For an intake team in Washington, a UnitedHealthcare card can mean two very different things. UnitedHealthcare Community Plan is an Apple Health managed care plan with its own Washington Medicaid criteria (see that guide). This guide covers commercial UnitedHealthcare, where Optum Behavioral Health applies its national ABA criteria, Washington’s mental health parity law applies to fully insured plans, and plan funding decides whether state law binds at all.
UnitedHealthcare administers commercial ABA through Optum Behavioral Health under the ABA Supplemental Clinical Criteria (BH803ABASCC; interim review April 2026): "Prior authorization is required for ABA (unless otherwise specified or mandated by contract or law)," with continued-service review looking hard at use below 80 percent of authorized hours over a two-week period. The criteria point to a separate ABA State Mandates document for listed states; its July 2026 edition lists Arizona, California, Connecticut, Florida, Indiana, Kansas Medicaid, Kentucky, Maryland, Massachusetts, New Jersey Medicaid, New York Medicaid, Ohio, Pennsylvania and Virginia, and Washington is not among them, so no Washington-specific criteria modify the commercial policy. (Optum’s Washington criteria apply only to UnitedHealthcare Community Plan’s Apple Health members.)[2][3][4]
Washington has no stand-alone autism insurance statute. ABA reaches state-regulated plans through the mental health parity laws instead. Until January 1, 2027, RCW 48.44.341 (health care service contractors), RCW 48.46.291 (HMOs) and RCW 48.21.241 (group disability insurers) require a plan that covers medical and surgical services to cover "mental health services," defined for plans issued or renewed on or after January 1, 2021 as "medically necessary outpatient and inpatient services provided to treat mental health and substance use disorders covered by the diagnostic categories listed in" the DSM. Autism spectrum disorder is a DSM diagnosis. Cost sharing for mental health services may be no more than for medical and surgical services, and "Treatment limitations or any other financial requirements on coverage for mental health services are only allowed if the same limitations or requirements are imposed on coverage for medical and surgical services." The statutes name no ABA-specific age, hour or dollar limit. For individual and small-group plans, the Insurance Commissioner’s essential health benefit rule (WAC 284-43-5642, effective January 19, 2026) lists "Behavioral treatment for a DSM category diagnosis" among the mental health services every plan must include, and says that when habilitative services treat a DSM diagnosis, "the mental health parity requirements apply." The law changes on January 1, 2027: Chapter 227, Laws of 2025 (E2SHB 1432) repeals those parity sections and replaces them with RCW 48.43.766, which covers DSM diagnoses plus the mental, behavioral and neurodevelopmental chapters of ICD and DC:0-5, and bars utilization review and clinical review criteria that "deviate from generally accepted standards of mental health and substance use disorder care." Regence’s own ABA policy names "Washington’s Mental Health Parity Act (RCW 48.44)" as the Washington basis for its coverage. None of this reaches self-funded employer plans, which answer to ERISA and federal parity law.[8][9][10][11][12][13][28]
Washington licenses ABA practitioners at three levels under chapter 18.380 RCW, administered by the Department of Health: licensed behavior analyst (LBA), licensed assistant behavior analyst (LABA) and certified behavior technician (CBT). The BACB’s licensure table lists Washington (2015, WA State Department of Health). "No person may engage in the practice of applied behavior analysis unless he or she holds a license or a temporary license under this chapter," and no one may practice as a technician without DOH certification (RCW 18.380.020). The exemptions in RCW 18.380.030 cover holders of another Washington credential practicing within their own scope (psychologists, for example), federal employees, school employees working only for their school, supervised students and trainees, and supervised family members; none of them exempts a BCBA licensed in another state. DOH may accept national certification in lieu of the education and exam requirements (RCW 18.380.050(3); WAC 246-805-100 accepts current certification from an approved credentialing entity). An out-of-state LBA has two quicker routes: reciprocity where the other state’s standards are "substantially equivalent" (WAC 246-805-510), and a 180-day temporary license for applicants who do not live in Washington and hold an active, unrestricted behavior analyst license elsewhere, which "will not be renewed, reissued, or extended" (WAC 246-805-520). Telehealth does not get around this. Washington’s Uniform Telehealth Act lets an out-of-state practitioner treat a patient located in Washington only with a Washington license, or for a consultation with the treating practitioner, a specialty assessment or recommendation "This does not include the provision of treatment," or follow-up for an established patient temporarily in the state (RCW 18.134.050). Supervision rules come from DOH: a CBT works "under close, ongoing supervision," with at least two face-to-face contacts a month (in person or by video) and direct supervision and observation of at least five percent of the CBT’s hours each month, including seeing the CBT with each client at least once every three months (WAC 246-805-330).[14][15][16][17]
Washington sets the claim-side floor for state-regulated plans. Prompt pay: participating-provider contracts must require the carrier to pay 95 percent of the monthly volume of clean claims within 30 days of receipt and to pay or deny 95 percent of all claims within 60 days; clean claims more than 61 days old earn interest at one percent a month (WAC 284-170-431). A denial must give "the specific reason," and a medical necessity denial must, on request, disclose how the claim failed the guidelines. Prior authorization: for health plans issued or renewed on or after January 1, 2024, a carrier must decide an electronic standard request within three calendar days (excluding holidays) and an electronic expedited request within one calendar day; non-electronic requests get five and two calendar days. A request for missing information must come within one calendar day of an electronic submission (five days for a non-electronic standard one), only a licensed physician or licensed health professional may deny on medical necessity, and since 2026 artificial intelligence "shall not be the sole means used to deny, delay, or modify health care services" (RCW 48.43.830). Members can take an adverse decision to a certified independent review organization (RCW 48.43.535). Timely filing limits and appeal windows for providers are set by each carrier’s contract; get them from your agreement.[6][1][25][18][19][21]
UnitedHealthcare’s ABA claims run through Optum Behavioral Health, whose National Network Manual (effective September 1, 2026) sets the deadlines. "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." The member may not be billed for a late claim. Payment: claims with all required information and any required authorization "will be paid within 45 calendar days after Optum receives the claim, or as required by state and federal laws," which may exclude claims needing a coordination-of-benefits determination; when Optum is secondary it pays up to the Optum contracted rate. UnitedHealthcare’s 2026 administrative guide adds that a corrected claim (frequency code 7, with the original claim number) must arrive within the same timely-filing limit as the original. No weekly payment cycle or submission cutoff is published.[6][1][25][18][19][21]
Which codes: Optum’s commercial ABA reimbursement policy (2022RP501A, updated June 2026) lists the reimbursable codes for the commercial ABA program as 97151–97158, 0362T and 0373T, each in 15-minute units with a credential modifier (HM, HN, HO or HP); no HCPCS H-code (H0031, H0032, H2014, H2019) is on that list.[6][1][25][18][19][21]
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 specific health care service provided to a member,” and says “Reimbursement to clinicians is based upon licensure rather than degree.” Optum’s commercial ABA Reimbursement Policy (2022RP501A) puts the credential level on every line: HM for an RBT, HN for a BCaBA, HO for a master’s-level BCBA, HP for a doctoral-level provider; the policy notes state requirements "may supplement, modify or supersede" it. For a public benchmark, Washington Apple Health’s fee-for-service ABA schedule (effective July 1, 2026) pays 97153 at $12.40 and 97155 at $14.09 per 15-minute unit; commercial contracts are negotiated separately.[1][6][24]
Neither UnitedHealthcare's 2026 commercial administrative guide nor Optum's commercial ABA reimbursement policy sets a referring-provider requirement for ABA claims. On plans that do require PCP referrals, the administrative guide lists "Mental health/substance use disorder services with network behavioral health clinicians" among the services members can get without one, and Optum manages the ABA benefit through its own two-step authorization.[25][6]
So box 17 is not a published condition of a UnitedHealthcare ABA claim in Washington; the authorization is. Enter a referring provider only when one exists.[25][6]
Optum's criteria publish no clock-time rule for ABA against speech, OT or PT, but they do rule out duplication. The Supplemental Clinical Criteria state that "ABA services do not duplicate the services provided to or available to the individual by other medical or behavioral services." They require coordination with "speech/occupational therapists and others," and they size intensity on "The individual's ability to participate in ABA, given participation in other therapies and engagements."[2][6]
In practice, list the child's other therapies, with their schedule, in the treatment plan, and show the ABA hours fit around them. Optum's own same-time rules cover ABA codes only: 97153 or 97154 with 97155 concurrently, but never by a single QHP.[2][6]
Optum’s ABA Supplemental Clinical Criteria (interim review April 2026) say that "With each clinical review for continued ABA treatment, the provider must submit 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." Progress "should include 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," with movement from baseline shown on validated, norm-referenced assessments and, where applicable, the caregiver’s own progress. Inadequate progress over six months calls for an analysis of the reasons and modified interventions, and the review looks at use below 80 percent of authorized hours over two weeks. The criteria do not require graphs as such.[2]
The questions that decide whether a family can start with UnitedHealthcare / Optum in Washington, 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, and use below 80 percent of authorized hours triggers review.[2]
A state-licensed physician, psychologist, or other state-licensed clinician qualified to diagnose under DSM-5-TR.[2]
At least one clinically validated tool, from a non-exhaustive list of first-level screens (M-CHAT and others), second-level screens (CARS/CARS-2 and others) and formal diagnostic tools (ADI-R, ADOS-2 and others).[2]
No separate physician referral; the SCC require prior authorization. Washington’s parity statutes add no referral requirement of their own; they allow a plan to require medical necessity and to manage mental health services only where it applies "a comparable requirement" to medical and surgical services (RCW 48.44.341(3)–(4)). Self-funded ERISA plans sit outside the statute.[2][8]
Optum’s Telehealth Billing guide (updated September 2025), 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 the list. Bill POS 02 or 10. For fully insured Washington plans, RCW 48.43.735 requires reimbursement of a covered, medically necessary service delivered by telemedicine "the same amount" as in person when it can be safely and effectively provided that way; ask Optum how it applies the three-code list to a fully insured Washington plan. Self-funded plans are outside the statute.[5][20]
The SCC carry no age criterion; the member’s benefit plan governs. For fully insured Washington plans, the parity statutes allow treatment limitations on mental health services "only if the same limitations or requirements are imposed on coverage for medical and surgical services," and they name no ABA-specific age or dollar limit. Self-funded ERISA plans are outside the statute, so plan funding type decides whether that binds.[2][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 Washington plans issued or renewed on or after January 1, 2024 fall under RCW 48.43.830: an electronic standard prior-authorization request must be decided "within three calendar days, excluding holidays," an electronic expedited request within one calendar day, a non-electronic standard request within five calendar days and a non-electronic expedited one within two. If information is missing, the carrier must ask within one calendar day of an electronic request (five days for a non-electronic standard 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," with one 15-day extension. UnitedHealthcare/Optum publishes no Washington-specific ABA turnaround.[19][23]
Ask the plan: At benefits verification ask whether the plan is fully insured in Washington or self-funded (ERISA), whether you are submitting through UnitedHealthcare/Optum’s electronic prior-authorization process, and what reauthorization lead time it expects.
For a child on two plans, Washington’s coordination-of-benefits rule is the birthday rule: unless a court decree says otherwise, "The plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (if both parents share a birthday, the plan that has covered a parent longer); a court decree assigning health coverage controls, and with no decree the custodial parent’s plan pays first (WAC 284-51-205). That binds state-regulated plans; a self-funded plan sets its own order. If the child also has Apple Health, UnitedHealthcare/Optum pays first: Apple Health requires providers to bill known third parties and does not pay when third-party benefits are available (WAC 182-501-0200; 42 CFR 433.139). TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[22][29][30][31][32]
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 Washington 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. Technicians work under a BCBA or licensed behavioral health clinician and "should be registered behavior technicians (RBT) or another appropriately certified behavior technician as allowable by state mandate" (Optum SCC). In Washington the state credential is the DOH CBT, supervised under WAC 246-805-330 (two face-to-face contacts a month; 5 percent direct supervision monthly).[2][15]
Two layers. Claim edits: Optum’s commercial ABA reimbursement policy (2022RP501A, updated June 2026), which applies to Commercial and Individual Exchange plans, 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); “MUE’s apply, per CMS guidelines,” and 97153 billed above 32 units a day may be subject to non-reimbursement or recovery. Authorization: there is no weekly hour cap; hours must be justified by documented clinical need at the least restrictive appropriate level, and use below 80 percent of authorized hours over two weeks must be explained at review.[6][2]
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 is allowed.[2]
Every line carries the rendering credential: HM (RBT), HN (BCaBA), HO (master’s-level BCBA or licensed clinician), HP (doctoral level), per Optum’s commercial ABA reimbursement policy; "Reimbursement to clinicians is based upon licensure rather than degree." In Washington the behavior analyst must hold a DOH license.[6][1][14]
Not addressed. The SCC define direct case supervision as happening during direct treatment but do not state the billing consequence.[2]
Ask the plan: Optum National Network Manual and the participating-provider agreement, or a written coding determination from Optum.
Not addressed. The SCC set what must be documented for coverage, not who signs a session note or when.[2]
Ask the plan: Optum National Network Manual (documentation standards) and the participating-provider agreement.
Optum’s criteria require updated progress data in the same measures used at baseline (mastery rates, change scores, updated standardized adaptive measures) at every continued review; they do not require graphs as such.
Optum’s commercial ABA reimbursement policy lists only CPT 97151–97158, 0362T and 0373T as reimbursable ABA codes, each with a credential modifier; no H-code (H0031, H0032, H2014, H2019) is on the list.
Optum requires everything needed to process the claim within 90 calendar days of the date of service and corrections within 90 days of first receipt; clean, authorized claims are paid within 45 calendar days or as state law requires. No weekly payment cutoff is published.
Yes, under Optum’s national ABA criteria for ASD on commercial plans. Fully insured Washington plans are also bound by the state’s mental health parity law. UnitedHealthcare Community Plan, the Apple Health plan, uses separate Washington Medicaid criteria.
No. Washington is not in Optum’s July 2026 ABA State Mandates document. Optum’s Washington criteria apply to Apple Health members of UnitedHealthcare Community Plan.
Optum’s commercial telehealth guide allows only 97155, 97156 and 97157 by telehealth, billed POS 02 or 10. Fully insured Washington plans are also subject to RCW 48.43.735, so ask Optum how it applies the list to your member’s plan.
UnitedHealthcare/Optum publishes no ABA rates: you are paid up to the Fee Maximum in your Optum agreement, with a credential modifier on each line. Apple Health’s 97153 rate ($12.40 per 15 minutes) is the public benchmark.
No published rule requires one. UnitedHealthcare exempts network mental health services from PCP referral requirements, and Optum gates ABA on prior authorization instead.
Optum publishes no clock-time rule, but its criteria say ABA must not duplicate other medical or behavioral services, and they weigh participation in other therapies when setting hours. Document the other therapies and schedule around them.
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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