Optum Behavioral Health Prior Authorization: 2026 Guide
How Optum Behavioral Health prior authorization works in 2026: which levels of care need review, Provider Express steps, LOCUS and ASAM, and appeals.
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Direct answer
Optum behavioral health prior authorization: what operators need to know
How Optum Behavioral Health prior authorization works in 2026: which levels of care need review, Provider Express steps, LOCUS and ASAM, and appeals. Identify the member's line of business and state first; Optum posts separate lists for commercial, Individual Exchange, Medicare Advantage, and Medicaid plans.
UnitedHealthcare's 2026 administrative guide says its specialized mental health and substance use disorder benefits are delivered by its affiliate United Behavioral Health, operating under the brand Optum. Optum's own summary of the authorization rule is short: plans it administers require authorization or notification for specialty outpatient services and most inpatient services. The work is in the details, because Optum publishes separate requirement lists by line of business and state.
This guide collects what Optum and UnitedHealthcare publish publicly about behavioral health prior authorization: which levels of care appear on the 2026 lists, how to submit, the criteria Optum names, the Gold Card exception, and how peer-to-peer and appeals work alongside federal rules. Last verified: September 2026, against Optum's Provider Express pages and UnitedHealthcare's 2026 provider documents.
Marsa Health is not affiliated with, endorsed by, or a partner of Optum or UnitedHealthcare; the names identify the payer only. Rules differ by plan, state, and line of business, so confirm every requirement on the member's plan before admission.
Key takeaways
The short version
- Identify the member's line of business and state first; Optum posts separate lists for commercial, Individual Exchange, Medicare Advantage, and Medicaid plans.
- Optum names LOCUS, CALOCUS-CASII, and ECSII for mental health by age and The ASAM Criteria, Fourth Edition for substance use, unless state, federal, or contract rules supersede them.
- On the 2026 Florida Exchange list, IOP, PHP, residential, TMS, psychological testing, and ABA all require prior authorization; emergency and urgent care do not.
- UnitedHealthcare's Gold Card replaces prior authorization with advance notification on eligible codes, and claims without that notification will not be paid.
- For Medicare Advantage and Medicaid managed care, CMS-0057-F sets 72-hour and 7-day decision clocks and requires a specific denial reason.
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A pre-submission checklist mapped to Optum's published lists and criteria. It contains no patient information; keep PHI in your EHR or the payer portal.
1. Identify which Optum rule set applies
Optum's Prior Authorization and Notification page links distinct requirement lists for Medicaid plans, UnitedHealthcare Individual and Family (Exchange) plans, commercial plans, and Medicare Advantage plans. UnitedHealthcare's commercial prior authorization list effective January 1, 2026 does not enumerate behavioral health codes; it says many benefit plans cover behavioral health only through a designated behavioral health network and tells providers to call the number on the member's ID card for specific codes.
| Member coverage | Where the requirement lives | Watch for |
|---|---|---|
| UnitedHealthcare commercial | Optum's commercial prior authorization list on Provider Express, plus the number on the member's ID card | Employer plan designs and state mandates can change what needs review |
| UnitedHealthcare Individual Exchange | State-specific Optum Exchange lists, posted by year and state | These plans may not cover out-of-area care or non-emergency out-of-network care |
| UnitedHealthcare Medicare Advantage | Optum's Medicare prior authorization list | For D-SNP members, the Medicare list confirms only the Medicare side of the benefit |
| Medicaid and D-SNP Medicaid services | Optum's Medicaid code list by state | Optum does not manage Medicaid benefits in Delaware, Georgia, Iowa, Oklahoma, or Pennsylvania; confirm with that state's managed care plan |
2. What the published 2026 lists require
Optum does not publish one national behavioral health table. The clearest public example is the Florida UnitedHealthcare Exchange list, effective January 1, 2026, issued for participating behavioral health providers. Use it to understand how Optum codes its requirements, not as the rule for another state or product.
| Service on the Florida Exchange list | Codes listed | Note |
|---|---|---|
| Inpatient mental health | Rev 114, 124, 134, 144, 154, 204 | Prior authorization is not required for emergency or urgent care |
| Hospital-based detox and SUD rehabilitation | Rev 116, 126, 136, 146, 156 and rev 118, 128, 138, 148, 158 | Listed as separate service lines |
| Mental health and SUD intensive outpatient | Rev 905 (mental health) and rev 906 (SUD) | Both require prior authorization on this list |
| Partial hospitalization and day treatment | Rev 912, 913; community behavioral health day treatment rev 907 | Mental health and SUD PHP share one line |
| Residential and supervised living | Rev 1001 psychiatric, 1002 chemical dependency, 1000, 1003; rehabilitation rev 944, 945 | Accommodations and supervised living are listed separately |
| Transcranial magnetic stimulation | 90867, 90868, 90869 | Planning, delivery, and motor-threshold redetermination each appear |
| Psychological testing | 96130, 96131; 96136 to 96139 | Administration and scoring codes need authorization only when billed with 96130 or 96131 |
| Applied behavior analysis | 97151 to 97158, 0362T, 0373T | Optum describes ABA authorization as a two-step process for most plans |
3. Submit through Provider Express or the UnitedHealthcare portal
- 01
Confirm benefits and the requirement
Check eligibility, network participation, and whether the service needs authorization or notification. For Exchange members, UnitedHealthcare also asks you to confirm grace-period status and the member's financial responsibility.
- 02
Use one of the documented online routes
The 2026 Exchange lists name two: the UnitedHealthcare Provider Portal's Prior Authorization and Notification tool, or Provider Express under Auths > Auth Request, both signed in with a One Healthcare ID. Optum calls portal submission the first step toward a timely decision; some states require specific forms if you fax or mail.
- 03
Call the ID-card number for commercial codes
UnitedHealthcare's 2026 commercial list and administrative guide both route behavioral health authorization questions to the phone number on the back of the member's ID card.
- 04
Run ABA as two steps
For most health plans, Optum starts with a comprehensive assessment that confirms the autism spectrum disorder diagnosis, then requires a prior authorization request with supporting clinical documentation before treatment begins.
- 05
Record the decision
Store the authorization or reference number, the approved level, units or days, start and end dates, and the next review date in the case, not in someone's inbox.
4. The criteria Optum says it applies
Optum says it uses clinical criteria based on sound clinical evidence and takes individual circumstances and the local delivery system into account. It also warns that other criteria may apply because of superseding federal or state requirements or specific contracts, so a state-mandated tool can replace the defaults below.
| Review type | Criteria Optum names | Detail from Optum |
|---|---|---|
| Adult mental health level of care | LOCUS | Adults 18 and older |
| Child and adolescent mental health | CALOCUS-CASII | Ages 6 to 18; replaced CASII on November 13, 2021 |
| Early childhood | ECSII | Ages 0 to 5 |
| Substance use disorder | The ASAM Criteria, Fourth Edition | Adult implementation began November 2023, commercial plans first; Medicaid timing depends on the state |
| Medicare Advantage | CMS NCDs and LCDs | Listed as Medicare-required criteria |
| ABA, testing, and other services | Behavioral Clinical Policies and Supplemental Clinical Criteria | Examples posted: ABA Clinical Criteria (April 2026), ABA State Mandates (July 2026), 2026 APA testing billing and coding guide |
5. Gold Card status and advance notification
UnitedHealthcare's annual National Gold Card Program, first run nationally in October 2024, waives prior authorization on eligible behavioral health procedure codes for qualifying groups across eligible commercial, Individual Exchange, Medicare Advantage, and Community plans. Optum handles the behavioral health waiver reviews. Groups qualify with at least 10 eligible prior authorizations a year for two consecutive years and an approval rate of 92.0% or more. For the 2026 cycle, status was available from September 1, 2026 and qualified groups became eligible October 1, 2026.
- Gold Card status replaces prior authorization with advance notification; it does not remove the need to tell UnitedHealthcare about the service
- Advance notification confirms eligibility and network status, and UnitedHealthcare says no clinical information is requested
- Claims with Gold Card-eligible codes will not be paid without the advance notification
- The approval rate is measured across all Gold Card-eligible codes, so preventable denials also put next year's status at risk
6. Peer-to-peer, appeals, and federal clocks
Optum's public pages do not state one behavioral health appeal deadline, so work from the denial letter. The medical management chapter of UnitedHealthcare's 2026 administrative guide says the member's benefit plan governs pre-service appeals, that a peer-to-peer review is highly recommended before you file one, and that the medical director will hold a peer review with the treating physician when requested. It expects the physician or a designee to have recently assessed the member and to speak to medication management, treatment goals, and measurable objectives.
Once the service has been delivered, an expedited appeal is no longer available; UnitedHealthcare directs you to submit the claim instead. Network providers can submit claim or clinical appeals online through Provider Express and download appeal documentation there.
| Coverage | Federal rule | Effect on an Optum case |
|---|---|---|
| Medicare Advantage and Medicaid managed care | CMS-0057-F, from January 1, 2026 | Decisions within 72 hours (expedited) and 7 calendar days (standard), with a specific denial reason |
| Individual plans on a Federally Facilitated Exchange | CMS-0057-F | Specific denial reason required; the 72-hour and 7-day clocks do not apply to FFE issuers |
| Employer group plans under ERISA | 29 CFR 2560.503-1 | Urgent decisions within 72 hours, pre-service within 15 days, at least 180 days to appeal |
| Group plans with MH/SUD benefits | MHPAEA, 29 CFR 2590.712(d) | Medical-necessity criteria available on request to participants and contracting providers |
7. Build the IOP or PHP request before you call
- The line of business, state, and the specific Optum list you checked, with its effective date
- Requested level, start date, schedule, and expected length of stay
- LOCUS or CALOCUS-CASII ratings for mental health, or an ASAM Fourth Edition dimensional assessment for substance use
- Dated evidence for why a lower level is not enough now, and what would support stepping down
- Medication, safety, and co-occurring medical factors that drive intensity
- Discharge criteria and the named next level of care from day one
Common questions
Answers before you build.
Does Optum require prior authorization for IOP?+
It depends on the plan. On the 2026 Florida UnitedHealthcare Exchange list, mental health IOP (rev 905) and SUD IOP (rev 906) require prior authorization. For commercial members, check Optum's commercial list or call the number on the member's ID card; do not assume an Exchange rule carries over.
What criteria does Optum use for residential and PHP reviews?+
Optum names LOCUS, CALOCUS-CASII, or ECSII by age for mental health and The ASAM Criteria, Fourth Edition for substance use disorders, unless state, federal, or contract requirements supersede them. Medicare Advantage reviews use CMS NCDs and LCDs.
Where do I submit an Optum behavioral health authorization?+
The 2026 Exchange lists name Provider Express (Auths > Auth Request) and the UnitedHealthcare Provider Portal's Prior Authorization and Notification tool. UnitedHealthcare's commercial guidance points to the phone number on the back of the member's ID card for behavioral health authorizations.
Does Gold Card status mean we never contact UnitedHealthcare?+
No. Qualifying groups submit advance notification instead of prior authorization, and UnitedHealthcare says claims with Gold Card-eligible codes will not be paid without it.
How long do I have to appeal an Optum denial?+
Use the deadline in the denial letter, because it depends on the plan. For ERISA group health plans, federal rules require at least 180 days to file an internal appeal; Medicare Advantage and Medicaid follow their own program timelines.
Practical closeout
Use this operator checklist.
- Identify the member's line of business and state first; Optum posts separate lists for commercial, Individual Exchange, Medicare Advantage, and Medicaid plans.
- Optum names LOCUS, CALOCUS-CASII, and ECSII for mental health by age and The ASAM Criteria, Fourth Edition for substance use, unless state, federal, or contract rules supersede them.
- On the 2026 Florida Exchange list, IOP, PHP, residential, TMS, psychological testing, and ABA all require prior authorization; emergency and urgent care do not.
- UnitedHealthcare's Gold Card replaces prior authorization with advance notification on eligible codes, and claims without that notification will not be paid.
- For Medicare Advantage and Medicaid managed care, CMS-0057-F sets 72-hour and 7-day decision clocks and requires a specific denial reason.
Continue through the cluster
Verified customer case studies are added only with customer permission and supporting evidence; none is implied by these operational examples.
Sources & methodology
Trace the operational claims.
Marsa Health Editorial reviewed the primary and research sources below on September 21, 2026. We translate them into workflow controls, distinguish proposals from final rules, and flag where plan, program, state, contract, or clinical requirements vary.
- 01Prior Authorization and Notification Information for Optum Behavioral Health Optum (Provider Express)Optum's hub for authorization and notification rules, with separate lists for Medicaid, Exchange, commercial, and Medicare Advantage plans, the ABA two-step process, D-SNP guidance, and Gold Card notes. Retrieved September 2026.Accessed or rechecked September 21, 2026
- 02Clinical Criteria and Guidelines Optum (Provider Express)Optum's list of adopted criteria (ASAM Criteria Fourth Edition, LOCUS, CALOCUS-CASII, ECSII), Medicare NCD/LCD use, Behavioral Clinical Policies, and 2026 supplemental ABA and testing criteria. Retrieved September 2026.Accessed or rechecked September 21, 2026
- 03Adoption of LOCUS/CASII/ECSII for Level of Care Guidance Optum (Provider Express)Explains Optum's use of LOCUS, CALOCUS-CASII, and ECSII in all states unless superseding requirements apply, including the November 13, 2021 CALOCUS-CASII transition.Accessed or rechecked September 21, 2026
- 04ASAM Clinical Criteria Information Optum (Provider Express)Optum's implementation notes for The ASAM Criteria, 4th Edition, beginning November 2023 for adults and commercial plans first.Accessed or rechecked September 21, 2026
- 05Online Appeal Status Optum (Provider Express)Describes submitting claim or clinical appeals online through Provider Express and downloading appeal documentation.Accessed or rechecked September 21, 2026
- 06Prior Authorization Code List: UnitedHealthcare Exchange Plans in Florida Optum and UnitedHealthcareBehavioral health prior authorization code list effective January 1, 2026, including IOP, PHP, residential, TMS, psychological testing, and ABA codes and the two online submission routes. Used here as a state example only.Accessed or rechecked September 21, 2026
- 07Prior Authorization Requirements for UnitedHealthcare (Commercial) UnitedHealthcareCommercial list effective January 1, 2026; its behavioral health row routes providers to the number on the member's ID card and a designated behavioral health network.Accessed or rechecked September 21, 2026
- 082026 UnitedHealthcare Care Provider Administrative Guide UnitedHealthcareCommercial, Individual Exchange, and Medicare Advantage guide covering Optum behavioral health contacts, Exchange behavioral health submission options, and pre-service appeal and peer-to-peer expectations.Accessed or rechecked September 21, 2026
Organizational author. Editorial review covers source accuracy, search intent, workflow boundaries, and human-oversight requirements. This material is educational and does not provide clinical, legal, coding, or coverage advice.
No named clinical or legal expert reviewer is attributed to this version. Marsa Health does not invent reviewer credentials.
Read our editorial methodRevision history
What changed and when
September 21, 2026
Initial publication, source review, and operational editing.