---
title: Aetna Better Health of New Jersey ABA coverage (NJ FamilyCare MCO).
url: "https://carelu.com/payers/aetna-better-health-new-jersey"
markdown_url: "https://carelu.com/payers/aetna-better-health-new-jersey.md"
state: NJ (New Jersey)
payer: Aetna Better Health of New Jersey
kind: Medicaid managed care plan (MCO)
parent_program: NJ FamilyCare
description: "How Aetna Better Health administers NJ FamilyCare ABA — the published rate sheet mirroring the state FFS schedule, MUE unit limits, Availity submission, PA turnaround times, and the one open rate question on 97153."
last_reviewed: October 2026
vob_data_updated: 2026-10-15
---

# Aetna Better Health of New Jersey ABA coverage (NJ FamilyCare MCO).

_Payer Guide · Aetna Better Health (NJ) · Last updated October 2026 · 14 primary sources_

> Closest to the state baseline: published rate sheet mirrors the FFS schedule, MUE limits verbatim.

Aetna Better Health of New Jersey is the most transparent of the five NJ FamilyCare MCOs about hewing to the state baseline: its published ABA Program sheet copies the DMAHS rates and unit limits verbatim. There's no distinct Aetna clinical ABA policy layered on top — authorization runs through the standard behavioral-health PA machinery on Availity, with defined turnaround clocks. The open question worth carrying into contracting: the published rate sheet still shows the launch-era $11.20 on 97153, and whether Aetna followed the state's 2022 increase to $15.00 is unverified.

This plan administers the **NJ FamilyCare** ABA benefit: the state rules are the floor, and this page covers what the plan layers on top. Read it together with the [NJ FamilyCare (New Jersey Medicaid) guide](https://carelu.com/payers/new-jersey-medicaid).

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — ABA is on the PA list; urgent requests decided in 24 hours, routine in 7 days [9][2]
- **Prior auth for treatment**: Required — via Availity or the BH prior authorization form; progress reports via Availity or fax (844) 404-3972 [3][2]
- **Autism diagnosis required?**: Yes — ASD (F84.0–F84.9) by a qualified healthcare professional (state baseline) [4]

## At a glance

- **Plan type:** NJ FamilyCare MCO (Aetna Medicaid)
- **Clinical rules:** State baseline — no distinct published ABA clinical policy
- **Prior auth:** Required — urgent decided in 24h, routine in 7 days
- **Published rates:** 97151/97156 $25.00 · 97155 $21.25 · 97153 $11.20 on the 2020 sheet (state since raised to $15.00 — verify)
- **Unit limits:** State suggested limits adopted verbatim as MUE claim edits
- **Submission:** Availity (provider ID 46320); ABA fax (844) 404-3972

## The state schedule, republished

Aetna's ABA Program sheet (effective 4/1/2020) publishes rates identical to the state FFS schedule — 97151 $25.00, 97153 $11.20, 97155 $21.25, 97156 $25.00, 0362T $25.00, 0373T $16.40 — and adopts the state's suggested daily unit limits verbatim, explicitly labeling them MUE (medically-unlikely-edit) limits: functionally claim edits, not soft guidance. The catch is the technician rate: the state raised 97153 from $11.20 to $15.00 effective February 1, 2022, and whether Aetna followed on its own schedule is unverified — make it an explicit contracting question rather than an assumption. [1][6]

## Authorization mechanics

ABA sits on the plan's prior-authorization list, with urgent requests decided within 24 hours and routine requests within 7 days. Requests go through Availity or on the plan's behavioral-health prior authorization form; progress reports upload via Availity or fax to (844) 404-3972, and the plan phone is 1-855-232-3596. Claims run through Availity or Office Ally under provider ID 46320; appeals go to NJAppealsandGrievances@AETNA.com. Named clinical ABA contacts (per the state's BH integration contact sheet) are Alyx Llorens and Vincenza Stone. The plan also maintains a published ABA/DIR provider directory PDF — useful for checking how your listing appears to referring families. [2][9][3]

## Does Aetna Better Health of New Jersey allow retroactive authorization for ABA?

Its provider manual (August 2026) provides for post-service review but does not say when one will be accepted. The decision table includes "Post-service approval of a service for which no pre-service request was received," decided "Within 30 calendar days of the request," and a post-service denial within 30 calendar days of receiving the necessary information. ABA is on the plan's authorization list ("ABA/DIR Therapy — Yes authorization"), so treat post-service review as an exception, not a substitute. Two related rules: when other insurance pays first, "prior authorization of a service is not required, unless it is known that the service provided is not covered by the primary payer"; and authorizations are valid for the dates authorized (or 60 days to start if no date is given), with the member "enrolled and eligible on each date of service." [9]

## What documents does Aetna Better Health of New Jersey require for ABA?

No ABA-specific template. Requests go through Availity or on the plan's behavioral health prior authorization form, whose ABA section asks for the request type (initial or concurrent, and how long the member has been in services), the treatment setting, clinical symptoms or social barriers and an anticipated discharge date. Attach clinical data (psychosocial and behavioral history, mental status, current maladaptive behaviors or skill deficits, co-occurring and medical conditions), progress or lack of it (for initial requests, the response to earlier interventions), compliance with treatment, and "For ABA Requests, include treatment plan." The form must be signed in its attestation section and "completed in its entirety in order to receive a determination." Neither the form nor the manual names a diagnostic instrument or a maximum age for the diagnosis. Session records fall under the plan's general medical-record standards, including signature and countersignature of ancillary staff's entries. [3][9]

## What are Aetna Better Health of New Jersey’s claim filing, payment and appeal rules?

Filing. The provider manual (updated 5/26): “Claims must be submitted within 180 calendar days from the date of services,” “Corrected claims must be submitted within 365 days from the date of service,” and COB claims within 60 days of the primary insurer’s EOB or 180 days from the date of service, whichever is later. For electronic claims the vendor’s Level Two report “is the only accepted proof of timely filing.” [9][12][13]

Payment. “Aetna Better Health of New Jersey generates checks biweekly. Claims processed during a payment cycle will appear on a remittance advice (“remit”) as paid, denied or reversed,” and “The Remit Date represents the end of the payment cycle.” The manual publishes no weekly submission cutoff. It prints clean-claim payment timeframes only for MLTSS providers, so the state contract is the rule for ABA: it requires each MCO to process claims under N.J.S.A. 17B:30-48 et seq. (30 days electronic, 40 days paper, 12% yearly interest when late) and holds “all Behavioral Health services (including ABA and DIR)” to 90% of electronic clean claims processed within 15 days and 90% of paper clean claims within 30 days. [9][12][13]

Appeals. “Participating and Non-Participating Providers have the right to appeal ABHNJ claims determination(s) within sixty (60) calendar days of receipt of the claim denial,” using the DOBI Health Care Provider Application to Appeal a Claims Determination, with a Stage Two external Alternative Dispute Resolution option after the internal appeal. [9][12][13]

EVV. Under its home healthcare heading the manual says: “Providers delivering Personal Care Assistant Providers (PCAs), Skilled Nursing, or Therapies in the member’s home are responsible for verifying all of their visits using an electronic visit verification system,” through the state aggregator (HHAeXchange) or an integrated vendor. ABA is not named, and the state contract limits EVV to personal care services; ask the plan if it counts home-based ABA as a home “therapy” before you skip EVV. DMAHS’s September 2026 EVV newsletter (Vol 36 No 09, effective January 1, 2027) is addressed to “Personal Care Assistance (PCA) and Home Health Services (HHS) provider agencies” and sets an 80% electronic-verification minimum for those services only; it does not name ABA. [9][12][13]

## Does Aetna Better Health of New Jersey accept H0031 or H0032 for ABA?

Aetna Better Health of New Jersey’s published ABA program rate sheet (effective April 1, 2020) lists only CPT 97151–97158 and 0362T/0373T, and its provider manual names no H-code for ABA. The state contract’s ABA service description lists the same ten codes as the “HIPAA Compliant Billing Codes.” H0031 and H0032 appear in neither, so bill ABA with 97151–97158, 0362T and 0373T. [1][9][12]

## Does Aetna Better Health of New Jersey require a referring provider on ABA claims?

Aetna Better Health of New Jersey publishes no rule that every ABA claim must name a referring provider, but it has published what happens when one is named. From October 1, 2026 it enforces the NJ Medicaid (Gainwell) claim edits, including edit 1270: “Referring NPI Same as Billing/Servicing NPI – The referring provider NPI cannot be the same as the billing and/or servicing provider NPI.” Edits 1269 and 1271 do the same for attending and “Other” provider NPIs. Claims that break them are rejected at EDI or denied on paper, and providers “are not permitted to balance-bill the Medicaid beneficiary.” So never put your own agency or BCBA NPI in box 17b; if you report a referring provider, it is the clinician who referred or diagnosed the child. The manual’s prior authorization request list separately asks for the “Name, address, phone and fax number and signature, if applicable, of the referring provider.” Claim-edit questions go to the Claims Inquiry/Claims Research department at 1-855-232-3596. [15][9]

## Intake gates

The questions that decide whether a family can start with Aetna Better Health of New Jersey, and what they have to bring.

- **Age limit**: Two published numbers, and they differ in precision rather than in substance. The founding DMAHS newsletter sets the benefit for "any Medicaid eligible child, under the age of 21, who has been diagnosed with ASD as defined by ICD 10 diagnoses F84.0 through F84.9 by a qualified healthcare provider," delivered under EPSDT, which reaches "individuals under the age of twenty-one." Optum's New Jersey Medicaid entry adds the floor as well as the ceiling: "ABA services shall be made available to children 18 months to 21 years of age based on medical necessity," and its NJ FamilyCare provider orientation repeats it — "Must be 18 months – 21 years old," including in the specialized FamilyCare carve-out. No hour caps are attached to the age band. Aetna Better Health of New Jersey publishes no deviation from this, and its own material was checked for one. [4][5]
- **Who may diagnose**: New Jersey names them twice, and the second list is narrower than the first. The newsletter's general test: "The need for ABA services must be determined by a qualified healthcare professional (QHP) capable of making a diagnosis of autism. QHPs include licensed health care professionals, who are qualified by education, training, or licensure/regulation (when applicable) to perform a professional service within his/her scope of practice." The enumerated list of acceptable QHPs "for the diagnosis and treatment planning for adaptive behavior services" is then: Physicians; Psychologists, which "Requires an active board certified behavior analyst (BCBA) certification in good standing and a qualifying doctoral-level degree (BCBA-D)"; and BCBAs, who appear for treatment planning rather than diagnosis. Optum's NJ entry restates the split: the diagnosis comes from "a physician or psychologist," and "It is not uncommon for one QHP to make the diagnosis (such as a physician) and a separate QHP (such as a BCBA) to develop and supervise the treatment plan." [4][5]
- **Diagnostic tools required**: None required — and New Jersey is one of the few states that says so in terms. Optum's NJ Medicaid entry: "A comprehensive diagnostic evaluation is not required to access ABA services," with "ABA services … available to any child diagnosed with autism spectrum disorder as defined by ICD-10 diagnoses F84.0 through F84.9." The DMAHS newsletter names no instrument either. That makes this the friendliest diagnostic bar of the three states on this page — intake should not queue a New Jersey family for an ADOS-2 before starting the authorization. Aetna Better Health of New Jersey adds none of its own: its behavioral health prior authorization form asks only for the ICD-10/DSM-5 code, and its ABA section asks for request type, treatment setting, clinical symptoms or social barriers and a discharge plan, plus clinical data, progress, compliance and "For ABA Requests, include treatment plan" — no ADOS-2, adaptive scale or other named instrument. The August 2026 provider manual names no ABA diagnostic instrument either. [5][4][3][9]
- **Referral required?**: No PCP referral and no physician order. The sequence the state sets is QHP determination, then MCO authorization: "Once an individual is properly diagnosed with ASD, the MCO shall authorize a QHP to assess the child for the development of a proposed treatment plan," and treatment follows "Contingent upon approval of the treatment plan." The genuine intake asset sits one step earlier — members still fee-for-service pending MCO enrollment are covered through Gainwell with no prior authorization required at all, so enrollment status, not a referral, is the routing question. Plan practice adds paperwork rather than a referral: Horizon wants an ASD diagnosis "script" from a QHP attached to the assessment request, which is the diagnosis document under another name. Aetna Better Health is the plan that hews closest to the state baseline — its published ABA Program sheet copies the DMAHS rates and unit limits verbatim — and adds no referral requirement of its own; what it adds is a clock, with urgent requests decided in 24 hours and routine in 7 days. [4][1]
- **Telehealth**: The plan publishes no ABA telehealth rule of its own, so the state statute governs. N.J.S.A. 30:4D-6k (as amended by P.L.2021, c.310) requires the State Medicaid and NJ FamilyCare programs to "provide coverage and payment for health care services delivered to a benefits recipient through telemedicine or telehealth, on the same basis as" in person, for services otherwise covered in person, with payment to the practitioner or the employing agency. The programs may limit coverage to participating providers, but may not restrict the originating site (the child's home counts) or the distant site except to keep the in-person standard of care, may not restrict the platform (audio-only included) if it meets that standard and HIPAA, and may not require a member to use telehealth instead of in-person care. Coverage can still be limited to medically necessary services. No DMAHS ABA document names an ABA telehealth code list, POS or in-person supervision minimum, so the 97151 assessment and 97155 supervision are covered by telehealth on the same basis as in person when medically necessary, and billing details come from the MCO. Aetna Better Health of New Jersey’s telehealth page (not specific to ABA) gives its billing rule: providers “may bill for any Medicaid billable service using the same billing codes and rates provided for face-to-face services. There is no need to use any additional procedure codes or modifiers,” GT “isn’t necessary for billing,” and “You’ll want to use place of service code POS 02 to indicate telehealth.” That page predates the state’s April 2023 Medicaid Alert MA-2023-02, which requires POS 10 for “Telehealth Provided in a Patient's Home” and POS 02 only for telehealth elsewhere, on “both Fee-For-Service and encounter claims.” For 97153 to a child at home, ask the plan whether it wants POS 10 (the state rule) or POS 02 (its page) before billing. Its documentation rule: note “that the service was provided through telehealth,” the location of the patient and provider, and anyone else taking part. The plan’s behavioral health prior authorization form has an ABA section with a place-of-service and treatment-setting field but no separate telehealth box, so state telehealth delivery in the treatment setting answer. [8][4][10][11][3]
- **Prior-auth decision time**: Aetna Better Health of New Jersey's provider manual: urgent pre-service decisions "Within twenty-four (24) hours of receipt of necessary information, but no later than 72 hours from receipt of request"; non-urgent pre-service "Within seven (7) calendar days (or sooner as required by the needs of the member) of receipt of necessary information sufficient to make an informed decision"; continued/extended services within 24 hours of receipt of necessary information, no later than 72 hours. These apply "Unless otherwise required by the New Jersey Division of Medical Assistance and Health Services (DMAHS) or state law." Note the older BH prior authorization request form still reads "Routine services processed within 14 days" — the manual's 7-day standard is the current one. Federal floor for every NJ FamilyCare MCO: standard decisions within 7 calendar days of the request for contract rating periods starting on or after January 1, 2026 (14 days before that), extendable by up to 14 calendar days at the member's or provider's request or when the plan justifies needing more information; expedited within 72 hours. [9][16]
- **Other insurance (who pays first)**: Aetna Better Health of New Jersey's manual: "If other insurance is the primary payer before Aetna Better Health of New Jersey, prior authorization of a service is not required, unless it is known that the service provided is not covered by the primary payer. If the service is not covered by the primary payer, the provider must follow our prior authorization rules." So a commercial plan that covers ABA → its authorization only; one that excludes ABA → Aetna's PA before services. Submit COB claims within 60 days of the primary insurer's EOB or 180 days from the date of service, whichever is later. State rule underneath: NJ FamilyCare pays last: "All TPL, for example, health insurance, Medicare, CHAMPUS, prepaid health plans… shall, if available, be used first and to the fullest extent." Bill the commercial plan first; supplementation claims "shall not be filed with the program unless accompanied by a statement of payment, Explanation of Benefits (EOB), or denial from the other carrier." Two traps: "No program payments shall be made when the third-party payer requires a contracting or participating provider to accept that third-party payer's payment as payment in full," and when NJ FamilyCare is secondary it pays the lesser of its allowed amount minus other payments, or the patient liability. TRICARE and CHAMPVA both pay ahead of Medicaid: TRICARE rules state "Medicaid is not a double coverage plan. In any double coverage situation involving Medicaid, CHAMPUS is always the primary payer," and CHAMPVA "assumes primary payer status" over Medicaid. [9][17][18][19]
- **Diagnosis recency** _(ask the plan)_: Not published. Aetna Better Health of New Jersey's provider manual (August 2026) and its behavioral health prior authorization form set no maximum age for the diagnostic report: the form asks for the ICD-10/DSM-5 code, the treatment plan and current clinical data, not a dated evaluation. The state's written position runs the same way: Optum's NJ Medicaid entry says a "comprehensive diagnostic evaluation is not required to access ABA services." What the plan does date is the authorization: prior authorization numbers "are valid for the date of service authorized. If a date is not specified, service must be initiated within sixty (60) days after the service was authorized," and the member must be eligible on each date of service. [9][3][5]
  - Ask the plan: Aetna Better Health of New Jersey provider services (1-855-232-3596) or the plan's named ABA clinical contacts on the DMAHS BH integration contact sheet.

## Delivery and billing rules

Coverage decides whether Aetna Better Health of New Jersey pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: The state sets who supervises whom, but no ratio, percentage or caseload cap. The NJ FamilyCare managed care contract’s ABA service description (01/2026): “A BCaBA may only practice under the supervision of a BCBA or BCBA-D. A BCaBA may supervise a Registered Behavior Technician (RBT) or Behavior Technician (BT) but may not create or modify a treatment plan,” and “Behavior Technicians (BTs) are paraprofessionals practicing under the supervision of a BCaBA, BCBA, or BCBA-D.” A BT or RBT “may provide only those services delegated to them by a licensee,” the licensee may not delegate “the assessment of a client, the development of a treatment plan, or the development of interventions,” and the licensee “is responsible for the care a client receives.” The billing side of supervision is the founding DMAHS newsletter’s: 97155 counts only while the analyst is with the child or directing the technician, never for supervision without the technician present. Aetna Better Health of New Jersey publishes no technician-per-analyst cap or supervision percentage of its own (its provider manual and behavioral health prior authorization form checked), so no numeric cap applies beyond your contract and the BACB’s RBT supervision standard. [12][4]
- **Concurrent billing (97153 + 97155)**: New Jersey says yes, in writing, and draws the line precisely. “If the QHP is overseeing the activities of the technician, the time of direct supervision by the QHP shall be concurrently billable using code 97155.” But “billing for 97155 is limited to time where the QHP is either engaged directly with the patient or is directing a technician in implementing a modified protocol with the patient. Billing for supervision where the technician is not present is not allowed.” Two other concurrency rules ride along: 97156 may be billed while the RBT delivers direct treatment to the child “in a separate location”; and for 0373T “providers may not bill for the QHP time concurrently” and billing is limited to a single technician’s face-to-face time, never the combined time of multiple technicians (three technicians for two hours bills eight units, not twenty-four). This is NJ FamilyCare state policy and the operative floor for Aetna Better Health of New Jersey; no plan-specific deviation was found in Aetna Better Health of New Jersey’s published material. [4]
  - Ask the plan: Aetna Better Health of New Jersey provider services, to confirm the plan has not layered its own concurrency edit on top.
- **Daily limits / MUEs**: The current rule is the NJ FamilyCare managed care contract, not the 2020 newsletter. The contract’s ABA service description (Appendix B.4.4, 01/2026 edition) sets “Medically Unlikely Edit (MUE) Limits” per day, in 15-minute units: 97151 32, 97152 16, 97153 32, 97154 18, 97155 24, 97156 16, 97157 16, 97158 16, 0362T 16, 0373T 32. That is higher on three codes than the founding DMAHS newsletter’s April 2020 table (97152 8, 97154 12, 0362T 8), which the newsletter labelled “for guidance purposes only” and overridable “when medically necessary based on individual need” under EPSDT. Plan against the contract figures as the edits the MCOs run; a request above them needs explicit EPSDT medical-necessity framing rather than a quiet resubmission. Aetna Better Health of New Jersey’s own ABA Program sheet (4/1/2020) still reprints the older newsletter numbers as its MUE limits; the contract table is the newer one, so confirm with the plan which edit it runs on 97152, 97154 and 0362T. [12][4]
  - Ask the plan: Aetna Better Health of New Jersey’s provider manual / claim-edit list.
- **Session-note signature**: No ABA-specific rule, but the plan's minimum medical-record standards for all practitioners apply: "Signatures — entries are signed and dated by the responsible licensed provider; the responsible licensed provider countersigns care rendered by ancillary personnel; alterations of the record are signed and dated," and every entry must identify its author. Read for ABA, a technician's session note needs the supervising licensed provider's countersignature. No signing deadline is set, but records the plan requests "must be sent to us within 14 days of our request." [9]
  - Ask the plan: Aetna Better Health of New Jersey provider services (1-855-232-3596) — confirm who may countersign technician notes (LBA/BCBA) on audit.
- **Place of service** _(plan-dependent)_: This one has moved and the two live sources disagree. The founding DMAHS newsletter is flat: “ABA services may be provided in the therapist’s office, a community setting or the child’s home. Services may not be provided within a school facility.” Optum’s ABA State Mandates document (annual review 7/2026), whose NJ Medicaid entry tracks the same state policy, now reads: “Services may be provided in the school setting as long as services are not provided during normal school hours.” Office, home and community are settled; school is plan-dependent and moving; group home is addressed by neither. The NJ FamilyCare managed care contract (01/2026) now says: “Services may be provided in the home, provider office or community settings,” and “Covered services do not include services required to be provided in school as part of a child’s Individual Education Plan (IEP).” That carves out IEP services rather than every school building, so school stays a question for the plan. Neither position is republished by Aetna Better Health of New Jersey, so resolve it with the plan before scheduling school-based sessions. [12][4][5]
  - Ask the plan: Aetna Better Health of New Jersey provider services.
- **Bill as provider** _(ask the plan)_: Not published by the plan. Aetna Better Health of New Jersey’s provider manual (updated 5/26) asks for billing and rendering provider details in general but sets no ABA rule on whether technician-delivered 97153 goes out under the technician, the supervising BCBA or the group. The state sets who may render each code: 97152 and 97153 by an RBT or BCaBA; 97151, 97155, 97157 and 97158 by a BCBA or BCBA-D; 97156 by a BCBA-D, BCBA or BCaBA. [4][9]
  - Ask the plan: Aetna Better Health of New Jersey provider services (1-855-232-3596): ask which NPI goes in the rendering field (box 24J / loop 2310B) for technician-delivered ABA.

## What intake should collect for Aetna Better Health of New Jersey

- **ASD diagnosis + QHP script:** The state baseline applies — diagnosis from a physician/psychologist opens the assessment authorization.
- **Urgency classification:** Urgent requests get 24-hour decisions vs. 7 days routine — classify honestly but deliberately.
- **Requested units vs. MUE limits:** Aetna runs the state daily limits as hard claim edits — plan intensity within them or document the EPSDT override.
- **Current 97153 contract rate:** The published sheet predates the state's $15.00 increase — confirm what your contract actually pays.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How Aetna Better Health of New Jersey ABA benefits route and read on an eligibility check. Data last updated 2026-10-15.

### EDI routing

- **Payer ID (pVerify):** 000942 — pVerify 000942 = "AETNA BETTER HEALTH (NJ)" (legacy line "Aetna Better Health NJ-REV" 00921 also exists).
- **Payer ID (Availity):** 46320 — Provider/claims ID 46320 per the Aetna Better Health of NJ provider QRG (Availity / Office Ally).
- **Payer ID (Change Healthcare / Optum):** 46320 — Change Healthcare/Optum lists 46320 = "Aetna Better Health of New Jersey" (supports 270/271).
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** none (Aetna administers BH in-house)
- **BH administrator payer ID:** 46320
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 32 units/day — NJ FamilyCare managed care contract MUE limit (01/2026; the 2020 newsletter's "guidance" table was lower on 97152, 97154 and 0362T); overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97152 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 16 units/day — NJ FamilyCare managed care contract MUE limit (01/2026; the 2020 newsletter's "guidance" table was lower on 97152, 97154 and 0362T); overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97153 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 32 units/day — NJ FamilyCare managed care contract MUE limit (01/2026; the 2020 newsletter's "guidance" table was lower on 97152, 97154 and 0362T); overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97154 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 18 units/day — NJ FamilyCare managed care contract MUE limit (01/2026; the 2020 newsletter's "guidance" table was lower on 97152, 97154 and 0362T); overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97155 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 24 units/day — NJ FamilyCare managed care contract MUE limit (01/2026; the 2020 newsletter's "guidance" table was lower on 97152, 97154 and 0362T); overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97156 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 16 units/day — NJ FamilyCare managed care contract MUE limit (01/2026; the 2020 newsletter's "guidance" table was lower on 97152, 97154 and 0362T); overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97157 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 16 units/day — NJ FamilyCare managed care contract MUE limit (01/2026; the 2020 newsletter's "guidance" table was lower on 97152, 97154 and 0362T); overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 97158 | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 16 units/day — NJ FamilyCare managed care contract MUE limit (01/2026; the 2020 newsletter's "guidance" table was lower on 97152, 97154 and 0362T); overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 0362T | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 16 units/day — NJ FamilyCare managed care contract MUE limit (01/2026; the 2020 newsletter's "guidance" table was lower on 97152, 97154 and 0362T); overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |
| 0373T | Yes | Required via the MCO (assessment + treatment) — NO prior authorization while a member is FFS pending MCO enrollment (a real fast-start window for newly eligible children). | 32 units/day — NJ FamilyCare managed care contract MUE limit (01/2026; the 2020 newsletter's "guidance" table was lower on 97152, 97154 and 0362T); overridable under EPSDT medical necessity per day | home, office/clinic (11), community, telehealth, school (outside normal school hours — see Optum NJ entry) | Allowed; school-setting services permitted outside normal school hours per Optum's Nov 2025 NJ entry (a looser position than the state's original 2020 no-school rule) — confirm per MCO. | Provider-specialty based (RBT / BCaBA render direct codes; BCBA / BCBA-D render assessment/protocol/family codes), H0032 retired for ABA by Horizon eff. 7/15/2026 — use the 97151–97158 / 0362T / 0373T set |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** Aetna's published ABA Program sheet (4/1/2020) reprints the state's 2020 suggested daily limits as MUE (medically-unlikely-edit) claim limits — lower than the current contract table on 97152 (8u), 97154 (12u) and 0362T (8u); confirm which edit the plan runs. Urgent requests decided in 24h, routine in 7 days; submit via Availity or the BH prior authorization form; progress reports via Availity or fax (844) 404-3972.

### Medicaid rates

Source: Aetna Better Health of NJ — ABA Program rate sheet (eff. 4/1/2020), read in full: mirrors the state FFS LAUNCH schedule and reproduces the suggested daily unit limits verbatim as MUE limits. NOTE: this 2020 sheet still shows the launch-era $11.20 on 97153 and $11.20 on 97152 — the state raised 97153 to $15.00 eff 2/1/2022, and whether Aetna followed on its own schedule is UNVERIFIED. Confirm the current contracted 97153 rate directly with the plan. Effective 2020-04-01.

| Code | Rate | Unit | Modifier tiers |
| --- | --- | --- | --- |
| 97151 | $25.00 | 15min | suggestedDailyUnits: 32 |
| 97152 | $11.20 | 15min | suggestedDailyUnits: 8 |
| 97153 | $11.20 (launch sheet; state since raised to $15.00 — verify) | 15min | suggestedDailyUnits: 32 |
| 97154 | $4.80 | 15min | suggestedDailyUnits: 12 |
| 97155 | $21.25 | 15min | suggestedDailyUnits: 24 |
| 97156 | $25.00 | 15min | suggestedDailyUnits: 16 |
| 97157 | $12.40 | 15min | suggestedDailyUnits: 16 |
| 97158 | $5.60 | 15min | suggestedDailyUnits: 16 |
| 0362T | $25.00 | 15min | suggestedDailyUnits: 8 |
| 0373T | $16.40 | 15min | suggestedDailyUnits: 32 |

### Contacts

- **Benefits by phone:** Yes
- **Provider services phone:** 1-855-232-3596
- **Phone menu path:** Press * for healthcare provider. Also serves as Availity registration support routing.
- **Hours:** Mon-Fri 8am-5pm (general contact line also answers 24/7 per the Aetna Better Health NJ portal page)
- **Portal:** [Availity Essentials](https://www.aetnabetterhealth.com/newjersey/providers/portal.html)
- **Fax:** 844-404-3972

Questions to ask on a verification call:

- Can you confirm the current contracted rate for 97153 — our reference (Aetna's 2020 sheet) still shows $11.20, but the state raised the FFS rate to $15.00 in 2022?
- What are today's rates for 97151, 97152, 97154, 97157, 97158, 0362T, and 0373T?
- Which places of service are approved under this member's ABA authorization?

### VOB data sources

- https://www.aetnabetterhealth.com/content/dam/aetna/medicaid/newjersey/pdf/Applied%20behavioral%20analysis%20program.pdf (accessed 2026-07-23; source document older than 18 months)
- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://www.optum.com/content/dam/o4-dam/resources/pdfs/guides/professional-claims-payer-list.pdf (accessed 2026-07-23)
- https://test.njmmis.com/downloadDocuments/5010_270-271_HIPAACompanionGuide.pdf (accessed 2026-07-23)
- https://www.nj.gov/humanservices/dmhas/documents/pdf/resources/providers/DMAHS-BH-Integration-Points-of-Contact.pdf (accessed 2026-07-23)
- https://nj.gov/humanservices/dmahs/documents/providers-stakeholders/hmo-contract.pdf (accessed 2026-10-07)
- https://web.archive.org/web/2023/https://www.nj.gov/humanservices/dmahs/news/Provider_Newsletter_for_Applied_Behavior_Analysis_Therapy.pdf (accessed 2026-07-23)
- https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/scc/ABA_SCC_SM.pdf (accessed 2026-07-23)
- https://autismnj.org/news/autism-new-jerseys-advocacy-leads-to-medicaid-rate-increase-for-aba-services/ (accessed 2026-07-23)
- https://www.aetnabetterhealth.com/newjersey/providers/portal.html (accessed 2026-07-23)
- https://www.aetnabetterhealth.com/content/dam/aetna/medicaid/newjersey/pdf/ProviderQuickReference-NJ.pdf (accessed 2026-10-14)

## Common questions

### What POS and modifier does Aetna Better Health of New Jersey want for telehealth ABA?

Its telehealth page says to bill the same codes as in person with no extra modifier, and to use POS 02. The state’s 2023 Medicaid Alert requires POS 10 when the child is at home, so confirm with the plan which it wants for home sessions.

### How often does Aetna Better Health of New Jersey pay, and is there a weekly cutoff?

Its manual says it generates checks biweekly and lists each payment cycle on a remittance advice. It publishes no submission cutoff. The state contract expects clean behavioral health claims, ABA included, to be processed within 15 days electronic and 30 days paper.

### Can the referring provider on an Aetna Better Health of New Jersey ABA claim be our own BCBA or agency?

No. From October 1, 2026 Aetna Better Health of New Jersey enforces NJ Medicaid edit 1270: "The referring provider NPI cannot be the same as the billing and/or servicing provider NPI." EDI claims are rejected and paper claims denied. Use the referring or diagnosing clinician’s NPI, or leave the field empty if no one referred.

### Does Aetna Better Health of New Jersey cover ABA?

Yes — it administers the NJ FamilyCare ABA benefit closest to the state baseline of all five MCOs, with a published rate sheet and unit limits copied from the DMAHS schedule. PA is required, via Availity or the BH prior auth form.

### What does Aetna Better Health NJ pay for ABA?

Its published 2020 sheet mirrors the state FFS schedule: $25.00 for 97151/97156, $21.25 for 97155, and $11.20 for 97153. The state raised 97153 to $15.00 in February 2022 — whether Aetna followed is unverified, so confirm in your contract.

### How fast does Aetna Better Health NJ decide ABA authorizations?

Urgent requests within 24 hours; routine requests within 7 days. Progress reports go via Availity or fax (844) 404-3972.

### Can NJ FamilyCare ABA be delivered by telehealth, including the 97151 assessment?

Yes. N.J.S.A. 30:4D-6k requires NJ FamilyCare to cover telehealth on the same basis as in-person care, with no originating-site restriction, so the child can be at home. That includes the 97151 assessment and 97155 supervision when medically necessary. No state ABA document sets a code list or POS, so confirm billing with the MCO.

### Does Aetna Better Health NJ Medicaid allow retro auth for ABA?

Its manual lists a post-service review for services with no pre-service request, decided within 30 calendar days, but ABA still requires prior authorization and the manual sets no conditions for accepting a late request. If a commercial plan is primary and covers ABA, Aetna Better Health does not require its own prior authorization.

### Does Aetna Better Health of New Jersey have specific document rules for ABA?

It has a required form, not a template. The BH prior authorization form's ABA section asks for request type, treatment setting, clinical symptoms and a discharge plan, with clinical data, progress, compliance and the treatment plan attached. It names no diagnostic instrument and no diagnosis age limit; technician notes need the licensed provider's countersignature under its medical-record standards.

### What is Aetna Better Health of New Jersey’s timely filing limit?

180 calendar days from the date of service for initial claims, 365 days for corrected claims, and for COB claims 60 days from the primary insurer’s EOB or 180 days from service, whichever is later.

### Does Aetna Better Health of New Jersey bill ABA under the rendering technician or the supervising BCBA?

Its provider manual sets no ABA-specific rule on whose NPI goes on the claim. The state rule is a specialty table: RBTs or BCaBAs render 97152/97153, BCBAs render 97151, 97155, 97157 and 97158. Ask the plan’s provider services which NPI it wants in the rendering field.

## Primary sources

1. [Aetna Better Health NJ — ABA Program rates (eff. 4/1/2020)](https://www.aetnabetterhealth.com/content/dam/aetna/medicaid/newjersey/pdf/Applied%20behavioral%20analysis%20program.pdf)
2. [DMAHS BH Integration Points of Contact V3.1 — Aetna ABA contacts](https://www.nj.gov/humanservices/dmhas/documents/pdf/resources/providers/DMAHS-BH-Integration-Points-of-Contact.pdf)
3. [Aetna Better Health NJ — BH prior authorization request form](https://www.aetnabetterhealth.com/content/dam/aetna/medicaid/new-jersey-medicaid/provider/pdf/aetna_bh_prior_auth_form.pdf)
4. [DMAHS Provider Newsletter Vol 30 No 06 — Provision of ABA services (4/1/2020)](https://web.archive.org/web/2023/https://www.nj.gov/humanservices/dmahs/news/Provider_Newsletter_for_Applied_Behavior_Analysis_Therapy.pdf)
5. [Optum ABA State Mandates BH803ABASTM12026 — NJ Medicaid entry](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/guidelines/scc/ABA_SCC_SM.pdf)
6. [Autism NJ — Medicaid rate increase for ABA services](https://autismnj.org/news/autism-new-jerseys-advocacy-leads-to-medicaid-rate-increase-for-aba-services/)
7. [Optum/UHC Community Plan — NJ FamilyCare ABA Provider Orientation (2022)](https://public.providerexpress.com/content/dam/ope-provexpr/us/pdfs/clinResourcesMain/autismABA/njaba/NJ.FamilyCare.Medicaid.ABA.pdf)
8. [P.L.2021, c.310 — amends N.J.S.A. 30:4D-6k (Medicaid/NJ FamilyCare telehealth coverage) and 26:2S-29 (carrier telehealth coverage)](https://nj.gov/treasury/pensions/documents/laws/ch310-2021.pdf)
9. [Aetna Better Health of New Jersey — Provider Manual](https://www.aetnabetterhealth.com/content/dam/aetna/medicaid/new-jersey-medicaid/provider/pdf/aetna_provider_manual.pdf)
10. [Aetna Better Health of New Jersey — Telehealth services (provider page)](https://es.aetnabetterhealth.com/newjersey/providers/telehealth.html)
11. [DMAHS Medicaid Alert MA-2023-02 — Facility Code (place of service) values for telehealth (April 2023)](https://www.njmmis.com/documentDownload.aspx?document=MA-2023-02.pdf)
12. [NJ FamilyCare Managed Care Contract (01/2026) — Art. 7.16.5 timely payments; App. B.4.4 ABA service description](https://nj.gov/humanservices/dmahs/documents/providers-stakeholders/hmo-contract.pdf)
13. [DMAHS Newsletter Vol 36 No 09 — EVV compliance requirements for MCO providers billing PCA and Home Health Services (Sept 2026; eff. 1/1/2027)](https://www.njmmis.com/documentDownload.aspx?document=36-09.pdf)
14. [Aetna Better Health of New Jersey — Provider notices & newsletters (notices archive)](https://www.aetnabetterhealth.com/newjersey/providers/notices-newsletters.html)
15. [Aetna Better Health of New Jersey — Provider Notification: Upcoming Enforcement of NJ Medicaid Claim Edits (July 16, 2026; effective Oct. 1, 2026)](https://es.aetnabetterhealth.com/content/dam/aetna/medicaid/newjersey/providers/pdf/abhnj_Self_Referral_Claim_Edits_7-16-26.pdf)
16. [42 CFR 438.210(d) — Medicaid managed care authorization timeframes (eCFR)](https://www.ecfr.gov/current/title-42/section-438.210)
17. [N.J.A.C. 10:49-7.3 — Third-party liability (TPL) benefits (LII)](https://www.law.cornell.edu/regulations/new-jersey/N-J-A-C-10-49-7-3)
18. [32 CFR 199.8 — TRICARE double coverage (eCFR)](https://www.ecfr.gov/current/title-32/section-199.8)
19. [38 CFR 17.272 — CHAMPVA benefit limitations; Medicaid exception (eCFR)](https://www.ecfr.gov/current/title-38/section-17.272)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.