---
title: "Aetna ABA coverage in Maine: the intake guide."
url: "https://carelu.com/payers/aetna-maine"
markdown_url: "https://carelu.com/payers/aetna-maine.md"
state: ME (Maine)
payer: Aetna in Maine
kind: Commercial insurance
description: "How Aetna covers ABA for Maine families: the national medical necessity guide, precertification on all ABA codes, Maine’s autism mandate (age 10 and under, $36,000 ABA cap allowed), credentialing without a state license, and what intake should verify."
last_reviewed: October 2026
---

# Aetna ABA coverage in Maine: the intake guide.

_Payer Guide · Aetna · Maine · Last updated October 2026 · 19 primary sources_

> Aetna’s national ABA guide + precert on all ten ABA codes + Maine’s autism mandate (age 10 and under, $36,000 ABA cap allowed).

For an intake team in Maine, an Aetna card means three layers: Aetna’s national ABA policy, Maine’s autism mandate in Title 24-A, and the plan’s funding type, which decides whether the mandate applies at all. Maine’s mandate is narrower than most: it reaches children 10 and under and lets plans cap ABA at $36,000 a year. This guide stacks the layers in order.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required: all ten ABA codes, 97151 included, are on Aetna’s behavioral health precertification list (eff. 8/1/2024); CPB 0554 itself sets no precertification rule [4][1]
- **Prior auth for treatment** _(plan-dependent)_: Required: 97153–97158, 0362T and 0373T are on the precertification list; the reauthorization interval is set by the plan [4]
  - Ask the plan: The member’s Aetna plan (benefits line on the card): ask what reauthorization interval it uses for ABA.
- **Autism diagnosis required?**: Yes: ASD only (F84.0, F84.3–F84.9); Aetna considers ABA experimental for other diagnoses [1][3]

## At a glance

- **Covers ABA?:** Yes, for ASD, per Aetna’s national policy
- **State mandate:** 24-A M.R.S. § 2768 (individual), § 2847-T (group), § 4259 (HMO)
- **Mandate age:** 10 years of age or under (raised from 5 by P.L. 2013, c. 597, from 1/1/2015)
- **Mandate caps:** Plans may cap ABA at $36,000 per year; no visit limits allowed
- **Exempt from mandate:** Self-funded ERISA employer plans (outside state insurance law)
- **Licensure:** None: Maine does not license behavior analysts; the mandate requires national-board (BACB) certification or supervision
- **Fee schedule:** Not public — Aetna pays the contracted rate in your participation agreement

## The national policy, applied in Maine

Aetna covers ABA for autism spectrum disorder and, under CPB 0554 (last reviewed October 14, 2026), "considers ABA experimental, investigational, or unproven for all other non-ASD indications." Its medical necessity guide (©2026) requires a DSM-5 ASD diagnosis "obtained by an appropriate provider," services billed by the appropriately licensed or certified provider, functional impairment on a standardized scale from the past 12 months at least one standard deviation below the mean (or a significant risk of harm), and a measurable treatment plan. Its only state exhibit is Maryland’s, so the national criteria apply in Maine unchanged. The behavioral health precertification list names all ten ABA codes, 97151 through 97158, 0362T and 0373T. [1][3][4]

## The Maine mandate: what it guarantees

Maine’s autism mandate is written three times, once for each kind of contract: 24-A M.R.S. § 2768 for individual health insurance, § 2847-T for group policies, and § 4259 for individual and group HMO contracts. The operative text is the same in all three. The plan "must provide coverage for autism spectrum disorders for an individual covered under a policy or contract who is 10 years of age or under." It must cover "any assessments, evaluations or tests by a licensed physician or licensed psychologist to diagnose whether an individual has an autism spectrum disorder," and must cover treatment "when it is determined by a licensed physician or licensed psychologist that the treatment is medically necessary," with ongoing medical necessity demonstrable "at least annually." It "may not include any limits on the number of visits," but it "may limit coverage for applied behavior analysis to $36,000 per year" (the group and HMO versions add "to the extent allowed by federal law"), and payments for unrelated care may not count toward that cap. ABA is covered as a habilitative or rehabilitative service, and "To be eligible for coverage, applied behavior analysis must be provided by a person professionally certified by a national board of behavior analysts or performed under the supervision of" such a person. The mandate does not change a school’s obligations under an IEP or IFSP. The age ceiling was 5 until P.L. 2013, c. 597 raised it to 10 for policies issued or renewed from January 1, 2015. Two practical consequences: a child turns out of the mandate at 11, after which ABA depends on the plan’s own terms; and the mandate binds fully insured plans regulated in Maine, not self-funded employer plans, which answer to ERISA and their plan documents. [7][8][9][10]

## Credentialing, licensure and rates

Maine does not license behavior analysts. The BACB’s U.S. licensure table, which lists every state with a behavior-analyst licensure law and its board, does not include Maine, and Title 32 of the Maine Revised Statutes (professions and occupations) has no behavior-analyst chapter (chapter 141, sometimes cited for this, is the professional land surveyors chapter). The working credential is BACB certification, which the mandate itself requires for whoever provides or supervises ABA. Maine’s credentialing statute still helps: under 24-A M.R.S. § 4303(2)(D) a carrier must decide a completed credentialing application "within 60 days," must review a new application within 30 days and return an incomplete one "with a comprehensive list of all corrections needed," and "may not require that a provider have a home address within the State." Under § 4303(2-A), once credentials are granted the carrier pays claims for services rendered "from the date a complete application for credentialing is submitted," though you may not submit those claims until the carrier tells you the credentialing outcome and effective date. Commercial ABA rates are negotiated and unpublished, and the MaineCare ABA rate (Section 28, H2021 U1 HK) sits on a fee schedule we could not retrieve this month. [16][17][13][8][20]

## What is Aetna’s fee schedule for ABA?

Aetna publishes no ABA rate table. Its provider manual (6/26) treats payment as a contract term: the "rates and compensation under your agreement are subject to the Aetna coding/claim edit policies," and where a provider has both an intermediary contract and a direct agreement, "your direct Aetna rates will apply unless we specifically notify you otherwise." Even when a member’s benefits run out, the provider "cannot charge them more than the contracted rate." Get the rates from your Aetna agreement or Aetna provider services. [5]

## Claims in Maine: payment timing, retro denials and appeals

Maine’s prompt-pay law, 24-A M.R.S. § 2436, makes a health claim "payable within 30 days after proof of loss is received"; a claim "neither disputed nor paid within 30 days is overdue" and bears interest at 1½% a month. A provider may submit a claim to every carrier that may be liable, primary and secondary, at the same time, and each must pay or deny "within 30 calendar days after the carrier has received all information needed," whether or not the other carrier has acted. A claim the carrier rejects for not using the standard claim form cannot be billed to the family; fix and resubmit it. After payment, § 4303(10) bars a carrier from retrospectively denying a paid claim more than 12 months after payment unless it gives the reason in writing and the claim falls within narrow exceptions (up to 36 months for duplicate payment, services not delivered, adjustment with another insurer or legal action; beyond that only for fraud or Medicaid/Medicare/CHIP claims). Appeals of an adverse treatment decision must be heard by a clinical peer who was not involved in the first decision (§ 4304(7)). The timely-filing limit itself is a contract term, not a statute. [14][13][11][5]

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. [14][13][11][5]

## Can a BCBA licensed in another state treat an Aetna member in Maine?

Maine issues no behavior-analyst license, so there is no Maine license to add; the mandate asks for national-board (BACB) certification or supervision by a certificant. Aetna’s guide names the billing credential as a licensed behavior analyst "in states with behavior analyst licensure laws," a BCBA, or a licensed psychologist, and its network criteria require that "All BCBAs, BCaBAs and paraprofessionals must meet state requirements. If state requirements are not defined, all BCBAs, BCaBAs and paraprofessionals must meet Aetna standards." For telehealth, Aetna’s provider manual says providers "must act within the scope of their license and ensure that they have the proper licensure based on state requirements." Maine’s telehealth law for insured plans keys eligibility to "acting within the scope of the provider’s license" and bars telehealth-only credentialing. Check your home state’s rules on serving clients located in Maine. [3][6][5][12][16]

## What a reauthorization must show

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. [3]

## Intake gates

The questions that decide whether a family can start with Aetna in Maine, and what they have to bring.

- **Diagnosis recency**: No expiry on the ASD diagnosis itself, but medical necessity requires functional impairment shown on a standardized scale administered in the past 12 months (at least one standard deviation below the mean) or a significant risk of harm. [3]
- **Who may diagnose**: 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)." For a fully insured Maine plan, the mandate covers diagnostic testing by a licensed physician or licensed psychologist. [3][8]
- **Diagnostic tools required**: CPB 0648 names the Autism Diagnostic Interview-Revised (ADI-R), ADOS-2, CARS-2 and the Asperger Syndrome Diagnostic Scale. The ABA guide requires a standardized functional measure from the past 12 months (Vineland-3, ABAS, VB-MAPP or ABLLS as examples). [2][3]
- **Referral required?**: Aetna’s national ABA policies require no physician referral; what they require is precertification of all ten ABA codes. For a fully insured Maine plan, the mandate covers treatment "when it is determined by a licensed physician or licensed psychologist that the treatment is medically necessary," and the plan may require that physician or psychologist to demonstrate ongoing medical necessity "at least annually." Self-funded ERISA plans sit outside the statute. [4][3][8]
- **Age limit** _(plan-dependent)_: Aetna’s national ABA policies set no age cap; the guide lists typical, not limiting, age ranges. For fully insured Maine plans, 24-A M.R.S. §§ 2768, 2847-T and 4259 require autism coverage for a covered person "10 years of age or under" and allow ABA to be capped at $36,000 a year; from age 11 the plan’s own terms decide. Self-funded ERISA plans are outside the statute. [3][7][8][9]
  - Ask the plan: Live benefits verification on the member ID: establish fully insured vs. self-funded ERISA, then the plan’s own age terms for a child 11 or older.
- **Telehealth** _(plan-dependent)_: 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 that providers must have "the proper licensure based on state requirements." Aetna’s posted Telemedicine payment policy, which carries the ABA code table, shows a last review of June 2021, so we do not restate its code list here. For a fully insured Maine plan, 24-A M.R.S. § 4316 says a carrier "may not deny coverage on the basis that the health care service is provided through telehealth if the health care service would be covered if it were provided through in-person consultation," that "Prior authorization is required for telehealth services only if prior authorization is required for the corresponding covered health care service," and that "An in-person consultation prior to the delivery of services through telehealth is not required." Coverage may not be limited "on the basis of geography, location or distance for travel," and the carrier may not add telehealth-only credentialing. Self-funded employer plans are outside the statute. [5][12]
  - Ask the plan: Availity or the precertification line on the card: ask whether the plan is fully insured in Maine or self-funded (and opted out of telehealth), and which ABA codes, POS and modifier Aetna pays by telehealth.
- **Prior-auth decision time** _(plan-dependent)_: Depends on how the plan is funded. Fully insured Maine plans fall under 24-A M.R.S. § 4304(2): a provider’s prior-authorization request for a nonemergency service "must be answered by a carrier within 72 hours or 2 business days, whichever is less." The same clock restarts when the carrier asks for more information (from receipt of it) or says outside consultation is needed. "If a carrier does not grant or deny a request for prior authorization within the time frames required under this subsection, the request for prior authorization by the provider is granted." Once approved, the carrier "may not retrospectively deny coverage or payment for the originally approved service" absent fraudulent or materially incorrect information, and may not deny the claim when the service is delivered within 14 days before or after the approved date. 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," one 15-day extension. Aetna publishes no Maine-specific ABA turnaround or reauthorization lead time. [11][18]
  - Ask the plan: At benefits verification ask whether the plan is fully insured (Maine-regulated) or self-funded (ERISA), and what reauthorization lead time Aetna expects.
- **Other insurance (who pays first)** _(plan-dependent)_: Maine lets a provider bill every potentially liable carrier at once: under 24-A M.R.S. § 2436(1-A) each carrier, primary or secondary, must pay or deny "within 30 calendar days after the carrier has received all information needed to pay or deny the claim whether or not another carrier with which it is attempting to coordinate has acted." If two carriers cannot agree on the order of benefits within 30 days of having everything they need, Bureau of Insurance Rule ch. 790 says they "shall immediately pay the claim in equal shares" and settle up afterward, with neither paying more than it would have as primary. We did not find Maine’s order-of-benefit (birthday-rule) text this month, so ask the carriers which plan is primary. If the child also has MaineCare, Aetna pays first: "MaineCare is the payer of last resort," and a medical-necessity denial from the commercial plan must be appealed before MaineCare will consider the claim (MaineCare Benefits Manual Ch. I, § 1.07-3). TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270). [14][15][19][21][22][23]
  - Ask the plan: Ask Aetna at benefits verification for the member’s coordination-of-benefits order (and whether a self-funded plan follows its own order), and record every other coverage the child has, including MaineCare.

## Delivery and billing rules

Coverage decides whether Aetna in Maine pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: Aetna’s guide: services must be provided directly or billed by licensed behavior analysts (where states license them), BCBAs, or licensed psychologists where ABA is within scope, unless mandates, plan documents or contracts say otherwise, with supervision of others "in line with practice standards." Aetna’s Network Participation Criteria (5/26) set the technician tier: "A minimum of one hour of face-to-face supervision is required of the unlicensed or noncertified paraprofessional by a BCBA or licensed psychologist (or behavioral health professional) for each 10 hours of applied behavior analysis," and "the supervisor must be onsite with the child at least one hour a month." The Maine mandate requires ABA to be provided by, or supervised by, a national-board certificant. [6][3][8]
- **Daily limits / MUEs**: No per-day or per-week cap is published. Hours follow the guide’s severity assessment, with typical intensities of 10–25 hours a week for comprehensive and 1–20 for focused programs (typical, not caps); progress is evaluated every six months. A fully insured Maine plan may cap ABA at $36,000 a year but may not limit visits. [3][8]
- **Place of service**: Outpatient ABA is setting-neutral in Aetna’s guide; when treatment is in an inpatient, residential or partial hospitalization setting, that level of care’s criteria apply and no separate ABA authorization is needed. The guide expects coordination "with existing providers and/or the school district." The Maine mandate leaves a school’s IEP and IFSP obligations untouched. [3][8]
- **Bill as provider**: Services must be provided directly or billed by the appropriately licensed or certified provider (licensed behavior analyst where a state licenses them, BCBA, or licensed psychologist where in scope), unless mandates, plan documents or contracts say otherwise. Maine has no behavior-analyst license, so the BCBA is the billing credential. [3][16]
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not addressed in Aetna’s published ABA policies (CPB 0554, CPB 0648, the medical necessity guide). [1][3]
  - Ask the plan: Aetna provider services, the participating-provider agreement, or a written coding determination from Aetna Behavioral Health.
- **Session-note signature** _(ask the plan)_: Not addressed. Aetna sets treatment-plan content requirements but not who signs a session note or by when. [3]
  - Ask the plan: The participating-provider agreement and the Aetna Behavioral Health Provider Manual section on documentation.

## What intake should collect for Aetna in Maine

- **Plan funding type:** Fully insured (Maine mandate applies) vs. self-funded ERISA (plan document governs). Ask for the employer and check the card.
- **Child’s age:** The Maine mandate covers children 10 and under; from 11 the plan’s own terms decide.
- **Diagnosis report:** DSM-5 ASD diagnosis, diagnosing provider and credentials, evaluation date. Aetna’s policy is ASD-only.
- **Standardized functional measure:** Aetna wants one from the past 12 months (for example Vineland-3).
- **Other coverage:** Second parent’s plan, MaineCare (pays last), TRICARE or CHAMPVA.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Common questions

### Does Aetna require graphs for ABA reauthorizations?

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.

### What are Aetna’s claim filing deadlines for Maine ABA claims?

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.

### Does Aetna cover ABA therapy in Maine?

Yes, under its national policy for ASD, with Maine’s autism mandate layered on for fully insured plans (children 10 and under, ABA cap of $36,000 a year allowed). Self-funded employer plans follow their own documents.

### What does the Maine autism mandate require?

Fully insured plans must cover diagnosis and medically necessary treatment of autism, including ABA by or under a national-board certified behavior analyst, for children 10 and under, with no visit limits; plans may cap ABA at $36,000 a year.

### Does the Aetna ABA assessment need prior authorization in Maine?

Yes. 97151 and 97152 are on Aetna’s behavioral health precertification list along with every other ABA code.

### What does Aetna pay for ABA in Maine?

Aetna publishes no ABA rates. Its provider manual says payment follows the rates and compensation under your agreement, so the numbers are in your Aetna participation agreement.

### Does Aetna require RBT certification for ABA technicians?

Aetna’s network criteria do not require the RBT credential by name: technicians may be paraprofessionals supervised by a BCBA or licensed psychologist, with at least 1 hour of face-to-face supervision per 10 hours of ABA and the supervisor onsite with the child at least 1 hour a month. Maine sets no technician license.

## Primary sources

1. [Aetna CPB 0554 — Applied Behavior Analysis (last review 10/14/2026)](https://www.aetna.com/cpb/medical/data/500_599/0554.html)
2. [Aetna CPB 0648 — Autism Spectrum Disorders](https://www.aetna.com/cpb/medical/data/600_699/0648.html)
3. [Aetna — Applied behavior analysis medical necessity guide (©2026; Maryland exhibit only)](https://www.aetna.com/content/dam/aetna/pdfs/health-care-professionals/applied-behavioral-analysis-necessity-guide.pdf)
4. [Aetna — Participating provider behavioral health precertification list (eff. 8/1/2024)](https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/healthcare-professionals/documents-forms/bh_precert_list.pdf)
5. [Aetna Health Care Professional Toolkit / provider manual (8102800-01-01, 6/26)](https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/health-care-professionals/office_manual_hcp.pdf)
6. [Aetna — Provider and facility participation criteria (Network Participation Criteria, 8100606-01-01, 5/26)](https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/healthcare-professionals/documents-forms/network-participation-criteria-document.pdf)
7. [24-A M.R.S. § 2768 — Coverage for the diagnosis and treatment of autism spectrum disorders (individual policies)](https://legislature.maine.gov/statutes/24-A/title24-Asec2768.html)
8. [24-A M.R.S. § 2847-T — Coverage for the diagnosis and treatment of autism spectrum disorders (group policies)](https://legislature.maine.gov/statutes/24-A/title24-Asec2847-T.html)
9. [24-A M.R.S. § 4259 — Coverage for the diagnosis and treatment of autism spectrum disorders (HMO contracts)](https://legislature.maine.gov/statutes/24-A/title24-Asec4259.html)
10. [P.L. 2013, c. 597 — An Act To Amend Insurance Coverage for Diagnosis of Autism Spectrum Disorders (age 5 → 10; applies from Jan. 1, 2015)](https://legislature.maine.gov/legis/bills/bills_126th/chapters/PUBLIC597.asp)
11. [24-A M.R.S. § 4304 — Utilization review (prior authorization timeframes)](https://legislature.maine.gov/statutes/24-A/title24-Asec4304.html)
12. [24-A M.R.S. § 4316 — Coverage for telehealth services](https://legislature.maine.gov/statutes/24-A/title24-Asec4316.html)
13. [24-A M.R.S. § 4303 — Plan requirements (sub-§ 2 credentialing, 2-A payment during credentialing, 10 retrospective denials)](https://legislature.maine.gov/statutes/24-A/title24-Asec4303.html)
14. [24-A M.R.S. § 2436 — Interest on overdue payments (30-day claim payment)](https://legislature.maine.gov/statutes/24-A/title24-Asec2436.html)
15. [Bureau of Insurance Rule 02-031 ch. 790 — Procedures for Resolving Coordination of Benefits Disputes](https://www.maine.gov/sos/sites/maine.gov.sos/files/content/assets/031c790.doc)
16. [BACB — U.S. Licensure of Behavior Analysts (Maine not listed)](https://www.bacb.com/u-s-licensure-of-behavior-analysts/)
17. [Maine Revised Statutes, Title 32 (Professions and Occupations) — chapter list (no behavior-analyst chapter; ch. 141 is Professional Land Surveyors)](https://legislature.maine.gov/statutes/32/title32ch0sec0.html)
18. [29 CFR 2560.503-1 — ERISA claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
19. [MaineCare Benefits Manual, Ch. I, Section 1 — General Administrative Policies and Procedures (1.07 TPL, 1.10 claims, 1.14 prior authorization, 1.23 provider appeals)](https://www.maine.gov/sos/sites/maine.gov.sos/files/inline-files/c1s001.docx)
20. [MaineCare Benefits Manual, Ch. II, Section 28 — Adaptive Behavior Services for Children (eff. April 29, 2026, filing 2026-101)](https://www.maine.gov/sos/sites/maine.gov.sos/files/inline-files/c2s028-2026-101%20NEW.docx)
21. [42 CFR 433.139 — Medicaid third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
22. [10 U.S.C. 1079(i)(1) — TRICARE pays after other coverage except Medicaid](https://www.govinfo.gov/content/pkg/USCODE-2023-title10/html/USCODE-2023-title10-subtitleA-partII-chap55-sec1079.htm)
23. [38 CFR 17.270 — CHAMPVA is the last payer](https://www.ecfr.gov/current/title-38/section-17.270)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.