For an intake team in Texas, a UnitedHealthcare card means three layers at once: the carrier's national clinical policy, Texas's autism insurance mandate (Tex. Ins. Code § 1355.015), and the plan's funding type deciding which of the two actually binds. This guide stacks them in order.
UnitedHealthcare administers ABA through Optum Behavioral Health as a two-step authorization on the Provider Express portal — assessment authorized first, then treatment — under Optum's Supplemental Clinical Criteria, with continued-service reviews every 4–6 months. Notably, Optum's "ABA State Mandates" supplemental criteria document has no Texas entry — we verified the current edition's state list (Arizona through Pennsylvania) contains no Texas overlay — so Texas commercial ABA runs on Optum's standard criteria plus the state mandate below for state-regulated group plans. Plan funding type is therefore the first fact to establish on every benefits check. The full national policy breakdown lives in our UnitedHealthcare / Optum guide; this page covers what changes in Texas.[1][2]
Texas's mandate — Tex. Ins. Code § 1355.015, enacted by HB 1919 in 2007 and expanded several times since — applies to group health benefit plans (group policies, HMOs, group hospital service contracts, and TRS school-employee plans), and it has a structure intake teams must internalize: coverage runs from the date of diagnosis, but only if the ASD diagnosis was in place before the child's 10th birthday. Once eligible, coverage continues — the statute sets no upper age cutoff on continuing benefits. Covered services are broad ("all generally recognized services": evaluation, ABA, behavior training, speech/OT/PT, medications). The statute also requires autism screening at 18 and 24 months.[3][4][5]
The dollar terms split at the same birthday: under age 10 there is no dollar cap, and at age 10 and older the plan isn't required to cover ABA beyond $36,000 per year (§ 1355.015(c-1)). That cap should be framed carefully: ASD is generally treated as a mental health condition, and an annual dollar limit on MH benefits sits in tension with federal parity law for parity-covered large-group plans — the standard industry reading is that many fully-insured large-group plans don't enforce it, though we found no TDI or federal guidance document confirming that, so treat the parity argument as analysis, not settled rule. Exemptions: the state-employee (ERS) and UT/A&M system plans are carved out, self-funded ERISA plans are exempt by federal preemption, and small-group applicability has a genuine statutory ambiguity — § 1355.015 has no small-employer subsection, so confirm small-group cases with TDI rather than assuming either way.[3][4][5]
A family saying "we have UnitedHealthcare" in Texas may actually be on the carrier's Medicaid plan — UnitedHealthcare Community Plan of Texas (STAR, STAR Kids, CHIP) — which follows the state TMPPM rules with ABA carved out to Optum's behavioral health network, not this commercial policy. Verify which line of business the card belongs to, and use the dedicated guide for the Medicaid plan.
Texas has required licensure to practice ABA since 2018: the Licensed Behavior Analyst (LBA) and Licensed Assistant Behavior Analyst (LaBA) credentials under the Behavior Analyst Licensing Act (Occupations Code Chapter 506), administered by the Texas Department of Licensing and Regulation (TDLR) with BACB certification as the backbone — family members implementing plans and technicians working under an LBA/LaBA's authority are statutorily exempt. On rates: UnitedHealthcare does not publish commercial ABA fee schedules for Texas (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement. The Texas Medicaid fee schedule (97153 at $14.50/unit as of 9/1/2025) is the public benchmark to negotiate against.[6]
UnitedHealthcare's commercial ABA runs through Optum Behavioral Health. Optum's ABA FAQ sets the contracting criteria. An individual behavior analyst needs active BACB certification, state licensure where the state licenses behavior analysts (Texas does), compliance with state autism mandate requirements, at least six months of supervised ABA experience or training, and $1 million per occurrence / $1 million aggregate professional liability. An ABA group adds program oversight by a behavior analyst or licensed clinician, direct supervision of behavior technicians in joint sessions, training and supervision of BCaBAs and technicians "and hold applicable state licensure or certification," and $1 million / $3 million professional liability plus general or supplemental liability. Applications go through the "Join Our Autism/ABA Network" section of Provider Express. On payment, contracted providers bill "your contracted billing codes and customary charges as outlined on your Fee Schedule after receiving appropriate authorization" and are "reimbursed based on your contracted rate." A provider that is not yet contracted should call the Behavioral Health number on the member's ID card to get approvals.[7]
For fully insured Texas plans the Insurance Code sets both clocks. A physician or provider "must submit a claim to an insurer not later than the 95th day after the date the physician or provider provides the medical care or health care services" (PPO, § 1301.102), and the HMO rule is the same 95th day (§ 843.337), and the HMO statute says a provider who misses it forfeits the right to payment. Once a preferred or participating provider files a clean claim, the plan must decide and pay within 30 days of an electronic claim or 45 days of a nonelectronic one (§§ 1301.103, 843.338). These sections govern the insurer or HMO, so confirm the member’s plan is fully insured before relying on them.[11][12][13]
UnitedHealthcare’s 2026 administrative guide says timely filing limits "vary based on state requirements and contracts" and points to the participation agreement. It requires a valid billing NPI, rendering NPI and relevant taxonomy code on all claims, and takes reconsiderations and appeals within 12 months of the original EOB or PRA unless law or the agreement says otherwise.[11][12][13]
The questions that decide whether a family can start with UnitedHealthcare / Optum in Texas, and what they have to bring. Each maps onto something intake should ask on the first call.
Optum's criteria set no age bound — the gate is a valid ASD diagnosis, and its state-mandate supplement has no Texas entry. In Texas the legal floor is the mandate: Tex. Ins. Code § 1355.015 runs coverage from the date of diagnosis provided the ASD diagnosis predates the 10th birthday, with no upper age cutoff once eligible — and self-funded ERISA, ERS and UT/A&M system plans sit outside it.[1][2][3]
Optum's criteria set no recency window on the ASD diagnosis. What is tested for currency is the treatment side: continued-service reviews run every 4 to 6 months against updated standardized, norm-referenced adaptive measures.[1]
A valid ASD diagnosis (or other applicable diagnosis required by governing law) issued by a state licensed physician, psychologist, or other state licensed clinician qualified to make that diagnosis under DSM-5-TR criteria. The DSM-5 diagnosis and severity level must be confirmed and documented by the diagnosing clinician.[1]
The diagnosis and severity level must be confirmed with at least one clinically validated tool. Optum groups them: first-level screeners (ABC, CHAT/M-CHAT, CSBS-DP-IT, ASQ, AQ, CAST), second-level screeners and diagnostic aids (CARS/CARS-2, RITA-T, STAT), and formal diagnostic tools used in a comprehensive diagnostic evaluation (ADI-R, ADOS/ADOS-2, DISCO). Treatment intensity must separately be set from at least one validated measurement tool — ATEC, VB-MAPP, ABLLS/ABLLS-R, AFLS, PEAK, SSIS, RBS-R, SRS, Vineland (VABS) or CFQL-2 — plus norm-referenced instruments comparing the individual to age-matched neurotypical peers.[1]
Optum imposes no referral or physician order. Prior authorization is the gate — a two-step process on Provider Express, assessment first and then treatment — unless otherwise specified or mandated by contract or law. Optum publishes no ABA order form or validity period. On the claim, Optum’s National Network Manual (effective Sept. 1, 2026) lists the Form 1500 fields it needs (member and subscriber, diagnosis, dates and length of session, and the clinician who actually provided the service with credentials, Tax ID and NPI) and does not ask for a referring provider in box 17.[1][14]
Three codes, after an attestation. Optum’s Telehealth Billing guide (updated September 2025) is explicit for commercial plans: “For ABA services, telehealth is only allowed for these 3 CPT codes: 97155, 97156 or 97157” — virtual supervision of technicians and family training — so technician-delivered 97153 is not payable by telehealth. The provider must first be “an approved Optum virtual visits provider who has attested” (the virtual-visits attestation on Provider Express) and must tell the ABA Care Advocate at authorization. Bill the in-person code with the member’s location as the place of service: POS 10 when the member is at home, POS 02 anywhere else (the older ABA CPT FAQ says POS 02; the 2025 guide requires one of the two on every behavioral-health telehealth claim, and POS 11 or a telehealth modifier alone is not paid). Optum’s criteria add that telehealth is “not intended to supplant in-person service.” 97151 is not on the list, so the assessment is delivered in person; remote supervision of technicians is billed as 97155 under the same attestation.[9][7][1]
Turns on funding. UnitedHealthcare's 2026 Administrative Guide says "We notify you of our coverage decision within the time required by law," and for commercial prior authorization lists "Standard requests: up to 15 calendar days" and "Expedited requests: 72 hours," asking for notification "at least 15 calendar days in advance, if possible, but … at least 5 business days before the planned service date." For a fully insured Texas HMO/PPO, Texas law is tighter: a determination "not later than the third calendar day after the date the request is received" (Tex. Ins. Code §§ 843.348, 1301.135), and the plan must accept a renewal request "at least 60 days before the date the preauthorization expires" (28 TAC § 19.1718(l)). Self-funded ERISA plans: up to 15 days pre-service (one 15-day extension), 72 hours urgent. ABA itself is authorized by Optum Behavioral Health, whose ABA FAQ says to request continued services "no more than 30 days prior to the current approvals on file expiring" — on a fully insured Texas plan the state's 60-day renewal right governs.[13][15][16][17][18][19]
Ask the plan: Benefits verification: fully insured (Texas timelines) or self-funded/ASO (ERISA timelines)? Then confirm the continued-service request window with the Optum ABA line (behavioral health number on the member card).
UnitedHealthcare states only that "COB is administered according to the member's benefit plan and in accordance with law"; Optum puts the burden on the provider — "You are responsible for determining if the member has other insurance coverage. If so, you should bill the primary insurance carrier first" — and when Optum is secondary "you will be paid up to the Optum contracted rate" with no balance billing. On a fully insured Texas plan the order is set by 28 TAC § 3.3507: for a child of married or cohabiting parents, the plan of the parent whose birthday falls earlier in the calendar year is primary; for separated parents, a court order, then custodial parent, custodial parent's spouse, noncustodial parent. A self-funded plan's own document governs. UnitedHealthcare pays ahead of Medicaid (payer of last resort — get the Medicaid PA even when it is secondary), TRICARE (secondary to other health insurance by law) and CHAMPVA (pays after other health insurance).[13][20][21][22][23][24][25]
Ask the plan: Benefits verification: ask whether the plan is fully insured or self-funded and which COB rule and secondary-payment method (standard vs maintenance of benefits) its plan document uses.
Coverage decides whether UnitedHealthcare / Optum in Texas 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 of care, direct case supervision is required at 1 to 2 hours for every 10 hours of direct treatment per week. Technicians must work under the applicable supervision of a BCBA or licensed behavioral health clinician and should be RBTs or another appropriately certified behavior technician as allowable by state mandate; a BCaBA or non-licensed individual works under the direct supervision of a BCBA or licensed behavioral health clinician who takes responsibility for the individual's care. Where an individual displays significant challenging behaviors, a higher staff-to-patient ratio and on-site direction by the supervisor may be needed. Optum states it is not appropriate for a parent to serve in the RBT role for their own child, and that a BCBA supervising such a parent would violate the ethics code.[1]
Yes, with a single-provider exclusion. Optum’s commercial ABA reimbursement policy: “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 has to be two people — a technician on 97153 and an analyst on 97155 directing them with the patient present. Optum’s ABA CPT FAQ adds that 97153 and 97156 “may be billed concurrently” as separate services to different family members by different providers. 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.” Team meetings bill only as supervision with the member, supervisor and technician present, and “CPT codes 97153 and 97155 may not be billed for technician training.” Optum’s ABA documents do not address ABA at the same time as speech, occupational or physical therapy; its ABA FAQ expects the ABA provider to know "the other therapies in which the child is involved, how often those therapies occur" and their goals, and to document that coordination.[8][7]
Optum’s commercial ABA reimbursement policy (2022RP501A, updated June 2026) sets a maximum frequency per day for every code: 97151 32 units (8 hrs), 97152 16 (4 hrs), 97153 32 (8 hrs), 97154 18 (4.5 hrs), 97155 24 (6 hrs), 97156 16 (4 hrs), 97157 16 (4 hrs), 97158 16 (4 hrs), 0362T 16 (4 hrs), 0373T 32 (8 hrs) — and “If a provider bills in excess of 32 units per day, claims may be subject to non-reimbursement or recovery.” The ABA CPT FAQ confirms “For our commercial ABA program MUE’s apply.” There is no weekly hour cap: hours are authorized on documented clinical need, approved units can be shifted among codes within a cluster, and utilization below 80% of authorized hours over a two-week period is addressed at review. The Texas mandate caps dollars rather than units: no cap under age 10, $36,000/year for ABA at 10 and over on plans the statute reaches.[8][7][1][3]
“Provider signature is required on progress notes. Parent/guardian signatures are not required on progress notes” (Optum ABA CPT FAQ). Each daily session note records place of service, start and stop time, who rendered the service, the specific service, who attended and the interventions. Optum’s ABA documentation protocol (June 1, 2026) requires the “signature of the rendering provider” and “Legible identity of the rendering provider with credentials,” and “The date of signature must reflect the date the note is finalized” — a note signed after the date of service must follow late-entry rules and show the date it was signed. Same-date services must be “separate, distinct, and clearly documented in the progress notes,” or the claim may be denied.[7][10][8]
ABA must be provided at the least restrictive, most clinically appropriate level. The school boundary is explicit: ABA is not covered for services that are not ABA therapy, such as a 1:1 aide delivered simultaneously during classroom instruction, or for services covered under IDEA — but school ABA does cover coordination of services, including teacher training, meetings with school personnel, and observations in the school setting. The treatment plan must be coordinated with the school and any applicable IFSP or IEP.[1]
Optum's criteria define who may render — a master's- or doctoral-level BCBA, a licensed behavioral health clinician attested and credentialed to provide ABA, or a BCaBA or non-licensed technician under the direct supervision of one of those — but publish no rendering-versus-supervising NPI rule.[1]
Ask the plan: Optum provider services via Provider Express and the participating-provider agreement — claim-attribution rules are contractual.
Yes — under Optum's national clinical criteria for ASD, layered on Texas's mandate (Tex. Ins. Code § 1355.015) for state-regulated group plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.
For covered group plans: treatment coverage from the date of diagnosis, provided the ASD diagnosis was made before the child's 10th birthday (coverage continues once eligible), with no dollar cap under 10 and a $36,000/year ABA cap at 10+ that federal parity arguably limits for large-group plans.
No — Optum's ABA State Mandates supplement contains no Texas entry, so its standard national criteria apply, with the Texas mandate as the legal floor for state-regulated plans.
Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against the Texas Medicaid fee schedule (97153 at $14.50 per 15-minute unit effective 9/1/2025), and treat rate-setting as part of contracting.
Optum, which manages UnitedHealthcare’s behavioral health benefits, says “At a minimum, most treatment reviews are required every 4-6 months depending on the account/state law.” Call in the continued-care request “no more than 30 days prior to the current approvals on file expiring,” with updated progress data measured the same way as baseline and updated standardized measures. There is no fixed reassessment frequency (“There is no required frequency at which an assessment must take place”) — ask for reassessment hours inside the treatment request. If more hours are needed mid-authorization, call the ABA team with a clinical rationale.
Not on commercial plans. Optum allows telehealth only for 97155, 97156 and 97157 after a virtual-visits attestation, so 97151 is delivered in person. Remote supervision bills as 97155 with POS 02 or 10.
Rates are contracted. Optum pays participating providers "based on your contracted rate" for the codes on their fee schedule; non-contracted providers call the Behavioral Health number on the member's card.
Meet Optum's criteria (BACB certification, Texas LBA license, six months of supervised ABA experience, liability coverage) and apply through the "Join Our Autism/ABA Network" section of Provider Express.
For fully insured plans, 95 days from the date of service under the Texas Insurance Code; UnitedHealthcare’s guide defers to state law and the provider agreement.
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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