Optum Behavioral Health Billing: Authorization and Claims Submission Guide
Optum behavioral health billing trips up experienced billers because the rules live in two places. Optum, operating as United Behavioral Health, administers behavioral benefits on behalf of UnitedHealthcare, while medical authorizations and claims follow UnitedHealthcare’s own process. A claim can be clinically sound and still stall because it went to the wrong payer ID, skipped an authorization, or reached Optum on day 91.
This guide covers authorization and claims submission as they stand in November 2026, including the October 2026 announcement that mental health and substance use authorization requests are moving to Provider Express. Plan type, state and contract can override any national default below, so treat each figure as a starting point and confirm it against the member’s benefits.
Confirm who pays the claim
Start with the eligibility and benefits check in Provider Express, which Optum says shows what services a member’s plan requires authorization for. Access uses a One Healthcare ID, the same login that opens the UnitedHealthcare Provider Portal.
Payer routing has exceptions. Mass General Brigham Health Plan lists payer ID 04293 for medical claims but sends behavioral health claims to Optum under 87726. NYCE PPO members, who moved to the Optum behavioral network on January 1, 2026, use payer ID 26992 through the Optum iEDI clearinghouse.
Which services need authorization
Optum’s prior authorization page says plans it administers require authorization or notification for specialty outpatient services and most inpatient services. Routine outpatient therapy is the usual exception. Optum’s New Jersey quick reference guide exempts outpatient counseling by network providers, and its 2024 Mississippi addendum says routine outpatient services need no authorization.
| Service | Typical requirement | Notes |
|---|---|---|
| Routine outpatient therapy (90791, 90834, 90837) | Usually none for network clinicians | Confirm in the benefits check |
| Intensive outpatient and partial hospitalization (H0015, S9480, H0035, S0201) | Prior authorization, or advance notification with Gold Card status | Revenue codes 0905, 0906, 0912 and 0913 also apply |
| Psychological testing (96130, 96131, 96136 to 96139, 96146) | Prior authorization, or advance notification with Gold Card status | Requested through the Provider Express secure portal |
| Transcranial magnetic stimulation (90867 to 90869) | Prior authorization | Provider Express secure portal |
| Applied behavior analysis (for example 97151, 97153) | Prior authorization with clinical documentation | Assessment first, then the request |
| Inpatient and residential | Authorization or notification | Deadlines differ by state |
Testing requests fail on details. Optum states that self-reported questionnaires and rating scale screenings do not count as psychological or neuropsychological testing, and that a diagnostic interview should come before the request. Rules also differ by plan: Optum’s Kentucky list exempts neuropsychological testing from authorization, while its 2026 Colorado exchange list ties authorization to administration and scoring codes billed with evaluation codes 96130 and 96131.
Gold Card waivers
UnitedHealthcare’s National Gold Card program, which Optum manages for behavioral health, replaces clinical review with a short advance notification on 18 codes, among them intensive outpatient, partial hospitalization and the testing codes in the table above. The program launched October 1, 2024 with 17 codes, and 96146 was added in early 2025.
Qualification happens at the tax ID level. A practice needs network participation in at least one line of business, at least 10 eligible authorization requests for Gold Card codes in each of two consecutive 12-month periods, and an approval rate of 92% or more after appeals. For waivers effective October 1, 2026, Optum reviewed April 2, 2024 through March 31, 2026, and status is reassessed every year.
Waived practices still file an advance notification before treating, and UnitedHealthcare states that claims with Gold Card codes will not be paid without one.
Where requests are submitted
On October 1, 2026, UnitedHealthcare announced that mental health and substance use authorization requests will move to Provider Express. Requests started in the Prior Authorization and Notification tool of the UnitedHealthcare Provider Portal will redirect there, and organizations should connect to Provider Express beforehand using their existing One Healthcare ID. Surest and Rocky Mountain Health Plans are excluded. Optum’s guidance also lists the phone number on the member’s ID card as an alternative to the portal.
Decision deadlines and admission notices
For Medicare Advantage, Medicaid and CHIP plans, federal timing rules now apply. Under CMS-0057-F, which took operational effect for most affected payers on January 1, 2026, expedited requests get a decision within 72 hours and standard requests within seven calendar days, with a specific reason required for every denial (CMS fact sheet, January 17, 2024). Employer-sponsored commercial plans fall outside the rule.
Admission notice windows still vary by state. Optum’s New Jersey guide asks for notification of emergent admissions within 24 hours. Its Massachusetts addendum (January 2025) allows 72 hours for emergent acute inpatient admissions and 48 hours for substance use residential rehabilitation, which needs no authorization for the first 14 days.
Optum behavioral health billing channels and payer IDs
Optum accepts claims three ways. Provider Express Claim Entry is free, runs around the clock for outpatient behavioral health and EAP claims, needs no payer ID, and blocks submission when required fields are blank. Clearinghouse submission uses payer ID 87726 for claims and 86047 for electronic remittance advice. Paper claims go on an original CMS-1500 from a CMS-recognized vendor, typed and never photocopied, with an ICD-10 primary diagnosis and the ICD indicator completed.
Mailing addresses depend on the plan. One UnitedHealthcare provider contact page lists Optum at P.O. Box 30757, Salt Lake City, UT 84130-0757, while Optum’s North Carolina applied behavior analysis guide directs paper claims to P.O. Box 5280, Kingston, NY 12402-5240.
Timely filing and corrected claims
Optum’s claim tips page asks for all information needed to process a claim within 90 calendar days of the date of service, with corrections or additions due within 90 days of receipt of the initial claim. Contracts and programs can differ. Optum’s applied behavior analysis quick reference guides list 180 days for Florida and North Carolina and 120 days for New York.
A corrected claim replaces the original, so it must carry every service line, not only the changed one. UnitedHealthcare guidance republished by the HBMA warns that omitting previously billed services triggers overpayment recovery for them. Report frequency code 7 with the original claim number: in loop 2300 (CLM05-3) with the number in REF02 on an 837, or in box 22 on a CMS-1500. Code 8 voids a claim billed in error.
Telehealth and provider identifiers
Telehealth claims need a place of service code. Since November 1, 2023, Optum has required POS 02 or 10 on all behavioral health telehealth claims across commercial, Medicare Advantage and Medicaid lines, according to its Telehealth Billing Quick Reference Guide (updated September 2025). POS 10 applies when the member is at home and POS 02 covers any other location. Claims carrying only modifier 93, 95, FQ, GQ or GT are not reimbursed, and neither is a telehealth visit billed with POS 11.
Provider identifiers are the other recurring edit. In its September 2025 Top of Mind newsletter, Optum announced that commercial behavioral health claims will need the NPI and taxonomy code of both the billing and the rendering provider, validated against NPPES, with missing data rejected or denied. Informational edits began in October 2025. The notice promised an effective date in the first quarter of 2026, so confirm the current status on Provider Express before relying on any grace period.
Electronic claims carry the data in loops 2310 and 2420; paper professional claims use boxes 24J and 24I. Optum also states that a group billing provider cannot bill clinical services without naming the individual who performed them.
A worked example for a group practice
Consider a three-clinician group billing a 55-minute video session as 90837, a code whose CPT time range starts at 53 minutes. The member is at home, so the line carries POS 10. The group NPI and taxonomy fill the billing provider fields, the treating clinician’s individual NPI and taxonomy fill the rendering fields, and the claim reaches payer ID 87726 on day 12. If the clinician’s taxonomy later proves wrong, the fix is a frequency 7 replacement with every line and the original claim number, sent within 90 days of Optum receiving the first claim.
For Optum behavioral health billing, the figures worth memorizing are payer ID 87726, 90 days from date of service, POS 02 or 10 on telehealth, frequency code 7 for corrections, and a 92% approval rate across 10 eligible requests a year for Gold Card status. State rules such as the New Jersey and Massachusetts notification windows sit in the addenda under Our Network on Provider Express, so check there before assuming a national default applies.