For an intake team in Washington, an Aetna card means three layers: Aetna’s national ABA criteria, the District’s habilitative-services mandate in D.C. Code § 31-3272, and the plan’s funding type. In the District, check one more thing than usual: federal employee plans are outside the DC statute.
Aetna’s ABA medical necessity guide (©2026) requires a DSM-5 ASD diagnosis by an appropriate provider, services provided or billed by an appropriately licensed or certified provider, functional impairment on a standardized scale in the past 12 months (at least one standard deviation below the mean, or significant risk of harm), and a measurable plan with transition and discharge criteria; hours follow a severity grid. CPB 0554 makes ABA experimental for non-ASD indications. Aetna’s behavioral health precertification list names all ten ABA codes. The guide’s only state exhibit is for Maryland ("Other state laws and regulations may apply in other states"), so no District-specific criteria change the policy. DHCF lists no Aetna Medicaid plan in the District.[1][2][4][19]
The District’s autism coverage rule is a habilitative-services statute, not a stand-alone ABA law. D.C. Code § 31-3272 (D.C. Law 16-198, 2007) requires a health insurer to "Provide coverage of habilitative services for children under the age of 21 years and may do so through a managed care system." Section 31-3271 defines habilitative services as "services, including occupational therapy, physical therapy, and speech therapy, for the treatment of a child with a congenital or genetic birth defect to enhance the child’s ability to function," and says a congenital or genetic birth defect "includes: (A) Autism or an autism spectrum disorder." Denying a habilitative request because the condition is not a birth defect is, by statute, an adverse decision. The coverage "shall not be more restrictive than coverage provided for any other illness, condition, or disorder" for deductibles, durational or dollar limits, visit or treatment limits, and cost sharing. An insurer does not have to pay for habilitative services "actually delivered through early intervention or school services." The statute itself never names applied behavior analysis. ABA is named in the District’s essential-health-benefit standard: the DC Health Benefit Exchange Authority’s March 22, 2013 resolution defines the habilitative category as services that help a person "keep, learn or improve skills and functioning for daily living, including, but not limited, to applied behavioral analysis (ABA) for the treatment of autism spectrum disorder." CareFirst’s own ASD policy (3.01.015, updated for March 1, 2026) points DC members to § 31-3272 for mandated coverage. Two exclusions matter in Washington especially: the statute’s definition of a health benefit plan excludes "federal employee health plans, pursuant to contracts with the United States government" and Medicare coverage, and self-funded employer plans answer to ERISA rather than District insurance law.[7][8][9][20][18]
The District now licenses behavior analysts, but recently. D.C. Law 25-191 (effective July 19, 2024) gave the Board of Psychology the job of regulating "the practice of behavior analysis" and added a licensed behavior analyst seat to the Board (D.C. Code § 3-1202.11). Under § 3-1207.71 the Board licenses a person who completes a criminal background check, holds "a current certification issued by the Behavior Analyst Certification Board," and has a master’s or higher from a BACB-accredited program, with the education requirement waived for anyone certified by the BACB on or before July 19, 2024. The Mayor was to issue licensure rules (ethics code, education and clinical training, exam, continuing education) within one year. The BACB’s licensure table lists the District (2024, DC Board of Psychology). As of October 2026, though, DC Health’s Board of Psychology page links regulations for psychologists and psychology associates only and shows no behavior-analyst rule or application, so confirm with DC Health whether licenses are being issued before you tell a BCBA they need one. Carriers have not caught up either: CareFirst’s credentialing list still names "Licensed Board-Certified Behavior Analyst (Maryland and Virginia only)" and requires a practitioner to be "licensed in the state where the member receives the service." For telehealth or a BCBA based outside the District, plan on meeting the licensure rule of the place where the child is: DHCF’s telemedicine guidance applies that rule to Medicaid, and ask each commercial plan how it applies it. On rates: commercial ABA rates are negotiated and unpublished. DC Medicaid publishes its ASD fees on the dc-medicaid.com portal, which we could not open.[15][16][17][21][22][23]
D.C. Code § 31-3132 makes an insurer pay a clean claim "within 30 days after the receipt," with interest of 1.5% a month from day 31, 2% from day 61 and 2.5% after day 120, unless it disputes the claim in writing within 30 days and pays any undisputed part. It must allow at least 180 days from the date of service to file. An electronic claim is presumed received within 24 hours. Retroactive denials are limited to 6 months after payment (18 months for coordination-of-benefits cases). Aetna’s provider manual (6/26) ties payment to "the rates and compensation under your agreement," and members cannot be charged more than the contracted rate. Self-funded plans follow their own plan terms.[10][11][6]
Aetna’s Health Care Professional Toolkit (6/26) publishes no claim filing deadline: the limit for initial, corrected and secondary claims is the one in your Aetna participation agreement, and claim disputes "Must be submitted within contractual timeframes." The toolkit defines a clean claim as one "received in a timely manner" with all required data, and says a clean claim "Doesn’t involve coordination of benefits," so secondary claims sit outside the clean-claim clock. It publishes no check-run or weekly cut-off schedule.[10][11][6]
Not as a standing rule. Aetna’s provider manual (June 2026) says a clean claim includes “A corresponding referral (whether in paper or electronic format), if required for the applicable claim,” along with “All the data elements of the UB-04 or CMS-1500.” For behavioral health, which is where Aetna places ABA, “Members may access behavioral health care in three ways: Through direct access to the behavioral health provider; Through a recommendation from the primary care physician or other treatment provider; Through a referral from an employee assistance or student assistance program provider.” So box 17 is needed only when the member’s plan requires a referral for the service; in Aetna Open Access plans “referrals also are not necessary.” Where a PCP referral is required, it must be issued before the visit: “Referrals should not be retroactive.”[6]
Aetna’s ABA medical necessity guide (©2026) sets what a renewal must show: the plan records baseline levels of each target behavior by "frequency, rate, symptom intensity or duration, or other objective measures," with "quantifiable criteria for progress"; where target behaviors have improved, documentation of that improvement is included, and where they have not, documentation of "modification of the treatment, additional assessments that have been conducted, and/or there has been appropriate consultations from other staff or experts." "A member’s progress is to be evaluated every six months," and the guide relies on "Repeated measurement with standardized measures to assess progress." It does not require graphs and sets no data-recency window.[1]
The questions that decide whether a family can start with Aetna in the District of Columbia, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the diagnosis, but impairment must be shown on a standardized scale "in the past 12 months."[1]
An appropriate provider: "licensed psychologist/psychiatrist, physician or other health care professional qualified to diagnose mental health conditions within their scope of practice."[1]
CPB 0648 names ADI-R, ADOS-2, CARS-2 and the Asperger Syndrome Diagnostic Scale; the ABA guide requires a standardized functional measure (VABS-3, ABAS, VB-MAPP or ABLLS as examples).[3][1]
Aetna’s ABA documents require precertification of all ten ABA codes, not a physician referral. For a fully insured District plan, D.C. Code § 31-3272 sets no referral or treatment-plan requirement of its own; it lets the insurer deliver habilitative coverage "through a managed care system," which § 31-3271 defines as review and preauthorization of the treatment plan. Federal employee plans and self-funded ERISA plans sit outside the statute.[4][8][7]
Aetna’s guide sets no age cap; it lists typical age ranges only. For fully insured District plans, D.C. Code § 31-3272 requires habilitative coverage (autism included) for children under 21, with no dollar or visit cap allowed beyond what applies to other conditions. Federal employee plans and self-funded ERISA plans are outside the statute, so funding type decides whether that binds.[1][8][7]
Ask the plan: Live benefits verification: establish fully insured DC, federal employee or self-funded, then the plan’s own age terms.
Aetna’s provider manual (6/26) says Aetna Behavioral Health "offers telehealth services to all commercial fully insured members and to all commercial self-insured plan sponsors, unless those self-insured plan sponsors opt out," and providers must have "the proper licensure based on state requirements." Aetna’s current ABA telehealth code list was not available to us. For a District-regulated plan, D.C. Code § 31-3862 says an insurer "may not deny coverage for a healthcare service on the basis that the service is provided through telehealth if the same service would be covered when delivered in person," must reimburse it, and may review telehealth appropriateness only "in the same manner" as in-person care; cost sharing cannot exceed the in-person amount. The statute names no ABA codes, POS or modifiers, and self-funded and federal employee plans are outside it.[6][12]
Ask the plan: Availity or the precertification line on the card: ask which ABA codes, POS and modifier Aetna pays by telehealth for this plan.
Depends on how the plan is funded. Plans regulated by the District fall under the Prior Authorization Reform Amendment Act of 2023 (D.C. Code ch. 38F). Once it has all required information, a utilization review entity must decide and notify "within … 3 business days of receiving the request via electronic portal or 5 business days of receiving the request via mail, telephone, or facsimile" (24 hours for urgent services), and a request not answered in time "shall be deemed approved." Before an adverse determination it must tell the provider that medical necessity is being questioned and offer a chance to add information. An approval is valid "for at least one year," an approval for a chronic condition stays valid "for as long as medically reasonable and necessary," and it may not be revoked if care is provided within 45 business days. The family gets at least 15 calendar days to appeal. Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1 instead: pre-service decisions "not later than 15 days after receipt of the claim," with one 15-day extension. Aetna publishes no District-specific ABA turnaround or reauthorization lead time.[13][24][25][18]
Ask the plan: At benefits verification ask whether the plan is regulated by the District or self-funded (ERISA), and what reauthorization lead time Aetna expects.
For a child on two plans, the order of benefits comes from the plans’ coordination-of-benefits provisions; we did not read a District COB regulation, so ask Aetna which plan is primary. When a child changes plans mid-treatment, D.C. Code § 31-3875.07 makes a District-regulated plan "honor an approval granted by a previous utilization review entity for at least the initial 60 days" of new coverage. If the child also has DC Medicaid, Aetna pays first: Medicaid pays after other coverage (42 CFR 433.139), and DC’s Medicaid plans require the primary’s EOB with the claim. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270). If a payer later retracts payment because another carrier was primary, § 31-3133 limits that clawback to 18 months and gives you 180 days to bill the right carrier.[14][11][26][27][28]
Ask the plan: Ask Aetna at benefits verification for the member’s coordination-of-benefits order and record every other coverage the child has.
Coverage decides whether Aetna in the District of Columbia pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Aetna’s participation criteria (5/26): ABA services "must be provided directly or supervised by individuals licensed by the state or certified by the Behavior Analyst Certification Board"; supervised staff may be a BCaBA or a paraprofessional; at least "one hour of face-to-face supervision" per "10 hours of applied behavior analysis" by a paraprofessional, plus the supervisor "onsite with the child at least one hour a month." "All BCBAs, BCaBAs and paraprofessionals must meet state requirements."[5][1]
No per-day cap. Typical intensities in the guide are 10–25 hours a week for comprehensive and 1–20 for focused ABA (typical, not limits); QHP protocol modification may be authorized at 1 to 2 hours per 10 hours of treatment.[1]
The guide is setting-neutral for outpatient ABA and expects coordination with the school district. D.C. Code § 31-3272 does not require insurers to pay for habilitative services "actually delivered through early intervention or school services."[1][8]
Services must be provided directly or billed by licensed behavior analysts (where a state licenses them), BCBAs, or licensed psychologists with ABA in scope, unless mandates, plan documents or contracts say otherwise.[1]
Not addressed in Aetna’s published ABA documents (the medical necessity guide, CPB 0554).[1][2]
Ask the plan: Aetna provider services or a written coding determination from Aetna Behavioral Health.
Not addressed in Aetna’s ABA documents.[1]
Ask the plan: Your Aetna participation agreement and the Aetna Behavioral Health provider manual’s documentation section.
No. Aetna’s ABA medical necessity guide asks for objective baseline measures, quantifiable progress criteria, standardized re-measurement and a six-monthly progress evaluation, with treatment changes documented where there is no improvement, but it does not require graphs or set a data-recency window.
Aetna’s provider toolkit publishes no filing limit; the participation agreement sets it for initial, corrected and secondary claims, and a claim involving coordination of benefits is not a "clean claim." No check-run schedule is published.
Only when the member’s plan requires a referral. Aetna’s June 2026 provider manual counts a referral as part of a clean claim only "if required for the applicable claim," and members can reach behavioral health care by direct access. Open Access plans need no referral. Check the member’s plan on the eligibility response.
Yes, under its national ABA guide for ASD. Fully insured DC plans must also cover habilitative services for autism for children under 21 under D.C. Code § 31-3272. Federal employee and self-funded plans follow their own terms.
No. § 31-3272 bars limits on habilitative coverage that are more restrictive than those for other conditions. Its age limit is under 21.
Within 30 days under D.C. Code § 31-3132, with interest after that, and insurers must give you at least 180 days to file. Self-funded plans follow their own terms.
Aetna’s network criteria allow BCBA-supervised paraprofessionals, with at least 1 hour of face-to-face supervision per 10 hours of ABA and the supervisor onsite 1 hour a month, and require staff to meet state requirements.
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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