric cap in the SCC. Hours must be justified by clinical need at the least restrictive appropriate level, and use of authorized hours below 80% triggers review at continued-service requests. [1]
- **Place of service**: ABA is provided at "the least restrictive and 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]
- **Bill as provider**: Each claim line carries the rendering credential: HM for an RBT, HN for a BCaBA, HO for a master’s-level BCBA or licensed clinician, HP for a doctoral-level provider; the policy notes state requirements "may supplement, modify or supersede" it. Optum reimburses "based upon licensure rather than degree," so in North Dakota the ch. 43-64 license is the credential that matters. [4][5][12]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not addressed. The SCC describe direct case supervision during direct treatment but do not state the billing consequence. [1]
  - Ask the plan: Optum 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 National Network Manual (documentation standards) and the participating-provider agreement.

## What intake should collect for UnitedHealthcare / Optum in North Dakota

- **Plan funding type:** Insured in North Dakota (Bulletin 2018-1 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 confirmed with a validated tool (ADI-R, ADOS-2 and others). Optum asks for the instrument.
- **Credential level of each clinician:** Each claim line carries HM, HN, HO or HP; technicians should be RBTs.

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

## Common questions

### Does UnitedHealthcare (Optum) require graphs for ABA continued-service reviews?

No. Optum’s criteria ask for progress on every target using the baseline measurement method, mastery rates and change scores, updated standardized adaptive measures, and an explanation of low hour use, but they do not require graphs.

### What are UnitedHealthcare (Optum)’s claim filing deadlines for North Dakota ABA claims?

90 calendar days from the date of service (or longer where state law or the plan allows), corrections within 90 days of the original claim’s receipt, and payment of complete claims within 45 days or the state’s shorter clock. No check-run schedule is published.

### Does UnitedHealthcare cover ABA therapy in North Dakota?

Yes, under Optum’s national ABA criteria for autism. For insured North Dakota plans, Bulletin 2018-1 also bars excluding ABA as experimental. Self-funded employer plans follow their own documents.

### Does Optum have North Dakota-specific ABA criteria?

No. Optum’s ABA State Mandates supplement does not list North Dakota, so the national criteria apply.

### Can ABA be delivered by telehealth with UnitedHealthcare in North Dakota?

Optum’s commercial telehealth guide allows only 97155, 97156 and 97157 by telehealth, billed POS 02 or 10. The 97151 assessment and 97153 are not on that list.

### What does UnitedHealthcare pay for ABA in North Dakota?

Optum publishes no ABA rates. You are paid up to the Fee Maximum in your agreement, and each line carries a credential modifier (HM RBT, HN BCaBA, HO BCBA, HP doctoral). ND Medicaid’s 97153 rate ($10.81 per unit) is the only public benchmark.

### Does UnitedHealthcare require RBT certification for ABA technicians?

For commercial plans, Optum’s reimbursement policy defines the HM technician line as "a Registered Behavior Technician (RBT)," and notes state requirements may supplement it. North Dakota exempts technicians from licensure only while they work under a licensed behavior analyst’s direction.

## 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; North Dakota not listed)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/scc/ABA_SCC_SM.pdf)
3. [Optum — Telehealth Billing Quick Reference Guide (updated September 2025)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/home/Telehealth_Billing_Guide_Updates.pdf)
4. [Optum — ABA Reimbursement Policy, Commercial (2022RP501A, history through June 2026)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/reimbPolicies/abaReimburs2020s.pdf)
5. [Optum National Network Manual (BH02330, effective Sept. 1, 2026)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/adminResourcesMain/netwmanual/NNManual.pdf)
6. [ND Medicaid Billing and Policy Manual — Member Eligibility (updated July 2026)](https://www.hhs.nd.gov/sites/default/files/documents/medicaid-policies/member-eligibility.pdf)
7. [ND Insurance Department Bulletin 2018-1 — Coverage of Treatments for Autism Spectrum Disorder (July 10, 2018)](https://www.insurance.nd.gov/sites/www/files/documents/Bulletins/2018/20180711%20Bulletin%202018-1.pdf)
8. [ND Insurance Department — Insurance Commissioner Issues Bulletin Supporting Treatments for Autism Spectrum Disorder (July 11, 2018)](https://www.insurance.nd.gov/news/insurance-commissioner-issues-bulletin-supporting-treatments-autism-spectrum-disorder)
9. [N.D.C.C. ch. 26.1-36 — Accident and Health Insurance (26.1-36-09.15 telehealth; 26.1-36-10 coordination of benefits; 26.1-36-37.1 claim payment time limits)](https://ndlegis.gov/cencode/t26-1c36.pdf)
10. [N.D.C.C. ch. 26.1-36.12 — Prior Authorization for Health Insurance](https://ndlegis.gov/cencode/t26-1c36-12.pdf)
11. [N.D. Admin. Code ch. 45-08-01.2 — Coordination of Benefits Regulation](https://ndlegis.gov/api/acdata/pdf/45-08-01.2.pdf)
12. [N.D.C.C. ch. 43-64 — Behavior Analysts (license required from January 1, 2020; State Board of Integrative Health Care)](https://ndlegis.gov/cencode/t43c64.pdf)
13. [N.D. Admin. Code ch. 112-05-01 — Behavior Analysts (licensure, endorsement, exemptions; effective January 1, 2021)](https://ndlegis.gov/api/acdata/pdf/112-05-01.pdf)
14. [N.D.C.C. ch. 43-57 — State Board of Integrative Health Care](https://ndlegis.gov/cencode/t43c57.pdf)
15. [BACB — U.S. Licensure of Behavior Analysts (North Dakota: 2011, ND Board of Integrative Health Care)](https://www.bacb.com/u-s-licensure-of-behavior-analysts/)
16. [29 CFR 2560.503-1 — ERISA claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
17. [ND Medicaid Billing and Policy Manual — Third Party Liability (updated January 2026)](https://www.hhs.nd.gov/sites/default/files/documents/medicaid-policies/third-party-liability-tpl.pdf)
18. [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)
19. [38 CFR 17.270 — CHAMPVA is the last payer](https://www.ecfr.gov/current/title-38/section-17.270)
20. [ND Medicaid Professional Services Fee Schedule (data updated as of August 1, 2026; Autism category lines)](https://www.hhs.nd.gov/sites/default/files/documents/rate-2026-august-professional-fee-schedule.xlsx)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.