Aetna Better Health of West Virginia is one of the four Mountain Health Trust MCOs and, by BMS designation, "the single managed care organization" for Mountain Health Promise, the specialized program for children in foster, kinship and adoptive care (about 23,574 children, per BMS). Members eligible for the Children with Serious Emotional Disorder Waiver are automatically enrolled with it too. So a foster child’s ABA almost always runs through this plan.
The plan’s 2026–2027 provider manual does not name ABA, but its Behavioral Health Prior Authorization Request has a dedicated ABA section, and BMS Policy 519.23 sets the eligibility floor the plan works from.
Aetna Better Health’s Behavioral Health Prior Authorization Request lists "APPLIED BEHAVIOR ANALYSIS (ABA)" as Section 6. It asks whether the request is initial or concurrent (and how long services have run), the treatment setting, clinical symptoms or social barriers, and a discharge plan, and for ABA it wants the treatment plan attached along with clinical data, progress on target behaviors, and compliance with treatment. "For initial ABA requests, include progress or lack-of, with any previous treatment interventions." Every request needs the signed attestation; incomplete forms "may lead to delays in processing or lack of authorization." The form tells providers to check its ProPAT search tool to see whether a service needs PA and recommends Availity for submission and status checks. UM is reachable at 1-844-835-4930.[2][1][6]
For medical necessity the manual lists, in order, "Criteria required by applicable state or federal regulatory agency," then Aetna Medicaid guidelines, MCG, LOCUS/CALOCUS, ASAM, Aetna Clinical Policy Bulletins and other criteria. For ABA the state regulatory criteria are BMS Policy 519.23: ages 18 months through 20, ASD diagnosed before age 8, a diagnostic assessment from the past 24 months, an annual physician’s order, and the 40-hour weekly cap. A peer-to-peer request "must be received within 5 business days of the date the denial of coverage determination was sent" (medical directors at 1-833-459-1998).[2][1][6]
BMS runs Mountain Health Promise under a 1915(b) waiver effective March 1, 2021, and names Aetna Better Health of West Virginia as its only MCO. The SFY 2026 Mountain Health Promise contract holds the plan to the same authorization clock as the rest of Medicaid managed care: standard decisions "no later than five (5) business days of receiving the request" (extendable by up to 14 calendar days), expedited decisions within two business days, peer-to-peer appeals within five business days and PA appeals within ten (W. Va. Code § 9-5-32). Clean claims must be paid "within thirty (30) calendar days of receipt," with interest at 18% a year after that. BMS Policy 519.23 also says members in foster care "should receive assessment as quickly as possible." The plan’s manual adds that Mountain Health Promise members "are not able to opt out" of its case management unless they are adopted care members or youth who aged out of foster care while enrolled in WV Medicaid, so expect a case manager in the loop alongside the caseworker.[4][5][6][1]
New claims must be filed "within 365 days from the date services were performed"; coordination-of-benefits claims have 365 days from the primary remittance advice, and resubmissions 120 days from the original remittance. Provider appeals "must be received 90 days from original denial." Clean claims are paid within 30 days of receipt. The EDI payer ID is 128WV. The plan pays contracted rates, which are not published; the public benchmark is the BMS ABA fee schedule (97153 $9.90 and 97155 $29.14 per 15 minutes).[1][9]
The questions that decide whether a family can start with Aetna Better Health of West Virginia, and what they have to bring. Each maps onto something intake should ask on the first call.
The plan publishes no ABA age rule, so the state rule applies. Ages 18 months through 20. Policy 519.23.1 makes ABA available to "Medicaid members ages 18 months through age 20 with a primary diagnosis of Autism Spectrum Disorder (ASD) prior to their eighth birthday" who are referred for diagnostic and treatment services identified during an EPSDT encounter.[1][6]
The plan publishes no rule of its own. Within 24 months. The PA request must include "the qualifying diagnostic assessment establishing the ASD diagnosis prior to age eight and completed within the previous 24 months" and "A comprehensive diagnostic assessment completed by a qualifying provider within the previous 24 months" (519.23.6). The first request must also document that the primary diagnosis "was rendered prior to the child’s eighth year of age" (519.23.2).[1][6]
The plan publishes no list of its own. Policy 519.23.2 names the "qualified diagnostic provider": a licensed physician "such as a neurologist, pediatric neurologist, developmental pediatrician, psychiatrist, supervising psychologist, or a licensed psychologist, licensed independent social worker, licensed independent counselor." The glossary’s narrower definition of "Diagnostic Assessment" lists only physicians (neurologist, pediatric neurologist, developmental pediatrician, psychiatrist) and licensed psychologists, so a psychologist or physician diagnosis is the safe choice.[1][6]
The plan publishes nothing different from the state. Yes. Members must be "referred for necessary diagnostic and treatment services identified during an Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) encounter" (519.23.1), and every PA request must include "The annual physician’s order for ABA Services" (519.23.6).[1][6]
The plan publishes no ABA telehealth rule of its own, so the state rule applies. BMS lists every ABA code it pays except 97157 on its telehealth code list: Appendix A to Policy 519.17 (effective 1/1/2025) carries 97151, 97152, 97153, 97154, 97155, 97156 and 97158 with "provisional" status, meaning "temporarily approved for telehealth" and "subject to review." Policy 519.23 says telehealth "must align with" Policy 519.17, which requires real-time audio and video, POS 02 (or POS 10 when the member is at home, since January 1, 2022), written member consent, notes that record the telehealth mode, and HIPAA-compliant platforms. Two cautions: Policy 519.17’s list of distant-site practitioners does not name behavior analysts, and it requires interstate telehealth practitioners to register "with the appropriate board in West Virginia," a board that does not exist for BCBAs. Confirm with BMS or the MCO before building a remote program.[8][7][1]
Standard (non-urgent) pre-service decisions within 5 business days of receipt, extendable by up to 14 calendar days; urgent requests "processed within 2 calendar days." The Mountain Health Promise contract and W. Va. Code § 9-5-32 set the same five-business-day standard, with incomplete requests returned within two business days and decided within two business days of the missing information.[1][2][5][11]
"Aetna Better Health shall be used as a source of payment for covered services only after all other sources of payment have been exhausted." COB claims must arrive "within 365 days from the member’s primary carrier remittance advice date" with the primary RA, and providers must follow Aetna Better Health’s authorization rules "even when Aetna is not the primary payer."[1][13]
Neither the plan nor BMS names a diagnostic instrument. The plan wants clinical data, target behaviors and progress with the request; BMS wants severity levels, baseline data and an annual functional assessment of adaptive skills.[2][6]
Ask the plan: Aetna Better Health of WV UM, 1-844-835-4930: ask which standardized instruments it expects with an initial ABA request.
Coverage decides whether Aetna Better Health of West Virginia 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.
The plan publishes no ABA supervision rule of its own, so the state rule applies. BMS sets no numeric supervision ratio. Policy 519.23.4 recognizes a BCBA (master’s or BCBA-D), a BCaBA "working under the supervision of a BCBA or who meets Behavior Analyst Certification Board supervisor requirements," and an RBT "working under the supervision of a BCBA or BCaBA who meets the Behavior Analyst Certification Board supervisor requirements," each only while BACB certification is "current and in good standing." The glossary adds that BCaBA "Competency and supervision must be verified annually and submitted to supervisor," and that BMS follows the BACB ethics code. Group skills training is limited to "four members to each staff person."[1][6]
The plan publishes no ABA unit cap of its own; BMS Policy 519.23’s limit is 40 hours a week and/or 8 hours in 24 hours across 97151–97156 and 97158, with H0031 once a year. Authorized units are set per request.[1][6]
The PA form asks for the "TREATMENT SETTING" on every ABA request; the manual sets no ABA setting rule. Under state policy, services may be delivered in the member’s natural environment, educational services cannot be authorized, and school-administered services are outside managed care.[2][6][10]
The plan publishes no ABA concurrent-billing rule. BMS Policy 519.23 requires documentation showing "only one staff person’s time is billed for any specific activity," which the plan has not said it departs from.[1][6]
Ask the plan: Aetna Better Health of WV Provider Relations, 1-888-348-2922: ask whether 97153 and 97155 may be billed for the same minutes.
The plan publishes no ABA-specific billing rule. Under BMS Policy 519.23, the BCBA or BCaBA "may bill" the RBT-delivered codes (97152, 97153, 97154), and every MCO network provider must also be enrolled with West Virginia Medicaid (Chapter 527).[1][6][10]
Ask the plan: Aetna Better Health of WV Provider Relations, 1-888-348-2922: confirm the rendering NPI expected on RBT lines.
Yes. ABA is a West Virginia Medicaid state-plan service under BMS Policy 519.23, and the plan’s Behavioral Health Prior Authorization Request has a dedicated ABA section.
Yes. Foster, kinship and adoptive-care children are in Mountain Health Promise, and Aetna Better Health of West Virginia is its only MCO. The same BMS ABA rules apply, and BMS says foster children "should receive assessment as quickly as possible."
Within 5 business days for standard requests (extendable up to 14 calendar days) and 2 calendar days for urgent ones.
365 days from the date of service for new claims, 365 days from the primary remittance for COB claims, and 120 days from the original remittance for resubmissions. Provider appeals are due within 90 days of the denial.
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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