For an intake team in Arizona, an Aetna card means three layers at once: the carrier's national clinical policy, Arizona's autism insurance mandate (Steven's Law, its dollar caps freshly repealed by SB 1590), and the plan's funding type deciding which of the two actually binds. This guide stacks them in order — plus one Arizona twist: Aetna also administers Mercy Care, so "we have Aetna" often means a Medicaid member.
Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is national — what changes in Arizona is the legal floor underneath it: the state mandate below governs what fully-insured group plans must cover, while self-funded employer plans answer to ERISA and federal parity instead. Plan funding type is therefore the first fact to establish on every benefits check. The full national policy breakdown lives in our Aetna guide; this page covers what changes in Arizona.[1][2][16][17][9]
Steven's Law (HB 2847, 2008) lives in four parallel sections of the insurance code — A.R.S. §§ 20-826.04, 20-1057.11, 20-1402.03, and 20-1404.03 — covering state-regulated group coverage: large-group contracts, HMO plans, and group and blanket disability policies. Plans may not deny or limit treatment based solely on an autism spectrum disorder diagnosis, and may not exclude medically necessary behavioral therapy, which the statute defines to include ABA (discrete trial training, pivotal response training, intensive behavioral intervention), delivered or supervised by a licensed or certified provider. The headline change: SB 1590 (signed May 7, 2025) struck the dollar-cap subsection from all four sections — the old $50,000/year (under age 9) and $25,000/year (ages 9–16) behavioral-therapy maximums are repealed, taking the statute's only age tiers with them, and the ASD definition now tracks the current DSM. No annual dollar ceiling remains on any state-regulated group plan (federal parity had already made the caps largely unenforceable; SB 1590 cleaned the statute to match — do not treat the old $50K/$25K numbers as current). Exemptions: policies issued to an individual or small employer (those reach ABA via the ACA EHB benchmark instead), limited-benefit coverage, and self-funded ERISA plans. Ordinary cost sharing is still permitted.[3][4][5]
A family saying "we have Aetna" in Arizona may actually be a Mercy Care member — Mercy Care is administered by Aetna Medicaid Administrators LLC and covers the largest Phoenix-metro Medicaid, DDD, and foster-care books. Mercy Care runs on AHCCCS rules (AMPM 320-S), not this commercial policy: no autism diagnosis required, no PA on assessment codes. Verify which line of business the card belongs to, and use the dedicated Mercy Care guide for the Medicaid plan. Aetna publishes no Arizona-specific commercial ABA policy or supplement — the national policy plus the state mandate is the whole commercial picture.[8]
Arizona requires a state license to practice behavior analysis — A.R.S. § 32-2091, administered by the Arizona Board of Psychologist Examiners (behavior analysts sit under the psychology board, not a standalone board) — and BCBA certification alone is not sufficient; AHCCCS itself defines "Behavior Analyst" as a person licensed under § 32-2091. On rates: Aetna does not publish commercial ABA fee schedules for Arizona (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement. Benchmark against the AHCCCS fee schedule (97153 at $17.91–$23.69 per 15-minute unit by credential tier), remembering the ABA codes live on the AHCCCS physician fee schedule, not the behavioral-health one.[6][7]
Arizona licenses the practice: “A person who wishes to practice as a behavior analyst must be licensed pursuant to this article” (A.R.S. § 32-2091.02, Board of Psychologist Examiners), and practicing unlicensed is a class 2 misdemeanor (§ 32-2091.12). Arizona is unusual in giving out-of-state clinicians a telehealth-only route: under A.R.S. § 36-3606 a health care provider “who is not licensed in this state may provide telehealth services to a person located in this state” after registering with the board that licenses the comparable profession, holding “a current, valid and unrestricted license to practice in another state that is substantially similar,” carrying malpractice coverage that includes Arizona telehealth, and following Arizona’s scope and standard-of-care rules. Behavior analysts are licensed under Title 32, chapter 19.1, which § 36-3601 includes in the definition of “health care provider.” A registered provider may not open an Arizona office (except within a multistate group that includes an Arizona-licensed provider) or see Arizona patients in person without an Arizona license. Fewer than ten telehealth encounters a year, or care in consultation with an Arizona-licensed provider who keeps ultimate authority, is exempt from registration.[10][11][12][13][14]
Aetna’s own rule is written for telehealth explicitly. Its Network Participation Criteria (form 8100606-01-01, 5/26) bind every Hybrid and Virtual Only provider: “Providers must satisfy all applicable license, registration, and certification requirements noted in the participation criteria for all states in which members to whom they are providing Telehealth services are located. As required by applicable law, providers must also hold licenses, registrations, and certifications in the state(s) in which they are physically located.” The ABA criteria add that BCBAs “must meet the current Aetna® credentialing and recredentialing standards” and that “All BCBAs, BCaBAs and paraprofessionals must meet state requirements.” So a BCBA treating a child located in Arizona by video must meet Arizona’s requirements as well as those of the state the BCBA works from, and only codes on Aetna’s Telemedicine and Direct Patient Contact Payment Policy are payable by telehealth.[10][11][12][13][14]
Aetna’s national provider manual (edition 6/26) publishes no numeric filing limit: it defines a clean claim as one “received in a timely manner,” so the operative deadline is the one in your Aetna agreement. Claim disputes go through Availity — the claim must be in Finalized status, then “Dispute Claim” from the Claim Status transaction — and Aetna runs one level of provider appeal for payment decisions; medical-necessity appeals go through the member appeal process.[18]
Arizona’s prompt-pay statute, A.R.S. § 20-3102, requires a health care insurer to adjudicate a clean claim “within thirty days after the health care insurer receives the clean claim or within the time period specified by contract,” and, absent a written contract setting a different period, to pay the approved portion within thirty days after adjudication; late payment carries interest at the legal rate. If the claim is not clean, the insurer must ask for the missing information in writing within thirty days and then adjudicate within thirty days of receiving it. Neither side may reopen a paid or denied claim more than one year after the insurer paid or denied it, except for fraud (§ 20-3102(J)). These statutes bind fully insured plans issued in the state; a self-funded employer plan (ERISA) is not subject to them and follows its plan documents and your contract.[15]
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).”[18][19]
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.[18][19]
The questions that decide whether a family can start with Aetna in Arizona, and what they have to bring. Each maps onto something intake should ask on the first call.
Aetna puts the recency clock on the functional assessment, not the diagnosis: medical necessity requires "demonstration of functional impairment on a standardized scale of functioning in the past 12 months," and the impairment must be at least one standard deviation below the population mean or represent a significant risk of harm to self or others. The ABA Medical Necessity Guide sets no expiry on the ASD diagnosis itself.[9]
"There is a DSM-V diagnosis of Autism Spectrum Disorder (ICD-10/ F84.0; F84.3 - F84.9) 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)." Note the code set the guide actually prints: F84.0 plus F84.3–F84.9, which leaves out F84.1 and F84.2.[9]
No diagnostic instrument is mandated; the named instruments sit on the functional-impairment test — "the Vineland Adaptive Behavior Scales 3 (VABS-3), the Adaptive Behavior Assessment Scale (ABAS), VB-MAPP or ABLLS" are given as examples of the standardized scale that must show impairment within the past 12 months.[9]
No referral or physician order is required by the national guide — the gate is the diagnosis "obtained by an appropriate provider" plus precertification. The only prescription requirement Aetna publishes is its Maryland exhibit (COMAR 31.10.39), where the child's primary care or specialty physician must perform the evaluation and prescribe the treatment with specific goals; that exhibit does not reach plans outside Maryland.[9]
Aetna's Telemedicine and Direct Patient Contact Payment Policy lists the ABA codes it pays by telehealth, by line of business. On commercial plans the eligible codes are 97151 (the assessment), 97153, 97155 (protocol modification, the code for BCBA direction of the technician), 97156 and 97157, billed with modifier GT, 95 or FR; 97152, 97154 and 97158 are checked for Medicare Advantage only. The posted policy shows a last review of June 2021, so treat the list as perishable.[20]
Ask the plan: Aetna provider services or Availity — confirm the payment policy is still current and that the member's plan carries a telehealth benefit before scheduling remote hours.
Steven's Law now carries no explicit age limit: SB 1590 (signed May 7, 2025) struck the dollar-cap subsection from all four sections of the mandate, and the age tiers — under 9, and 9 through 16 — lived inside that subsection. Optum's own state-mandate entry describes the change as repealing "the maximum benefit limitations for behavioral therapy coverage for eligible persons who are 16 years old and younger." The carrier's national ABA policy adds no age bound of its own, so age comes from the benefit document, not the statute.[3][4][9]
Ask the plan: Benefits verification on the specific plan — funding type first, then the ABA benefit terms.
Aetna publishes no day counts of its own: its 2026 manual says "The timing of the review incorporates state, federal, CMS and NCQA requirements," and ABA services "require prior authorization" by calling the number on the member ID card. So the governing clock depends on funding. For a fully insured plan issued in Arizona, A.R.S. § 20-3404 governs: urgent requests "not later than five days after the receipt of all necessary information", non-urgent "not later than fourteen days after receipt of all necessary information", with the same five/fourteen days again after the provider completes an incomplete request — and "A prior authorization request is deemed granted if a health care services plan or its utilization review agent fails to comply with the deadlines." A granted authorization cannot be rescinded after services are rendered in good faith, absent fraud. A self-funded employer plan sits outside state law and follows ERISA: a non-urgent pre-service decision "not later than 15 days after receipt of the claim by the plan", extendable once by up to 15 days; an urgent one within 72 hours; the clock starts when the request is filed, whether or not it is complete; and an urgent request to extend an approved course is decided within 24 hours if made "at least 24 hours prior to the expiration" of the current authorization.[18][21][22]
Ask the plan: At benefits verification, ask whether the plan is fully insured (a policy issued in the state) or a self-funded employer (ERISA) plan — that decides which clock applies — then ask the carrier’s behavioral health precert line its expected ABA turnaround and how early it wants the reauth.
Arizona’s COB rule for group plans (A.A.C. R20-6-214) sets the order: the plan covering the person other than as a dependent pays first; for a dependent child, "The plan of a parent whose birthday occurs earlier in a calendar year shall cover a dependent child before" the other parent’s plan (month and day only); for separated or divorced parents, the custodial parent’s plan, then the custodial parent’s spouse’s, then the non-custodial parent’s, unless a court decree the plan knows of says otherwise. Self-funded plans follow their own plan document. Aetna says it coordinates "as allowed by state or federal law following the National Associations of Insurance Commissioners (NAIC) guidelines. If there is no applicable law, then we coordinate according to the member's plan" (it names the NAIC birthday and divorced-parent rules); on a secondary claim, send the primary payer’s paid/denied data in the 837 COB loops. Government coverage sorts itself by federal rule: a commercial plan pays before TRICARE, which is secondary to every other health plan but "In any double coverage situation involving Medicaid, CHAMPUS is always the primary payer"; CHAMPVA "is the last payer to OHI"; and Medicaid pays after all of them (42 CFR 433.139), so a child with commercial plus Medicaid needs this plan’s authorization and EOB before Medicaid will pay.[23][18][24][25][26][27]
Ask the plan: Collect both parents’ plans, dates of birth, and any custody decree at intake; confirm primary/secondary with each carrier’s COB unit (and whether the plan is self-funded) before the first claim.
Coverage decides whether Aetna in Arizona 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 sets a duty, not a number. Where a state mandate, plan document or contract allows services from someone neither state-licensed nor BACB-certified, "there must be supervision and direction of the unlicensed or non-certified providers in line with practice standards." The ABA Medical Necessity Guide publishes no supervision percentage, ratio or caseload cap — the operative standard is professional practice plus whatever the contract adds.[9]
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.[18][9]
The claim carries the analyst, not the technician. "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 behavior analysis is within their scope of practice definition, unless state mandates, plan documents or contracts require otherwise." The escape clause matters: a state mandate or your contract can move the line, so confirm before enrolling technicians.[9]
Aetna publishes no ABA place-of-service list. On school settings it says two things. CPB 0648: "Many Aetna plans exclude coverage of educational services. For example, speech therapy or ABA services during class would be excluded under these plans. Please check benefit plan exclusions." And precertification form GR-69017-4 asks "Are any ABA hours being requested during class?" and, if so, how many and for which codes. The IEP/IDEA carve-out in Aetna's ABA medical necessity guide sits in its Maryland exhibit, not in the national criteria. Where ABA is payable in a school, the community or a group home is a benefit-document question.[2][17]
Ask the plan: The member's benefit document (educational-services exclusion), and Aetna provider services for whether school-setting ABA is payable on that plan.
Not published. Neither the ABA Medical Necessity Guide nor Aetna's clinical policy bulletin on ABA addresses whether 97153 and 97155 may be billed for the same clock time; Aetna carries the concurrency question in its claim editing rather than in a public policy.
Ask the plan: Aetna precertification/provider services at the number on the member's ID card, and the plan's own reimbursement schedule — ask specifically whether 97155 pays alongside 97153 when analyst, technician and member are all face-to-face.
Not published. Aetna's ABA documents set medical-necessity criteria and precertification requirements for 97151–97158, 0362T and 0373T, but no per-day unit ceiling and no statement of which MUE table applies. The guide does publish typical intensity bands — comprehensive ABA 10–25 hours/week, focused ABA 1–20 hours/week — as clinical guidance, not claim edits.[9]
Ask the plan: Aetna provider services; confirm before promising a family more than four hours a day of 97153.
Yes — under the carrier's national policy for ASD, layered on Steven's Law for state-regulated group plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.
No — SB 1590 (signed May 7, 2025) repealed the $50,000/$25,000 annual behavioral-therapy caps from all four Steven's Law sections. No annual dollar ceiling remains on any state-regulated group plan.
Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against the AHCCCS physician fee schedule and treat rate-setting as part of contracting.
Arizona requires a license (A.R.S. § 32-2091.02) but lets an out-of-state provider deliver telehealth after registering under A.R.S. § 36-3606. Aetna requires telehealth providers to meet the license requirements “for all states in which members to whom they are providing Telehealth services are located.”
Aetna’s national provider manual (6/26) does not publish a number — the filing limit is the one in your Aetna agreement.
Arizona law (A.R.S. § 20-3102) gives a fully insured plan 30 days from receipt to adjudicate a clean claim and, unless your contract says otherwise, 30 more days to pay the approved amount, with interest at the legal rate after that. Self-funded employer plans are not bound by the statute.
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.
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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