For an intake team in Alaska, an Aetna card means three layers: Aetna’s national ABA criteria, Alaska’s autism mandate in AS 21.42.397, and the plan’s funding type and employer size, which decide whether the mandate applies at all. This guide stacks them in order. Alaska Medicaid has no managed care plans, so an Aetna card in Alaska is commercial (or Medicare).
Aetna applies its ABA medical necessity guide nationally: a DSM-5 autism diagnosis (F84.0, F84.3–F84.9) from an appropriate provider, functional impairment on a standardized scale within the past 12 months, and a measurable, time-limited treatment plan, with progress evaluated every six months. CPB 0554 considers ABA experimental for non-ASD indications. Aetna’s behavioral health precertification list names all ten ABA codes, 97151 through 97158, 0362T and 0373T. The guide’s only state exhibit is Maryland, so no Alaska-specific criteria modify it. Aetna runs no Alaska Medicaid plan; Alaska Medicaid is fee-for-service.[1][2][3][4][21]
Alaska’s autism mandate is AS 21.42.397. Every health care insurer that offers, issues, delivers or renews a health care insurance plan in the state (fraternal benefit societies excepted) "shall provide coverage for the costs of the diagnosis and treatment of autism spectrum disorders." The statute names ABA expressly: "habilitative or rehabilitative care" includes "applied behavior analysis or other structured behavioral therapies." Three conditions shape a claim. Treatment must be "prescribed by a licensed physician, psychologist, or advanced practice registered nurse, provided by or supervised by an autism service provider, and as identified in a treatment plan developed following a comprehensive evaluation." An "autism service provider" is someone "licensed, certified, or registered by the applicable state licensing board or by a nationally recognized certifying organization." And coverage "is required to be provided only to individuals under 21 years of age." The statute caps nothing by dollars and says coverage "may not limit the number of visits to an autism service provider for treatment," though ordinary copayments, deductibles, coinsurance and general exclusions apply. It also says coverage "must cover medically necessary treatment that is coordinated with an education program, but may not be contingent on" that coordination. Two employer-size carve-outs matter: an insurer covering a small employer with 20 or fewer employees "is not required to provide" the mandated coverage, and for a small employer with 21 to 25 employees the director may waive it if actual claims experience shows the mandate raised premiums by three percent or more over 12 months. The mandate reaches fully insured plans; self-funded employer plans answer to ERISA and federal parity instead.[8]
Alaska licenses behavior analysts. AS 08.15.010 says "A person may not practice behavior analysis in this state without a license," and practicing without one is a misdemeanor. The licensing agency is the Department of Commerce, Community, and Economic Development (the BACB’s table lists the Division of Corporations, Business and Professional Licensing, licensure since 2014); there is no separate board. A behavior analyst license requires passing the BCBA examination, current BACB certification and a fingerprint-based criminal history check; an assistant behavior analyst license requires BCaBA certification plus proof of direct supervision by a licensed behavior analyst. Technicians are not licensed: the chapter does not apply to "an individual who directly implements applied behavior analysis services, or family member implementing a behavior analysis plan within the home, who acts under the direction of a licensed behavior analyst or licensed assistant behavior analyst." For out-of-state clinicians, the only short route in statute is a temporary license "for 30 days or less in a calendar year" for someone licensed in a state whose requirements are "substantially equivalent." Telehealth does not remove the license requirement: AS 08.02.130 lets "a health care provider licensed in this state," a category that names behavior analysts licensed under AS 08.15, treat a patient in Alaska by telehealth without a prior in-person visit, and its out-of-state exception covers only physicians and members of an out-of-state physician’s multidisciplinary team for life-threatening conditions. The commercial telehealth statute, AS 21.42.422, likewise requires coverage of telehealth "by a health care provider licensed in this state." Commercial ABA rates are negotiated and unpublished; the public benchmark is the Alaska Medicaid autism-services rate chart, which from July 1, 2026 pays 97153 at $31.95 and 97151/97155/97156 at $41.97 per 15 minutes.[9][18][10][11][20]
Aetna publishes no ABA rate table. Its provider manual (6/26) makes payment a contract term: rates and compensation under the agreement are subject to Aetna’s coding and claim-edit policies, and where a provider has both an intermediary contract and a direct agreement, "your direct Aetna rates will apply unless we specifically notify you otherwise." When a member’s benefits are exhausted, the provider "cannot charge them more than the contracted rate." On payment, AS 21.36.495 requires a health care insurer to pay or deny a clean claim "within 30 calendar days after the insurer or a third-party administrator under contract with the insurer receives a clean claim," to send any denial or request for information within the same 30 days, and then to pay within 15 calendar days of receiving the requested information; a late claim is presumed clean and accrues 15 percent annual interest. AS 21.07.020 bars an insurer from retroactively denying a preauthorization based on medical necessity unless it rested on "materially incomplete or inaccurate information provided by or on behalf of the provider." Self-funded ERISA plans sit outside both statutes. For a public benchmark, Alaska Medicaid pays 97153 at $31.95 per 15 minutes from July 1, 2026.[6][12][13][20]
Aetna’s Health Care Professional Toolkit (6/26) publishes no claim filing deadline: the limit for initial, corrected and secondary claims is the one in your Aetna participation agreement, and claim disputes "Must be submitted within contractual timeframes." The toolkit defines a clean claim as one "received in a timely manner" with all required data, and says a clean claim "Doesn’t involve coordination of benefits," so secondary claims sit outside the clean-claim clock. It publishes no check-run or weekly cut-off schedule.[6][12][13][20]
Aetna publishes no requirement to report a referring or ordering provider on an ABA claim. Its office manual defines a clean claim as including “A corresponding referral (whether in paper or electronic format), if required for the applicable claim” plus “All the data elements of the UB-04 or CMS-1500 (or successor standard) forms (including but not limited to member identification number, National Provider Identifier (NPI), date(s) of service, and a complete and accurate breakdown of services).”[6][22]
A referral matters only on plans that require PCP referrals for specialist care. Those referrals must be issued before the visit (“Referrals should not be retroactive”), and “In Aetna Open Access® plans, referrals also are not necessary.” Aetna’s behavioral health manual lists direct access as the first way into care: members may reach behavioral health “Through direct access to the behavioral health provider,” through a recommendation from their PCP or another treating provider, or through an EAP referral.[6][22]
Since August 1, 2026, one Aetna form — “Outpatient Behavioral Health (BH) – ABA Treatment Request: Required Information for Precertification” (GR-69017-4) — “replaces all other” ABA precertification information forms. It does not start a request. Start the request on Availity (Authorization Add) or by phone, then attach the form and the records to the case, or fax them to FaxHub 833-596-0339 with the reference number.[23]
Section 1 asks for the member and provider group details; the current DSM-5 diagnosis code(s); the diagnosing provider’s name and credentials; hours per authorization period for the assessment codes 97151, 97152 and 0362T; hours per week for 97153–97158 and 0373T; and whether any hours fall during class. Section 2 asks who supervises the ABA services, and whether the child also gets PT, OT, speech, mental health or school services and whether you coordinate with those providers. It also asks for current impairment areas with supporting severity data.[23]
Attach the results of a standardized assessment (“i.e. Vineland, ABAS, VB-MAPP”) completed within the past 12 months. Also attach a time-limited, individualized treatment plan with baselines and measurable progress criteria, caregiver goals, titration and discharge criteria with an aftercare plan, and baseline, interim and current data for every goal. The form names CPB 0648 and the ABA Medical Necessity Guide as the review criteria.[23]
Aetna’s ABA medical necessity guide (©2026) sets what a renewal must show: the plan records baseline levels of each target behavior by "frequency, rate, symptom intensity or duration, or other objective measures," with "quantifiable criteria for progress"; where target behaviors have improved, documentation of that improvement is included, and where they have not, documentation of "modification of the treatment, additional assessments that have been conducted, and/or there has been appropriate consultations from other staff or experts." "A member’s progress is to be evaluated every six months," and the guide relies on "Repeated measurement with standardized measures to assess progress." It does not require graphs and sets no data-recency window.[1]
The questions that decide whether a family can start with Aetna in Alaska, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the ASD diagnosis itself, but medical necessity requires functional impairment shown on a standardized scale administered in the past 12 months (at least one standard deviation below the mean) or a significant risk of harm.[1]
A DSM-5 ASD diagnosis "obtained by an appropriate provider (i.e. licensed psychologist/psychiatrist, physician or other health care professional qualified to diagnose mental health conditions within their scope of practice)."[1]
The ABA guide requires a standardized functional measure from the past 12 months, naming the Vineland-3, ABAS, VB-MAPP or ABLLS as examples. CPB 0648 discusses ASD diagnostic instruments (ADOS-2, ADI-R and others) but the ABA guide does not require a specific one.[1][3]
Aetna’s national ABA policies require no physician referral; what they require is precertification of all ten ABA codes. For a fully insured Alaska plan, AS 21.42.397(a) requires the covered treatment to be "prescribed by a licensed physician, psychologist, or advanced practice registered nurse" and identified in a treatment plan developed after a comprehensive evaluation, so keep that prescription and the evaluation in the file. Self-funded ERISA plans sit outside the statute.[4][1][8]
Aetna’s national ABA guide sets no age cap; it describes typical, not limiting, age ranges. For fully insured Alaska plans, AS 21.42.397(b)(1) requires the autism coverage "only to individuals under 21 years of age," with no visit limits and no dollar cap; small-group plans of 20 or fewer employees are exempt. Self-funded ERISA plans are outside the statute, so plan funding type decides whether that binds.[1][8]
Ask the plan: Live benefits verification on the member ID: establish fully insured vs. self-funded ERISA and employer size, then the plan’s own age terms.
Aetna’s Telemedicine and Direct Patient Contact Payment Policy marks 97151, 97153, 97155, 97156 and 97157 as telehealth-eligible on commercial plans (modifier GT, 95 or FR), with 97152, 97154 and 97158 checked for Medicare Advantage only; the posted policy shows a last review of June 2021, so treat the list as perishable. Aetna’s provider manual (6/26) says Aetna Behavioral Health "offers telehealth services to all commercial fully insured members and to all commercial self-insured plan sponsors, unless those self- insured plan sponsors opt out," and that providers must "ensure that they have the proper licensure based on state requirements." For a fully insured Alaska plan, AS 21.42.422 requires coverage "for benefits provided through telehealth by a health care provider licensed in this state" and bars requiring "prior in-person contact" before payment; the statute does not list which services or codes. Self-funded employer plans are outside it. The clinician must hold an Alaska behavior-analyst license (AS 08.15.010; AS 08.02.130).[7][6][11][9][10]
Ask the plan: Availity or the precertification line on the card: ask whether the plan is fully insured in Alaska or self-funded (and opted out of telehealth), and which ABA codes, POS and modifier Aetna pays by telehealth.
Depends on how the plan is funded. Fully insured Alaska plans follow 3 AAC 28.910: for a prospective (pre-service) request the insurer must decide and notify "not later than five working days after the date the health care insurer receives the request," with one extension of up to five working days for matters beyond its control; the clock starts when the request is filed under the insurer’s procedures, "without regard to whether all of the information necessary to make the determination accompanies the filing." Urgent requests are decided within 24 hours (3 AAC 28.912). A reduction or termination of an already-certified course of treatment is an adverse determination that must be noticed in time for the member to appeal first. SB 133 (2025) tightens this for plans issued or renewed on or after January 1, 2027: 72 hours for a complete standard request (72 hours excluding weekends if faxed), 24 hours for an expedited one, and a request with no timely written decision or request for information "is considered approved." 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," one 15-day extension, urgent care within 72 hours. Aetna publishes no Alaska-specific ABA turnaround or reauthorization lead time.[14][15][19]
Ask the plan: At benefits verification ask whether the plan is fully insured (Alaska-regulated) or self-funded (ERISA), the plan’s issue or renewal date (SB 133’s 72-hour clock starts with plans issued or renewed on or after 1/1/2027), and what reauthorization lead time Aetna expects.
Alaska requires every major medical policy to carry a coordination-of-benefits provision (AS 21.42.205), and when a child has two plans the secondary insurer, "absent evidence of fraud, … must accept the primary insurer’s precertification, utilization review, or other managed care requirement determination and may not deny, delay, or reduce benefits" for a member who met the primary’s requirements (3 AAC 26.110(c)). Neither text sets the order of benefits between two parents’ plans, so get the order from the carrier. If the child also has Alaska Medicaid, Aetna pays first: Medicaid is payer of last resort (42 CFR 433.139), and an Alaska Medicaid provider must report any other payment and enter it "as a credit against the charge to the department" (7 AAC 145.005(i)). TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[16][17][24][25][26][27]
Ask the plan: Ask Aetna at benefits verification for the member’s coordination-of-benefits order (and whether the plan uses the birthday rule for two parents’ plans), and record every other coverage the child has.
Coverage decides whether Aetna in Alaska 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.
Aetna’s Network Participation Criteria (5/26) require services to be "provided directly or supervised by individuals licensed by the state or certified by the Behavior Analyst Certification Board"; supervised staff may be a BCaBA "or a paraprofessional," with "A minimum of one hour of face-to-face supervision" of an unlicensed or noncertified paraprofessional "for each 10 hours of applied behavior analysis" and the supervisor onsite with the child at least one hour a month; "All BCBAs, BCaBAs and paraprofessionals must meet state requirements." In Alaska that means a licensed behavior analyst (AS 08.15.010); an assistant needs a license and direct supervision by a licensed behavior analyst, and technicians are exempt only when acting "under the direction of a licensed behavior analyst or licensed assistant behavior analyst" (AS 08.15.070(3)).[5][1][9]
No per-day or per-week cap is published. Hours come from the guide’s severity assessment, with typical intensities of 10–25 hours a week for comprehensive and 1–20 for focused programs (typical, not caps); progress is evaluated every six months. For fully insured Alaska plans, AS 21.42.397(b)(2) bars limiting "the number of visits to an autism service provider."[1][8]
Aetna has a general rule, not an ABA-specific one. Its medical-record standards apply to "all participating practitioners," who "agree to maintain medical records in a current, detailed, organized, and comprehensive manner." The core components are: "All entries are dated," "All entries are legible to someone other than the writer," and "All entries in the record must contain the provider's signature/initials or electronic identifier." Aetna audits records against these at least every two years, with an 85% performance goal. Aetna's ABA documents do not say whether the technician, the supervising BCBA or both sign a session note, or how soon after the session it must be signed. Each person who writes an entry should sign or e-sign and date it.[6][1]
Outpatient ABA is setting-neutral in Aetna’s guide; inpatient, residential or partial hospitalization use that level of care’s criteria. AS 21.42.397(b)(4) requires fully insured plans to cover medically necessary treatment "coordinated with an education program," but coverage "may not be contingent on" that coordination.[1][8]
Services must be "provided directly or billed by licensed behavior analysts (in states with behavior analyst licensure laws), board-certified behavior analysts, or licensed psychologists" where in scope, unless mandates, plan documents or contracts say otherwise. Alaska licenses behavior analysts, so the Alaska-licensed behavior analyst is the billing credential (AS 08.15.010).[1][9]
Not addressed in Aetna’s published ABA policies (CPB 0554, the medical necessity guide, the precertification list).[2][1]
Ask the plan: Aetna provider services, the participating-provider agreement, or a written coding determination from Aetna Behavioral Health.
No. Aetna’s ABA medical necessity guide asks for objective baseline measures, quantifiable progress criteria, standardized re-measurement and a six-monthly progress evaluation, with treatment changes documented where there is no improvement, but it does not require graphs or set a data-recency window.
Aetna’s provider toolkit publishes no filing limit; the participation agreement sets it for initial, corrected and secondary claims, and a claim involving coordination of benefits is not a "clean claim." No check-run schedule is published.
Yes, under its national ABA medical necessity guide for ASD, with Alaska’s AS 21.42.397 mandate layered on for fully insured plans. Self-funded employer plans and small groups of 20 or fewer employees are outside the mandate.
Coverage of autism diagnosis and treatment, including ABA, for individuals under 21, prescribed by a physician, psychologist or APRN and delivered or supervised by an autism service provider, with no limit on the number of visits and no dollar cap in the statute.
Yes in practice. Alaska law bars practicing behavior analysis in the state without a license, and Aetna requires providers to meet state requirements. Technicians are exempt from licensure when working under a licensed behavior analyst’s direction.
For fully insured plans, AS 21.36.495 requires payment or denial within 30 calendar days of a clean claim, with 15 percent annual interest when the insurer misses its deadlines. Self-funded plans follow their own terms.
Aetna publishes no such requirement for ABA. A referral has to accompany a claim only when the member’s plan requires PCP referrals for specialist care. Behavioral health is a direct-access benefit in Aetna’s behavioral health manual.
Since August 1, 2026, use form GR-69017-4, “ABA Treatment Request: Required Information for Precertification.” Start the request on Availity or by phone first, then attach the completed form plus a standardized assessment from the past 12 months and the treatment plan.
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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