For an intake team in Colorado, a Aetna card means three layers at once: the carrier's national clinical policy, Colorado's autism insurance mandate (C.R.S. § 10-16-104(1.4)), and the plan's funding type deciding which of the two actually binds. This guide stacks them in order. Note the contrast with Colorado Medicaid: Aetna's commercial policy requires an ASD diagnosis, while Health First Colorado does not — so a family that qualifies for Medicaid ABA without a diagnosis will still need one here.
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 Colorado is the legal floor underneath it: the state mandate below governs what fully-insured 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 Colorado.[2][3][9][10][6]
Reauthorization: Aetna’s ABA medical necessity guide says “A member’s progress is to be evaluated every six months.” It calls for “Repeated measurement with standardized measures to assess progress” and a standardized functional-impairment score (Vineland-3, ABAS, VB-MAPP or ABLLS) from the past 12 months. Target behaviors need objective baselines and “quantifiable criteria for progress.” Document the improvement, or, where there was none, the treatment modifications, added assessments or consultations. The guide does not require graphs.[2][3][9][10][6]
Code set: Aetna’s ABA policy table lists CPT 97151–97158 plus 0362T and 0373T. No HCPCS H-code (H0031, H0032, H2014, H2019) is listed for ABA.[2][3][9][10][6]
Colorado's mandate — C.R.S. § 10-16-104(1.4), originally 2009's SB 09-244 — is one of the stronger ones in our directory: it applies to all health benefit plans issued or renewed in Colorado except short-term limited-duration policies and individual grandfathered plans, carries no age limits, and carries no dollar caps — the historical $34,000/year (birth-8) and $12,000/year (9-18) ABA caps no longer appear in the current statute text, and carriers may not deny or restrict coverage because of an ASD diagnosis or utilization of mandated benefits. The statute also defines "autism services provider" with six qualification pathways reaching down to BACB Registered Behavior Technician. Self-funded ERISA plans are exempt by federal preemption, and MHPAEA parity applies on top for plans covering mental-health benefits — the caps' removal from the statute aligns the mandate with parity rather than fighting it.[4]
We checked: Aetna publishes no Colorado-specific ABA policy, form, or supplement — the national policy plus the state mandate is the whole picture. That's worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where Colorado-specific answers come from, not a carrier document.[3]
Colorado currently requires no state license to practice behavior analysis — BCBA/BACB certification is the operative credential. That is changing: HB26-1425 (signed June 2, 2026) creates a Colorado Behavior Analyst Licensing Board under DORA's Division of Professions and Occupations, and on and after July 1, 2028 practicing ABA without a behavior analyst or assistant behavior analyst license becomes a class 2 misdemeanor; the law also mandates state licensure of ABA clinics. Practices should put the 2028 licensure conversion on their credentialing roadmap now. On rates: Aetna does not publish commercial ABA fee schedules for Colorado (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement; the Health First Colorado fee schedule (97153 at $17.20/unit for DOS 10/1/2025+) is the published in-state benchmark.[5]
Colorado does not license behavior analysts yet. HB26-1425 creates a Colorado Behavior Analyst Licensing Board in DORA, and “on and after July 1, 2028, an individual is prohibited from engaging in or offering the practice of applied behavior analysis unless the individual is licensed by the board”; unlicensed practice after that date is a class 2 misdemeanor. Until then there is no Colorado behavior analyst license to hold, and BACB certification is the operative credential.[5][7]
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 Colorado by video must meet Colorado’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.[5][7]
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.[11][1]
Corrected and secondary claims: Aetna’s manual and its COB billing tips give no separate deadline for a corrected or secondary claim, and no payment-cycle day or submission cutoff. The COB tips cover how to file a secondary claim electronically (claim filing indicator codes and primary-payer payment fields), not when. Ask Aetna provider services, or check your agreement, for the corrected-claim and COB windows.[11][1]
Aetna’s manual sets no EVV requirement (EVV is a Medicaid rule) and no taxonomy requirement for ABA claims.[11][1]
Colorado’s prompt-pay statute, C.R.S. § 10-16-106.5, requires clean claims to be “paid, denied, or settled within thirty calendar days after receipt by the carrier if submitted electronically and within forty-five calendar days after receipt by the carrier if submitted by any other means.” A claim that needs more information must get a written explanation of what is missing within thirty calendar days, and absent fraud every claim must be paid, denied or settled within ninety calendar days. A carrier that misses the clean-claim deadline owes 10% annual interest on the amount ultimately allowed, and one that misses the ninety-day deadline owes a penalty of 20% of that amount. 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.[8]
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).”[11][12]
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.[11][12]
The questions that decide whether a family can start with Aetna in Colorado, 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.[6]
"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.[6]
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.[6]
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.[6]
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.[13]
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.
Colorado's mandate carries no age limit: C.R.S. § 10-16-104(1.4) applies to all health benefit plans issued or renewed in the state except short-term limited-duration policies and individual grandfathered plans, with no age terms and no dollar caps (the cap language was struck effective 1/1/2017). The carrier's national ABA policy adds no age bound of its own, so age comes from the benefit document — and self-funded ERISA plans sit outside the mandate entirely.[4][6]
Ask the plan: Benefits verification on the specific plan — funding type first, then the ABA benefit terms.
Depends on how the plan is funded. Fully insured Colorado plans follow C.R.S. § 10-16-112.5: within five business days after receipt the carrier must say the request is "approved, denied, or incomplete" (naming the missing information), then decide within five business days after receiving it; urgent requests within "two business days but not longer than seventy-two hours." If the carrier misses those deadlines the request "is deemed granted" — but the provider must send any requested information within two business days of the notice or loses that protection. An approval "is valid for at least one hundred eighty days after the date of approval and continues for the duration of the authorized course of treatment." Self-funded (ERISA) plans follow the federal claims rule instead: pre-service decisions within 15 days of receipt (one 15-day extension), urgent within 72 hours. Aetna's office manual and ABA medical-necessity guide publish no ABA-specific decision clock.[14][15]
Ask the plan: Benefits verification: fully insured Colorado policy (5-business-day clock, 180-day approvals, deemed-granted rule) vs. self-funded ERISA plan (15 days / 72 hours).
For a child on two parents' plans, Colorado's group coordination-of-benefits regulation (fully insured plans): parents married or living together — "The plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (same birthday → the plan that covered the parent longer); otherwise a court decree controls, and without one the order is custodial parent, custodial parent's spouse, non-custodial parent, then the non-custodial parent's spouse. Self-funded plans set their own order in the plan document. Aetna says it follows the NAIC order-of-benefit rules, "as allowed by state or federal law," including the birthday rule, and that many self-funded plans use maintenance of benefits. If the child also has TRICARE, this plan pays first — TRICARE is the secondary payer to other health insurance under its double-coverage rule (Medicaid is the only coverage it pays ahead of). CHAMPVA likewise pays last: "In double coverage situations, CHAMPVA would be the last payer." If the child also has Medicaid, this plan is primary and Medicaid pays last.[16][11][17][18][19]
Ask the plan: Benefits verification with both plans: funding type, which is primary for the child, and whether the secondary plan requires its own authorization.
Coverage decides whether Aetna in Colorado 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. It does size the supervision authorization: QHP protocol modification and direction “at 1 to 2 hours per 10 hours of treatment by protocol.”[6]
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.[11][6]
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.[6]
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.[3][10]
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.[6]
Ask the plan: Aetna provider services; confirm before promising a family more than four hours a day of 97153.
No. The ABA medical necessity guide requires progress evaluated every six months with repeated standardized measures, objective baselines and quantifiable progress criteria, and a standardized functional score from the past 12 months. It does not specify graphs.
Yes — under the carrier's national policy for ASD, layered on Colorado's mandate (C.R.S. § 10-16-104(1.4)) for fully-insured plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.
It applies to all Colorado-issued or renewed health benefit plans (short-term limited-duration and individual grandfathered plans excepted), with no age limits and no dollar caps — the historical $34K/$12K annual ABA caps were removed from the statute. Self-funded ERISA plans are exempt by preemption.
Yes — ASD only (ICD-10 F84.0 and F84.3–F84.9 in the ABA Medical Necessity Guide) per the national policy, unlike Health First Colorado, which opens its benefit without an autism diagnosis. If a family lacks a diagnosis and holds a commercial Aetna plan, the diagnostic evaluation comes first.
Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against the Health First Colorado fee schedule, and treat rate-setting as part of contracting.
Colorado has no behavior analyst license yet; HB26-1425 makes one mandatory from July 1, 2028. 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.
Colorado law (C.R.S. § 10-16-106.5) gives a fully insured plan 30 calendar days to pay, deny or settle a clean electronic claim (45 for paper), 90 days for any claim absent fraud, with 10% interest and a 20% penalty after 90 days. 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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