For an intake team in Indiana, a Aetna card means three layers at once: the carrier's national clinical policy, Indiana's autism insurance mandate (Ind. Code 27-8-14.2), and the plan's funding type deciding which of the two actually binds. This guide stacks them in order.
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 — its 10/14/2026 review names Down syndrome without an ASD co-morbidity, and “all other non-ASD indications.” 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 Indiana 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 Indiana.[1][2][7][8][9]
Indiana’s mandate (2001) was the first autism insurance mandate in the country, and it remains one of the strongest: group accident and sickness policies must cover ASD treatment prescribed by the treating physician under a treatment plan, with no age limits and no dollar, visit, or hour caps — and cost-sharing no less favorable than for physical illness generally. Individual-policy insurers must offer (not automatically include) the coverage, and self-funded ERISA plans are exempt by preemption. There’s little parity tension here because the statute imposes no quantitative limits of its own.[3][4]
We checked: Aetna publishes no Indiana-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 Indiana-specific answers come from, not a carrier document.[1]
Indiana began licensing behavior analysts in May 2025 (IC 25-8.5, via the Professional Licensing Agency’s Behavior Analyst Committee), built on current BCBA/BCaBA certification with biennial renewal. Expect commercial payers to fold the LBA license into credentialing requirements as it phases in. On rates: Aetna does not publish commercial ABA fee schedules for Indiana (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement, so treat rate expectations as a contracting conversation, not a lookup.[5]
Indiana licenses the practice: an individual may not “practice applied behavior analysis” unless the individual “holds a license issued under this chapter” (IC 25-8.5-3-6(a)); the PLA takes reciprocity applications ($75 for an LBA). Indiana’s telehealth law (IC 25-1-9.5) defines a telehealth “practitioner” as someone holding “an unlimited license to practice” in Indiana and lists “a behavior analyst licensed under IC 25-8.5,” so plan on an Indiana license before treating a child located in Indiana remotely.[10][11][12][13]
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 Indiana by video must meet Indiana’s requirements as well as those of the state the BCBA works from, and only codes on Aetna’s Telemedicine and Direct Patient Contact Payment Policy are payable by telehealth.[10][11][12][13]
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.[16]
Indiana’s prompt-pay statute for insurers, IC 27-8-5.7, requires an insurer to pay or deny each clean claim within thirty days after receipt if it was filed electronically and within forty-five days if filed on paper (§ 6). The insurer must tell the provider of any deficiency within the same thirty or forty-five days and describe how to fix it; if it does not, “the submitted claim” is established “as a clean claim” (§ 5). Interest on a late clean claim starts on day 31 (electronic) or day 46 (paper) and runs until payment. 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.[14][15]
Reauthorization: Aetna’s ABA medical necessity guide evaluates progress “every six months.” Each request must show a functional impairment on a standardized scale in the past 12 months (Vineland-3, ABAS, VB-MAPP or ABLLS are the examples), a treatment plan whose target behaviors have recorded baseline levels and “quantifiable criteria for progress,” and either documentation that the frequency of the target behavior improved or, if it did not, documentation of treatment modification, added assessment or expert consultation; the level of impairment must justify the hours requested. Coverage ends on the guide’s thresholds — two or more standard deviations of improvement in multiple domains (one or more for a focused plan), or less than one standard deviation in all domains across successive authorization periods. The guide asks for objective, quantified data; it does not require graphs.[9][1]
Supervision: “additional authorization may be provided for QHP protocol modification and direction at 1 to 2 hours per 10 hours of treatment by protocol,” plus caregiver training. Aetna sets no cap on the number of technicians one behavior analyst may supervise.[9][1]
Code set: CPB 0554 lists the ABA codes as CPT 97151–97158 with 0362T and 0373T. Neither CPB 0554 nor the medical necessity guide lists a HCPCS H-code (H0031, H0032, H2019) for ABA, so whether your Aetna contract pays one is a question for Aetna, not something its policies grant.[9][1]
The questions that decide whether a family can start with Aetna in Indiana, and what they have to bring. Each maps onto something intake should ask on the first call.
The diagnosis must come from a provider qualified to diagnose within their scope — a licensed psychologist, psychiatrist or physician. Aetna's precertification form (GR-69017-4 (7-26), effective 8/1/2026) asks for the DSM-5 diagnosis code, the diagnosing provider and their credentials. Indiana's mandate adds no diagnosing-credential requirement of its own; its only gate is that the treatment be prescribed by the insured's treating physician.[9][3][8]
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. Indiana's April 2026 ban on modifier 95 for 97151/97152/97153/97154/0373T is a Medicaid rule and does not reach a commercial Aetna plan.[17]
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.
None from either direction, which is unusual. The carrier's national ABA policy states no age limit, and Indiana's mandate — the first autism insurance mandate in the country — imposes none either: group accident and sickness policies must cover treatment of an autism spectrum disorder prescribed by the insured's treating physician under a treatment plan, with no age limit and no dollar, visit or hour cap anywhere in IC 27-8-14.2. Individual-policy insurers must only offer the coverage, and self-funded ERISA plans are outside the chapter entirely — so an individual or self-funded plan may lawfully lack the benefit.[3]
Ask the plan: Benefits verification on the specific plan, via the payer portal or the number on the member’s card — ask three things: is this a fully-insured Indiana group policy (the mandate reaches it), an individual policy (IC 27-8-14.2-5 requires only that the coverage be offered, so ask whether this policy took it up), or a self-funded ERISA plan (outside the chapter entirely); and if the plan is outside the mandate, what age or hour limit the plan document itself imposes on ABA.
Yes on a fully-insured Indiana group plan, and it is the statute that requires it: coverage is “limited to treatment that is prescribed by the insured's treating physician in accordance with a treatment plan.” The mandate names no credential for the person delivering the service — that comes from the carrier and from Indiana's separate licensure chapter — but the treating physician's prescription is a coverage condition. Capture the prescribing physician and the plan they signed off on. Individual policies (offer-only) and self-funded ERISA plans are outside the chapter.[3]
Ask the plan: Benefits verification on the specific plan, via the payer portal or the number on the member’s card — confirm the funding type first, because the statutory prescription requirement only reaches fully-insured Indiana group policies. On an individual or self-funded ERISA plan, ask the carrier directly whether it requires a treating-physician prescription and a treatment plan, and get the answer with the authorization.
Depends on how the plan is funded. A fully insured plan issued in Indiana (group, individual or HMO) falls under IC 27-1-37.5-23, in force since July 1, 2025: urgent PA answered “not later than twenty-four (24) hours after receiving the request,” every other PA “not later than forty-eight (48) hours,” with weekends and state and federal holidays excluded; a missed deadline means the service “shall be automatically deemed authorized” (IC 27-1-37.5-28). A self-funded private-employer plan follows the federal ERISA claims rule instead: urgent within 72 hours; pre-service within a reasonable time “but not later than 15 days after receipt of the claim,” with one 15-day extension; and a request to extend an ongoing course of treatment that involves urgent care must be decided within 24 hours if made at least 24 hours before the authorization expires. Aetna publishes no ABA-specific reauthorization lead time in the precertification materials cited in this guide.[18][19][20]
Ask the plan: Benefits verification call or the Aetna (Availity) provider portal: ask whether the plan is fully insured and issued in Indiana (state 24/48-business-hour clock) or self-funded ERISA (federal 72-hour / 15-day clock), and what turnaround the plan quotes for ABA.
Depends on the family and on plan funding. For a fully insured Indiana group plan, 760 IAC 1-38.1 sets the order: the plan covering the person as employee or subscriber pays before one covering them as a dependent; for a child whose parents are married or living together, “the plan of the parent whose birthday falls earlier in a calendar year” is primary (same birthday: the plan that has covered that parent longest); for parents who are divorced, separated or do not live together, with no court decree, the order is custodial parent, custodial parent's spouse, noncustodial parent, noncustodial parent's spouse — and a decree that makes one parent responsible for health coverage overrides it. A self-funded ERISA plan sets its COB rules in its plan document instead. TRICARE is always “last pay” behind other health coverage (32 CFR 199.8), so this plan pays before TRICARE. If the child also has Indiana Medicaid, this plan pays first and IHCP pays last — but IHCP still requires its own PA (“must also obtain PA from the appropriate IHCP PA contractor”) and will not pay for services this plan denied as out-of-network, so be in this plan's network and get both authorizations.[21][22][23][24][25][26]
Ask the plan: At intake, collect every coverage the child has, both parents' birthdays and any custody or court-decree terms; then ask Aetna (and the other carrier) on the benefits call whether each plan is fully insured or self-funded and which one they show as primary.
Aetna publishes no recency rule for the ASD diagnostic evaluation, and Indiana's mandate sets none for commercial plans — the one-year CDE rule in this state belongs to Indiana Medicaid, not to IC 27-8-14.2. Capture the evaluation date anyway. Precertification form GR-69017-4 (7-26) asks for the diagnosis code and the diagnosing provider and credentials, and puts its date test on the standardized assessment instead: results "completed within the past 12 months."[8][1][3]
Ask the plan: The precertification call or Availity, when submitting form GR-69017-4 — ask whether an evaluation of this age will be accepted for this plan.
No instrument is named. CPB 0554 does not require or reference a specific diagnostic tool, and the precertification form asks for the DSM-5 diagnosis code, the diagnosing provider and their credentials rather than for an instrument and score. Indiana's mandate names none either, and defines autism spectrum disorder only by reference to the DSM.[1][3]
Ask the plan: Aetna precertification (Availity or the number on the card) — ask whether a specific instrument is expected for this plan before scheduling testing.
Coverage decides whether Aetna in Indiana 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.
Practitioners delivering ABA under Aetna's ABA Medical Necessity Guide need BACB national certification or state behavior-analyst licensure, with unlicensed staff working under supervision per practice standards; Aetna publishes no numeric ratio. Indiana now supplies the licensure half: LBA and LABA applications went live May 13, 2025 and practising applied behavior analysis without the licence is prohibited, with direct-contact technicians exempt only while acting under the extended authority and direction of a licensed analyst. Aetna’s medical necessity guide does authorize the analyst’s time against a ratio: QHP protocol modification and direction “at 1 to 2 hours per 10 hours of treatment by protocol”; it sets no cap on the number of technicians per analyst.[9][5][6]
Aetna publishes no per-day or per-week unit ceiling for ABA. Its ABA medical necessity guide sets typical intensities — 10–25 hours a week for comprehensive and 1–20 hours a week for focused ABA — as typical, not caps, and ties authorized hours to documented severity on its symptom-severity scale; QHP protocol modification is authorized at 1–2 hours per 10 hours of treatment. CPB 0554 lists the ABA codes but sets no unit limit, so the operative ceiling is the precertification, which lists requested hours code by code.[9][1]
Not published. Neither CPB 0554 nor CPB 0648 states whether 97155 and 97153 may be billed for the same clock time, and Aetna publishes no Indiana-specific ABA policy, form or supplement.[1]
Ask the plan: Availity Essentials for the plan's reimbursement and claim-editing policies, or the provider-services number on the member's card.
Not published. CPB 0554 and CPB 0648 set coverage criteria, and form GR-69017-4 sets precertification content; none states what a session note must contain, who signs it, or by when.[1]
Ask the plan: Aetna provider services or Availity — ask for the documentation standard applied at audit, and keep to the precertification form's own data elements in the meantime.
Not published as a payable-settings list. What Aetna does make a submission requirement is adjacent and useful: precertification form GR-69017-4 (7-26) asks for concurrent services — PT, OT, speech and school services — plus how care is coordinated across them, and asks "Are any ABA hours being requested during class?" — so the school picture is data Aetna collects even though it publishes no school-versus-home rule. CPB 0648 adds that "Many Aetna plans exclude coverage of educational services. For example, speech therapy or ABA services during class would be excluded under these plans."[8][2]
Ask the plan: Benefits verification on the specific plan — ask which places of service are payable for ABA and whether school-based delivery is excluded.
Not published for ABA. Aetna's ABA Medical Necessity Guide sets who may deliver or bill the service — BACB-certified or state-licensed behavior analysts, with unlicensed staff supervised — but does not state whose NPI carries a technician-delivered 97153 claim, or which degree-level modifiers apply, and Aetna publishes no Indiana-specific ABA supplement. Indiana supplies the licensure half: the supervising analyst must hold the state LBA (or LABA) licence, and direct-contact technicians are exempt from licensure only while acting under the extended authority and direction of a licensed behavior analyst.[9][6]
Ask the plan: Aetna provider services or Availity — confirm the rendering-versus-billing NPI convention and any required degree-level modifiers before the first claim.
Yes — under the carrier's national policy for ASD, layered on Indiana's mandate (Ind. Code 27-8-14.2) for fully-insured plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.
Indiana’s mandate (2001) was the first autism insurance mandate in the country, and it remains one of the strongest: group accident and sickness policies must cover ASD treatment prescribed by the treating physician under a treatment plan, with no age limits and no dollar, visit, or hour caps — and cost-sharing no less favorable than for physical illness generally. See the mandate section above for ages, caps, and exemptions — and remember federal parity limits how hard the numeric caps can be enforced against group plans.
Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against the Indiana Medicaid fee schedule where one exists, and treat rate-setting as part of contracting.
Indiana requires an Indiana license (IC 25-8.5-3-6), and its telehealth law counts only Indiana-licensed behavior analysts as practitioners. 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.
Indiana law (IC 27-8-5.7-6) requires an insurer to pay or deny a clean claim within 30 days of receipt if filed electronically and 45 days on paper; a deficiency not flagged within that window makes the claim clean. Self-funded employer plans are not bound by the statute.
Aetna's precertification form GR-69017-4 (7-26), which replaced its other ABA forms from August 1, 2026 (Maryland and Massachusetts excepted), lists them. It asks for the current DSM diagnosis code and the diagnosing provider's name and credentials, plus hours by code (assessment codes per authorization period, treatment codes per week) and any hours during class. Supporting documents: "Results of a standardized assessment (i.e. Vineland, ABAS, VB-MAPP) completed within the past 12 months," with the IQ if available. Add a time-limited treatment plan with baselines and measurable targets, FBA or skills-assessment results, data showing severity justifies the hours, measurable caregiver goals, titration and discharge criteria, and coordination with other providers. Start the request on Availity or by phone and attach the form and records.
Aetna’s ABA medical necessity guide reviews progress every six months and requires quantified baseline and progress data, a standardized functional scale from the past 12 months, and documentation of improvement (or of treatment changes when there is none). It does not require the data to be graphed.
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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