For an intake team in Louisiana, an Aetna card means three layers: Aetna’s national ABA criteria, Louisiana’s autism mandate in R.S. 22:1050, and the plan’s funding type, which decides whether the mandate applies. Aetna Better Health of Louisiana, the Medicaid plan, has its own guide.
Aetna’s ABA medical necessity guide (©2026) requires a DSM-5 ASD diagnosis from an appropriate provider, services "provided directly or billed by licensed behavior analysts (in states with behavior analyst licensure laws), board-certified behavior analysts, or licensed psychologists," functional impairment on a standardized scale administered in the past 12 months, a measurable treatment plan with titration and discharge criteria, and hours that match the documented severity; progress is reviewed every six months. Its only state exhibit is Maryland, so Louisiana plans get the national criteria plus whatever state law requires. The behavioral health precertification list (effective August 1, 2024) names all ten ABA codes.[1][2]
Louisiana’s autism mandate is La. R.S. 22:1050. Any "health coverage plan" issued, delivered or renewed in the state on or after January 1, 2014 must "provide coverage for the diagnosis and treatment of autism spectrum disorders in individuals less than twenty-one years of age," and the definition of a health coverage plan reaches insurance policies, HMO and PPO contracts, group plans and the Office of Group Benefits programs (state employees). Treatment includes habilitative care, defined to include applied behavior analysis, plus pharmacy, psychiatric, psychological and therapy care, but only care "prescribed, provided, or ordered" by "a physician or psychologist who shall be licensed in this state and who shall supervise provision of such care." Coverage may not be limited by visit count and may carry ordinary copays and deductibles, but it "shall be subject to a maximum benefit of thirty-six thousand dollars per year," and payments for unrelated care do not count toward that cap. An ABA provider must be BACB-certified or able to document equivalent education, training and supervised experience. Plans may review treatment against medical-necessity criteria "based in part on evidence of continued improvement," with appeal rights under R.S. 22:1121 et seq. The statute does not apply to individually underwritten guaranteed-renewable policies or limited-benefit policies, and self-funded employer plans answer to ERISA rather than state insurance law. legis.la.gov notes its text is current through the 2025 First Extraordinary Session.[5]
Louisiana licenses behavior analysts (La. R.S. 37:3701 et seq.; the BACB lists Louisiana’s law as enacted in 2013). The Louisiana Behavior Analyst Board issues three credentials: the licensed behavior analyst (LBA, master’s degree plus a nationally accredited exam and a Louisiana jurisprudence exam), the state-certified assistant behavior analyst (SCABA, bachelor’s level, practicing under an LBA), and the registered line technician (RLT, 18 or older with a high school diploma, registered with the board by the supervising LBA and renewed every year). It is a misdemeanor for anyone not licensed, certified or registered "to engage in the practice of behavior analysis," and to "employ as a line technician, a line technician who is not registered." Licensed psychologists may provide ABA within their training. Out-of-state BCBAs: BACB certification alone does not authorize practice in Louisiana. The board may make rules for temporary licensure and for reciprocity from states with standards "at least as stringent," and the Telehealth Access Act (R.S. 40:1223.4) requires each licensing board to provide by rule for "Licensing or registration of out-of-state healthcare providers who seek to furnish healthcare services via telehealth to persons at originating sites in Louisiana." We could not open the board’s own rules (its website is behind a captcha), so confirm the current telehealth or temporary-licensure route with the board before a remote BCBA treats a Louisiana child. The chapter is scheduled to terminate on July 1, 2028 unless the legislature extends it. On rates: commercial ABA rates are negotiated and unpublished; the public benchmark is the Louisiana Medicaid fee schedule (97153 $12.50 and 97155 $22.50 per 15 minutes), which Medicaid MCOs must pay at least.[6][7][8][9][10][11][12][13][18][19]
Louisiana’s prompt-pay law covers contracted providers of fully insured plans: an electronic clean claim "shall be paid, denied, or pended not more than twenty-five days" after receipt (R.S. 22:1833), a paper clean claim filed within 45 days of service within 45 days (60 days if filed later or resubmitted) (R.S. 22:1832), and a late payment carries "a late payment adjustment equal to twelve percent per annum." An issuer may elect a single 30-day standard by notice to the commissioner, and it gets the same window to audit a paid claim that it gives you to file one. These sections do not apply to the Office of Group Benefits, and self-funded ERISA plans are outside them. Aetna publishes no ABA rate table: its provider manual says "The rates and compensation under your agreement are subject to the Aetna coding/claim edit policies," and a member cannot be charged "more than the contracted rate."[15][16][4][24][25][1][3]
Billing details from Aetna’s own documents. Codes: Aetna’s ABA policy (CPB 0554) lists only CPT 97151–97158, 0362T and 0373T and no HCPCS code, so H0031, H0032 or H2019 are not ABA codes at Aetna. Telehealth: its Telemedicine and Direct Patient Contact Payment Policy names modifiers GT, 95 and FR but no place-of-service code, and none of Aetna’s documents says the precertification must flag telehealth; ask which POS (02 or 10) it wants when you precertify. Filing: the Health Care Professional Toolkit (6/26) prints no timely-filing deadline, so your agreement sets it, and its definition of a clean claim excludes any claim that involves coordination of benefits. Reauthorization: the ABA medical necessity guide calls for "Repeated measurement with standardized measures to assess progress" and says "A member’s progress is to be evaluated every six months"; it does not mention graphs. Supervision: the Network Participation Criteria set one hour of face-to-face supervision per 10 hours of paraprofessional ABA and publish no cap on technicians per BCBA.[15][16][4][24][25][1][3]
The questions that decide whether a family can start with Aetna in Louisiana, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the ASD diagnosis itself, but medical necessity requires functional impairment on a standardized scale "in the past 12 months" (at least one standard deviation below the mean) or a significant risk of harm.[1]
A DSM-5 ASD diagnosis "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)."[1]
The guide names functional measures, not diagnostic instruments: a standardized scale from the past 12 months such as VABS-3, ABAS, VB-MAPP or ABLLS.[1]
Aetna’s ABA documents require precertification of all ten ABA codes, not a physician referral. Aetna publishes no ABA order form or validity period, and its provider manual (6/26) says members "may access behavioral health care … through direct access to the behavioral health provider." A PCP referral matters only on plans that require referrals for specialist care; a clean claim then includes "a corresponding referral (whether in paper or electronic format), if required for the applicable claim." The manual names no ABA-specific referring-provider (box 17) requirement. For a fully insured Louisiana plan, R.S. 22:1050(G)(11) covers autism treatment "prescribed, provided, or ordered" by "a physician or psychologist who shall be licensed in this state and who shall supervise provision of such care," so keep that order on file. Self-funded ERISA plans sit outside the statute.[2][5][4]
Aetna’s national guide sets no age cap; it describes typical, not limiting, age ranges. For a fully insured Louisiana plan, R.S. 22:1050 requires autism coverage for individuals "less than twenty-one years of age," subject to "a maximum benefit of thirty-six thousand dollars per year." Self-funded ERISA plans, individually underwritten guaranteed-renewable policies and limited-benefit policies are outside the statute.[1][5]
Ask the plan: Live benefits verification on the member ID: fully insured vs. self-funded, then the plan’s autism age and dollar terms.
Aetna’s provider manual (6/26): 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 act within the scope of their license and ensure that they have the proper licensure based on state requirements." Aetna’s current ABA telehealth code list was not published in a document we could read. For a fully insured Louisiana plan, R.S. 22:1821(F)(2) makes services by telehealth subject to the insurer’s "utilization review criteria and requirements" and voids policy terminology "that either discriminates against or prohibits" telehealth. The clinician still needs Louisiana authority to practice: the behavior analyst licensing law applies, and R.S. 40:1223.4 tells each board to license or register out-of-state providers serving patients located in Louisiana. Self-funded employer plans are outside the state insurance statute. Aetna’s Telemedicine and Direct Patient Contact Payment Policy (posted policy shows last review June 2021) marks 97151, 97153, 97155, 97156 and 97157 as telehealth-eligible on commercial plans with modifier GT, 95 or FR; neither it nor the provider toolkit names a telehealth place-of-service code or says the precertification must flag telehealth.[4][14][12][25]
Ask the plan: Availity or the precertification line: ask whether the plan is fully insured or self-funded (and opted out of telehealth), and which ABA codes, POS and modifier Aetna pays by telehealth.
Depends on how the plan is funded. Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1: pre-service decisions "not later than 15 days after receipt of the claim," one 15-day extension, urgent care within 72 hours. For fully insured Louisiana plans whose contract requires prospective review, R.S. 22:1821(D)(3) treats an answer within "two working days" of the provider’s request as not unreasonable, and says a longer delay "may be considered unreasonable depending on the circumstances"; that section governs the insurer’s liability for unreasonable delay rather than setting a hard deadline. Aetna publishes no Louisiana-specific ABA turnaround or reauthorization lead time.[20][14]
Ask the plan: At benefits verification ask whether the plan is fully insured or self-funded and what reauthorization lead time Aetna expects.
For a child on two plans, ask both carriers for the order of benefits; Louisiana’s commissioner sets the order by regulation (R.S. 22:1836(B)), which we did not read. What the statute does say: no plan may call itself "always excess" or "always secondary" outside those rules, a plan may not reduce benefits because the child could have enrolled in another plan, and a plan may not "pend, delay, or deny payment" to a provider "solely on the basis of the insured’s failure" to report other coverage (a contracted provider must pass along any coordination-of-benefits information it gets). If the child also has Louisiana Medicaid, the commercial plan pays first: Medicaid is payer of last resort (42 CFR 433.139), and since November 2025 the Medicaid plans hold ABA authorizations as pending until you send the primary insurer’s determination. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[17][21][26][22][23]
Ask the plan: Ask Aetna at benefits verification for the coordination-of-benefits order, and record every other coverage the child has.
Coverage decides whether Aetna in Louisiana 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," with "A minimum of one hour of face-to-face supervision" of an unlicensed or noncertified paraprofessional "for each 10 hours of applied behavior analysis" and the supervisor "onsite with the child at least one hour a month." Staff "must meet state requirements," and in Louisiana that means a licensed LBA and registered line technicians (R.S. 37:3708, 37:3716). Aetna’s guide and Network Participation Criteria publish no cap on the number of technicians one BCBA may supervise.[3][8][10]
No per-day cap is published. Hours follow the guide’s severity grid; typical intensity is 10–25 hours a week for comprehensive and 1–20 for focused programs (not caps), with QHP protocol modification at "1 to 2 hours per 10 hours of treatment by protocol." For fully insured Louisiana plans the mandate allows no visit limits but a $36,000 annual benefit cap.[1][5]
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 in scope. Louisiana licenses behavior analysts, so the LBA (or a licensed psychologist) is the billing credential.[1][6]
Aetna’s guide sets no outpatient setting restriction; ABA delivered in an inpatient, residential or partial hospitalization setting is reviewed under that level of care’s criteria instead.[1]
Ask the plan: Aetna Behavioral Health at precertification: confirm the places of service the plan pays for ABA, including school.
Not addressed in Aetna’s published ABA guide, precertification list or participation criteria. The medical necessity guide and the provider manual also say nothing about ABA at the same time as speech or occupational therapy.[1][4]
Ask the plan: Aetna provider services, your participation agreement, or a written coding determination from Aetna Behavioral Health.
Not addressed in Aetna’s published ABA documents, which set treatment-plan content but not session-note signatures.[1]
Ask the plan: Your Aetna participation agreement and the Aetna Behavioral Health provider manual’s documentation section.
No. Aetna’s ABA policy lists only CPT 97151–97158, 0362T and 0373T.
Its ABA guide asks for repeated measurement with standardized measures and a progress evaluation every six months; it does not mention graphs.
Aetna’s provider toolkit (6/26) does not print one; the filing limit is in your Aetna agreement.
Yes, for autism spectrum disorder under Aetna’s national criteria, with Louisiana’s R.S. 22:1050 mandate on fully insured plans. Self-funded employer plans follow their own documents.
Fully insured plans must cover diagnosis and treatment of autism, including ABA, for people under 21, with no visit limits, up to $36,000 a year. Treatment must be ordered by a Louisiana-licensed physician or psychologist.
Aetna requires providers to hold the licensure their state requires, and Louisiana licenses behavior analysts; practicing without a Louisiana license is a misdemeanor. Ask the Louisiana Behavior Analyst Board about its out-of-state telehealth route.
For fully insured plans, Louisiana law requires electronic clean claims to be paid, denied or pended within 25 days (paper within 45), with 12% a year interest when late. Self-funded plans are outside the statute.
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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