---
title: "UnitedHealthcare / Optum ABA coverage in South Dakota: the intake guide."
url: "https://carelu.com/payers/unitedhealthcare-south-dakota"
markdown_url: "https://carelu.com/payers/unitedhealthcare-south-dakota.md"
state: SD (South Dakota)
payer: UnitedHealthcare / Optum in South Dakota
kind: Commercial insurance
description: "How UnitedHealthcare / Optum covers ABA for South Dakota families: Optum’s ABA criteria and prior authorization, the three-code commercial telehealth list, South Dakota’s SDCL 58-17-154 autism mandate (floors through age 18), state licensure and what intake should verify."
last_reviewed: October 2026
---

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

_Payer Guide · UnitedHealthcare · South Dakota · Last updated October 2026 · 18 primary sources_

> Optum criteria (BH803ABASCC) + South Dakota’s SDCL 58-17 mandate; no SD state supplement, no SD Medicaid plan.

For an intake team in South Dakota, a UnitedHealthcare card means three layers: Optum Behavioral Health’s national ABA criteria, South Dakota’s autism mandate, and the plan type, which decides whether the mandate applies. South Dakota Medicaid has no managed care plans, so a UHC card here is commercial (or Medicare).

## 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; the review interval is set per authorization, and use below 80% of authorized hours draws review [1]
  - Ask the plan: Optum Provider Express support: 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:** SDCL 58-17-154 to 58-17-162 (SL 2015, ch 250; plan years from 1/1/2016)
- **Mandate age:** Coverage duty names no age limit; minimum annual benefits run through age 18 only
- **Mandate caps:** Plans may cap ABA, but not below $36,000/yr through age 6, $25,000 ages 7–13, $12,500 ages 14–18
- **Exempt from mandate:** Self-funded ERISA plans; ACA individual and small-group (EHB) plans; the State of South Dakota employee plan
- **Licensure:** Yes: SDCL 36-38, behavior analysts licensed by the SD Board of Social Work Examiners
- **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 South Dakota

UnitedHealthcare administers ABA through Optum Behavioral Health under the ABA Supplemental Clinical Criteria (BH803ABASCC; interim review April 2026). Prior authorization is required, continued-service review looks hard at use below 80% of authorized hours, and direct case supervision runs 1–2 hours for every 10 hours of direct treatment, consistent with CASP standards. Optum’s ABA State Mandates supplement lists Arizona, California, Connecticut, Florida, Massachusetts, New Jersey, New York, Ohio, Pennsylvania and Virginia. South Dakota is not there, so no South Dakota-specific criteria modify the commercial policy. [1][2]

## The South Dakota mandate: what it guarantees

South Dakota’s autism mandate is SDCL 58-17-154 to 58-17-162 (SL 2015, ch 250), in force for plan years beginning on or after January 1, 2016. Every policy it reaches "shall provide coverage for applied behavior analysis for the treatment of autism spectrum disorders" (58-17-157). "Treatment" means evidence-based care "prescribed or ordered for a person diagnosed with an autism spectrum disorder by a licensed physician or psychologist" (58-17-154(4)). The carrier may use "pre-authorization, prior approval, and other care management requirements," visit limits, deductibles, copayments and coinsurance that apply to other medical services, and it may cap the benefit, but the annual maximum "may not be less than" $36,000 through age 6, $25,000 from age 7 through 13, and $12,500 from age 14 through 18 (58-17-158). The statute sets no benefit floor for anyone 19 or older. Anyone who performs or supervises ABA must be a physician or psychologist licensed in South Dakota with documented ABA training, or a licensed behavior analyst (58-17-159). The carrier may review the treatment "not more than once every three months" unless the insurer and the treating physician or psychologist agree to more frequent review, and the carrier pays for that review (58-17-160). School IEP and family-service-plan obligations are untouched (58-17-161). The reach is narrower than in most states. The mandate covers individual and group policies from health carriers and self-funded non-federal governmental plans, but it does not apply to the State of South Dakota employee plan (58-17-156), to self-funded ERISA plans, or to "nongrandfathered plans in the individual and small group markets that are required to include essential health benefits" under the ACA (58-17-155). In practice it binds fully insured large-group and grandfathered plans and local-government self-funded plans. For an ACA individual or small-group plan, check the plan’s own benefit documents. [6]

## Credentialing, licensure and rates

South Dakota licenses behavior analysts. Under SDCL 36-38 (SL 2016, ch 199) the license is issued by the Board of Social Work Examiners (36-38-1(3)), advised by a three-member Applied Behavior Analyst Advisory Committee. An applicant needs a master’s or doctoral degree and current BCBA certification (36-38-7). No one may "engage in the practice of, or attempt to practice applied behavior analysis" without the license or an exemption (36-38-6), and practicing without one is a Class 2 misdemeanor (36-38-19). BCaBAs and technicians are exempt if they work "under the extended authority and direction of a behavior analyst" and are supervised under BACB requirements, but each must pass a fingerprint background check, which the supervising analyst pays for (36-38-5(6), 36-38-25). Credentialing is on a state clock. A carrier must send an application within 10 business days of a request (58-17-151). It must flag an incomplete application within 30 days and decide a complete one within 90 days, longer only for a "special review." It must then pay clean claims for covered services delivered during the credentialing period, and its timely-filing clock starts only when you are notified that you are credentialed (58-17-150). Do not submit claims during that period (58-17-150(3)). The rule does not apply to Medicaid (58-17-152). Commercial ABA rates are negotiated and unpublished. The public benchmark is the South Dakota Medicaid ABA fee schedule (97153 $21.73 and 97155 $39.00 per 15-minute unit, effective July 1, 2026). [7][15][9][17]

## Can an out-of-state BCBA treat a UnitedHealthcare member in South Dakota?

Can a BCBA licensed in another state treat a South Dakota child? Generally not without a South Dakota license. SDCL 36-38-6 requires the state license to practice ABA here. The only exemption for out-of-state analysts is narrow: a provider "who is not a resident of this state, and who has established an office in this state," authorized in their home state, may practice for no more than an aggregate of 20 days a year, and must report to the board once past 20 consecutive days (36-38-5(2)). Telehealth does not get around this. SDCL 34-52-2 says any health care professional "treating a patient in the state through telehealth" must be "fully licensed to practice in the state" or employed by one of the listed facility types (a licensed health care facility, accredited prevention or treatment facility, community support provider, nonprofit mental health center, or licensed child welfare agency). The carriers say the same thing: Aetna tells providers to "ensure that they have the proper licensure based on state requirements," and Aetna’s ABA guide requires billing by "licensed behavior analysts (in states with behavior analyst licensure laws)." For a remote BCBA, plan on a South Dakota license before the first session. [7][8][19][20]

## What is UnitedHealthcare’s fee schedule for ABA, and what are the claim deadlines?

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 most 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) 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. It also says "There is no CPT code for reporting indirect services separately," so indirect work is bundled into the direct codes. Claims information "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." For insured South Dakota plans, the prompt-pay law requires a clean claim to be paid within 30 days electronic or 45 days paper (SDCL 58-12-20). For a public benchmark, South Dakota Medicaid pays 97153 at $21.73 per 15 minutes. [5][4][11][17]

Optum’s manual adds that "Any corrections or additions to a claim should be made within 90 days of initial claim receipt," and that complete, authorized claims "will be paid within 45 calendar days after Optum receives the claim, or as required by state and federal laws" (claims needing coordination-of-benefits decisions may take longer). It sets no separate secondary-claim deadline and publishes no check-run schedule. [5][4][11][17]

## 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 South Dakota, and what they have to bring.

- **Diagnosis recency**: No expiry on the diagnosis; it must be confirmed with severity level using validated tools. 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 Optum’s non-exhaustive list, which includes formal diagnostic tools such as ADI-R and ADOS/ADOS-2. [1]
- **Referral required?**: No separate physician referral; the SCC require prior authorization. For a plan subject to the South Dakota mandate, treatment is care "prescribed or ordered" for a child diagnosed with autism "by a licensed physician or psychologist" (SDCL 58-17-154(4)), so keep that order on file. Self-funded ERISA and ACA individual or small-group plans sit outside the statute. [1][6]
- **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." The 97151 assessment and technician 97153 are not on that list. Bill POS 02 or 10. The SCC add that telehealth options "are not intended to supplant" in-person service. For an insured South Dakota plan, SDCL 58-17-168 says no health insurer "may exclude a service for coverage solely because the service is provided through telehealth," and 58-17-169 bars discrimination between in-person and telehealth coverage for services "appropriate to be provided through telehealth" (policies issued or renewed from January 1, 2020). South Dakota’s insurance definition of telehealth is "HIPAA-compliant interactive audio-video" and excludes audio-only (58-17-167(4)). The insurer may still set criteria for a service it does not already pay others to deliver by telehealth, as long as they are not "unduly burdensome or unreasonable." Separately, the clinician must hold a South Dakota license (SDCL 34-52-2). Ask Optum how it applies the three-code list to an insured South Dakota plan. [3][1][10][8]
- **Age limit** _(plan-dependent)_: The SCC carry no age criterion; the member’s benefit plan governs. For plans subject to the South Dakota mandate, the coverage duty in SDCL 58-17-157 names no age limit, but the minimum annual benefits in 58-17-158 run only through age 18: $36,000 through age 6, $25,000 from 7 to 13, and $12,500 from 14 to 18. Self-funded ERISA plans, the State employee plan and ACA individual or small-group plans are outside the statute, so the plan type decides whether those floors apply. [1][6]
  - Ask the plan: Provider Express benefits check or the behavioral health number on the card: establish plan type first.
- **Prior-auth decision time** _(plan-dependent)_: Depends on how the plan is funded. Insured South Dakota plans fall under SDCL 58-17H. A prospective (pre-service) decision is due "within a reasonable period of time appropriate to the covered person’s medical condition, but in no event later than fifteen days after the date the health carrier receives the request," with one 15-day extension for matters beyond the carrier’s control. If the extension is for missing information, the family gets "at least forty-five days" to supply it, and the clock stops in the meantime (58-17H-28, -31). An urgent request is decided within 24 hours of receipt (58-17H-43). A request to extend an ongoing course, made at least 24 hours before it ends, is also decided within 24 hours (58-17H-46). Cutting or ending an authorized course early counts as an adverse determination, and the service continues until the internal review is decided (58-17H-29). An appeal (first-level grievance) may be filed within 180 days of the denial notice (58-17I-7) and is decided within 30 days for a pre-service request (58-17I-9). 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. UnitedHealthcare/Optum publishes no South Dakota-specific ABA turnaround. [12][13][16]
  - Ask the plan: At benefits verification ask whether the plan is insured (South Dakota-regulated) or self-funded (ERISA), and what reauthorization lead time Optum expects.
- **Other insurance (who pays first)** _(plan-dependent)_: For a child on two group plans, South Dakota uses the birthday rule. When the parents are married or living together, "the plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (SDCL 58-18A-70); a court decree controls for separated parents. That binds plans regulated by the state; a self-funded plan sets its own order. If the child also has South Dakota Medicaid, the commercial plan pays first, because Medicaid is generally the payer of last resort (42 CFR 433.139). South Dakota Medicaid also processes the claim "even if the commercial payer denies the claim (i.e., out of network)." A claim filed with the primary insurer’s EOB is timely if it reaches Medicaid within 6 months of the primary’s payment or denial. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)), and CHAMPVA is the last payer (38 CFR 17.270). [14][21][18][22][23]
  - 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.

## Delivery and billing rules

Coverage decides whether UnitedHealthcare / Optum in South 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 1–2 hours for every 10 hours of direct treatment per week." Optum does not recommend parents serving as their own child’s RBT. In South Dakota the supervising analyst must hold the state license (SDCL 36-38-6), and supervised technicians must pass a fingerprint background check (36-38-25). [1][7]
- **Daily limits / MUEs**: No numeric cap. Requested hours must be justified by documented clinical need; at continued-service review, use of authorized hours below 80% must be explained. [1]
- **Place of service**: Not covered: services that are not ABA, "such as 1:1 aid delivered simultaneously during classroom instruction," or services covered under IDEA; coordination with the school and IEP is allowed. SDCL 58-17-161 leaves IEP and IFSP obligations untouched. [1][6]
- **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. State regulatory requirements "may supplement, modify or supersede" the policy, and South Dakota requires the behavior-analyst license. [4][7]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not addressed. The SCC define direct case supervision but do not state whether 97153 and 97155 may be billed for the same time. [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 National Network Manual (documentation standards) and the participating-provider agreement.

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

- **Plan type:** Insured large-group or grandfathered (mandate applies) vs. ACA individual or small-group, self-funded ERISA or the State employee plan.
- **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.
- **Physician or psychologist order:** Under the SD mandate, treatment is care ordered by a licensed physician or psychologist.

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 South 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 South Dakota?

Yes, under Optum’s national ABA criteria for ASD, with South Dakota’s mandate layered on for the plans it reaches. Self-funded employer plans and ACA individual and small-group plans follow their own documents.

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

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

### Is UnitedHealthcare a South Dakota Medicaid plan?

No. South Dakota Medicaid has no managed care plans; DSS authorizes and pays ABA directly.

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

Optum’s commercial telehealth guide allows only 97155, 97156 and 97157 by telehealth, billed POS 02 or 10. Insured South Dakota plans are also subject to SDCL 58-17-168, which bars excluding a service solely because it is delivered by telehealth, so ask Optum how it applies the list.

### What is Optum’s timely filing limit?

90 calendar days from the date of service, unless state or federal law or the member’s plan allows longer.

## 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; South 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 (BH01511, 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)](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. [SDCL 58-17-154 to 58-17-162 — Coverage for applied behavior analysis for autism spectrum disorders (SL 2015, ch 250)](https://sdlegislature.gov/Statutes/58-17)
7. [SDCL 36-38 — Behavior Analysts (licensure by the Board of Social Work Examiners, SL 2016, ch 199)](https://sdlegislature.gov/Statutes/36-38)
8. [SDCL 34-52 — Telehealth utilization by health care professionals (34-52-2 licensure)](https://sdlegislature.gov/Statutes/34-52)
9. [SDCL 58-17-149 to 58-17-152 — Credentialing timelines and retrospective payment of clean claims (SL 2014, ch 236)](https://sdlegislature.gov/Statutes/58-17-150)
10. [SDCL 58-17-167 to 58-17-170 — Coverage for health care services provided through telehealth (SL 2019, ch 211)](https://sdlegislature.gov/Statutes/58-17-168)
11. [SDCL 58-12-19 to 58-12-21 — Clean claims: 30 days electronic, 45 days paper](https://sdlegislature.gov/Statutes/58-12-20)
12. [SDCL 58-17H — Utilization Review and Benefit Determinations (58-17H-28, -29, -30.1, -43, -46)](https://sdlegislature.gov/Statutes/58-17H)
13. [SDCL 58-17I — Health carrier grievance procedures (58-17I-7, -9)](https://sdlegislature.gov/Statutes/58-17I)
14. [SDCL 58-18A-70 — Coordination of benefits: plan covering a dependent child (birthday rule)](https://sdlegislature.gov/Statutes/58-18A-70)
15. [BACB — U.S. Licensure of Behavior Analysts (South Dakota, 2016)](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. [South Dakota Medicaid — Applied Behavior Analysis Fee Schedule, Current SFY (Power BI report; rates updated 7/1/2026)](https://app.powerbigov.us/view?r=eyJrIjoiZTAyMjdhZWItZmQzMi00Nzk3LTk0MTktMGFhMmVkYWU1YWM4IiwidCI6IjcwYWY1NDdjLTY5YWItNDE2ZC1iNGE2LTU0M2I1Y2U1MmI5OSJ9)
18. [South Dakota Medicaid Billing and Policy Manual — General Claim Guidance (updated July 2026)](https://dss.sd.gov/docs/medicaid/providers/billingmanuals/General/General_Claim_Guidance.pdf)
19. [Aetna Health Care Professional Toolkit / provider manual (8102800-01-01, 6/26)](https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/health-care-professionals/office_manual_hcp.pdf)
20. [Aetna — Applied behavior analysis medical necessity guide (©2026; state exhibit: Maryland only)](https://www.aetna.com/content/dam/aetna/pdfs/health-care-professionals/applied-behavioral-analysis-necessity-guide.pdf)
21. [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)
22. [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)
23. [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 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.