For an intake team in Maryland, an Aetna card means three layers at once: the carrier's national clinical policy, Maryland's habilitative-services mandate (Md. Code Ann., Insurance § 15-835, implemented by COMAR 31.10.39.03), and the plan's funding type deciding which of the two actually binds. Maryland's mandate is unusual — it carries hour FLOORS below which ABA can't be denied. This guide stacks the layers 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. Precertification is required for both the assessment and treatment: Aetna's behavioral health precertification list names 97151–97158, 0362T and 0373T, and requests go through Availity or a call to Aetna precertification (commercial plans 1-888-632-3862) — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is national — what changes in Maryland 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. Two Maryland-specific points, both from Aetna's own documents. Aetna's ABA medical necessity guide carries an Exhibit A that applies COMAR 31.10.39 criteria to plans in Maryland subject to Maryland law. And Aetna's national ABA Treatment Request form, GR-69017-4 (revision 7-26, which from August 1, 2026 replaces all other ABA precertification information forms), says twice: "Don't use this form for Maryland and Massachusetts." Aetna publishes a standard ABA prior-authorization form for Massachusetts but none for Maryland, so confirm the Maryland submission path and the clinical information Aetna wants with Aetna precertification or in Availity before filing.[1][2]
Maryland has no standalone "autism mandate" — ABA is covered as a habilitative service for children with ASD under Insurance § 15-835, with the ABA-specific rules in COMAR 31.10.39.03 (effective April 3, 2014). The statute requires Maryland-regulated insurers, nonprofit health service plans, and HMOs to cover habilitative services until at least the end of the month the enrollee turns 19. The COMAR layer is where the teeth are: ABA may not be denied solely on the basis of prescribed hours up to 25 hours/week for ages 18 months through 5 years and up to 10 hours/week for ages 6 through 18 — with additional hours authorized when medically necessary — and ABA may not be denied as experimental or investigational. There is no dollar cap. COMAR 31.10.39.03(C) lets a carrier’s review criteria require a comprehensive evaluation, a prescription with specific treatment goals from the PCP or a specialty physician, and annual review by the prescriber; Aetna’s Maryland exhibit adopts all three, so the prescription and its renewal date are intake data. Carriers aren't required to reimburse services delivered through early intervention or the schools, and self-funded ERISA plans are exempt — for those, MHPAEA parity is the fallback lever, and the hour floors don't apply.[3][4]
A family saying "we have Aetna" in Maryland may be on Aetna Better Health of Maryland, a HealthChoice MCO — but unlike other states, that changes nothing for ABA. Maryland carves ABA (and all specialty behavioral health) out of the MCOs entirely: authorizations and claims go to Carelon Behavioral Health, the state's BHASO, under the Medicaid fee-for-service rules. If the card is Aetna Better Health, use our Maryland Medicaid guide and route everything to Carelon — Aetna's Medicaid plan never touches ABA.[6]
Maryland has required licensure to practice behavior analysis since January 2015: the Licensed Behavior Analyst (LBA) credential, administered by the Behavior Analyst Advisory Committee of the State Board of Professional Counselors and Therapists (Health Occupations Title 17, Subtitle 6A; COMAR 10.58.16), built on current BACB certification, a qualifying master's degree, and a criminal-history check. The mandate's COMAR criteria likewise expect licensed delivery. On rates: Aetna does not publish commercial ABA fee schedules for Maryland (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement. Maryland's Medicaid fee schedule (effective February 1, 2026 — e.g., 97153 at $24.41/15-min BCBA tier) is the public benchmark to negotiate against.[5]
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. For a public benchmark, Maryland Medicaid's fee schedule (eff. 2/1/2026, unchanged for FY27) pays 97153 at $24.41 per 15 minutes at the BCBA tier, $20.91 BCaBA and $19.17 RBT/BT.[10][12]
Maryland licenses the practice: “an individual shall be licensed by the Board before the individual may practice behavior analysis in the State” (Health Occupations § 17-6A-10(a)). Section 17-6A-10 itself exempts only students in a qualifying unpaid clinical educational experience, so plan on a Maryland license before treating a child located in Maryland remotely.[14][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 Maryland by video must meet Maryland’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.[14][13]
Who bills: Aetna’s ABA Medical Necessity Guide requires services to be “provided directly or billed by licensed behavior analysts (in states with behavior analyst licensure laws), board-certified behavior analysts, or licensed psychologists.” In Maryland that means the licensed BCBA who supervises the technician bills the technician’s time. Aetna credentials the BCBA, and its participation criteria treat BCaBAs and paraprofessionals as supervised staff. Exhibit A of the same guide carries COMAR 31.10.39 for Maryland-regulated plans, including that the ABA provider “must be licensed, certified or otherwise authorized under the Maryland Health Occupations Article.”[9][10][16][17][18]
Filing and payment: Aetna’s provider manual (6/26) defines a clean claim as one “received in a timely manner” with all the CMS-1500 data elements, including the NPI and “A corresponding referral … if required for the applicable claim.” It leaves the filing window to your agreement. For a fully insured Maryland plan, Insurance § 15-1005 sets the floors: at least 180 days from the date of service to file; payment, or a notice of what is denied, disputed or missing, within 30 days of receipt; and interest on a clean claim still unpaid after 30 days, at 1.5% a month for days 31–60, 2% for days 61–120 and 2.5% after that.[9][10][16][17][18]
Disputes: Aetna runs two steps. A reconsideration must be filed “within 180 calendar days of the initial claim decision,” and an appeal “within 60 calendar days of the reconsideration decision.” For Maryland members on fully insured plans, Aetna’s state-exceptions table extends the time to file an initial claim-payment dispute to 365 days for all providers, participating and nonparticipating. Dispute online through Availity’s claim status inquiry (“Dispute Claim”), or by mail with the Provider and Practitioner Complaint and Appeals Form. The request must include the billed TIN and NPI, the name of the servicing provider, the claim ID, the dates of service, the expected reimbursement and your rationale. “If these requirements are not met, the original claim decision will be deemed final.” No Aetna document we read requires electronic visit verification (EVV) for ABA.[9][10][16][17][18]
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.”[10]
Aetna’s ABA documents name CPT codes only. Its behavioral-health precertification list puts applied behavioral analysis under “97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T.” Its ABA precertification request asks for hours by those same codes: assessment codes 97151, 97152 and 0362T per authorization period, treatment codes 97153–97158 and 0373T per week. CPB 0554 (reviewed October 14, 2026) also lists 97151–97158, with 0362T and 0373T as related codes. None of these documents lists a HCPCS H-code (H0031, H0032, H2014, H2019) for ABA. If a plan or contract seems to call for one, confirm with Aetna before billing it.[7][8][1]
Aetna’s ABA Medical Necessity Guide sets the evidence for any authorization: “demonstration of functional impairment on a standardized scale of functioning in the past 12 months” (for instance VABS-3, ABAS, VB-MAPP or ABLLS), target behaviors with “frequency, rate, symptom intensity or duration, or other objective measures of baseline levels” and “quantifiable criteria for progress,” and either documentation that the target behavior has improved or, if not, documentation of treatment modification, added assessments or consultation. The level of impairment must justify the hours requested. The guide does not require graphs.[9][8]
Aetna’s national precertification information request says “Don’t use this form for Maryland and Massachusetts,” so confirm the state’s submission package with Aetna precertification.[9][8]
The questions that decide whether a family can start with Aetna in Maryland, 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 national precertification form (GR-69017-4) asks for the DSM-5 diagnosis code, the diagnosing provider and their credentials, but that form says not to use it for Maryland, so confirm what Aetna wants on a Maryland request through Availity or the precertification line.[1][2]
Yes on Maryland-regulated plans, and Aetna writes it into its own policy. Exhibit A of Aetna’s ABA Medical Necessity Guide, which applies “for plans subject to Maryland law”: “The child’s primary care provider or specialty physician must perform a comprehensive evaluation identifying the need for applied behavior analysis”; “Such primary care provider or specialty physician must prescribe the treatment. Such prescription must include specific treatment goals”; and treatment “shall be reviewed annually for medical necessity with the primary care provider or specialty physician, and in consultation with the applied behavior analysis provider,” documenting benefit, new or continuing goals and a new or continuing treatment plan. Outside Maryland-regulated plans, Aetna’s ABA documents set no referral or order, only precertification. COMAR 31.10.39.03 is where that comes from; it lets carriers require “A comprehensive evaluation of a child by the child’s primary care provider or specialty physician,” “A prescription from a child’s primary care provider or specialty physician that includes specific treatment goals,” and an annual review by the prescriber “in consultation with the habilitative services provider” documenting benefit, new or continuing goals and a new or continuing treatment plan. So the order has to come from the child’s primary care provider or a specialty physician, not the BCBA, and it must state treatment goals; no carrier form is published, and no validity period is set other than the annual review. Self-funded ERISA plans are outside the Maryland rule.[9][19][7]
Two answers, and plan funding type picks between them. The carrier's national ABA policy states no age limit. Maryland's habilitative-services mandate does: for Maryland-regulated insurers, nonprofit health service plans and HMOs, habilitative services must be covered “until at least the end of the month the enrollee turns 19,” and COMAR 31.10.39.03 pins its no-denial hour floors to age bands — up to 25 hours/week for ages 18 months through 5 years and up to 10 hours/week for ages 6 through 18, with more when medically necessary. Self-funded ERISA plans are exempt from all of it, so establish funding type before quoting either bound.[3][4]
Ask the plan: Benefits verification on the specific plan, via the payer portal or the number on the member’s card — ask whether the plan is Maryland-regulated (an insurer, nonprofit health service plan or HMO, which the habilitative-services mandate and COMAR 31.10.39.03 age bands reach) or a self-funded ERISA plan (exempt). If it is self-funded, ask what age limit and weekly hour limit the plan document sets for ABA before you quote either bound to the family.
Aetna requires prior authorization for ABA but publishes no decision clock of its own, and its national ABA request form says “Don’t use this form for Maryland and Massachusetts” — in Maryland the treatment plan goes on the state uniform form. The clock depends on how the plan is funded. If the child’s plan is fully insured in Maryland, Insurance §15-10B-06 sets the clock: an initial request is decided “within 2 working days after receipt of the information necessary to make the determination,” “additional visits or days of care submitted as part of an existing course of treatment or treatment plan within 1 working day,” emergency requests within 24 hours, and a reviewer missing information must say so within 3 calendar days. Maryland’s teeth: “If a private review agent fails to make a determination within the time limits required under this section, the request shall be deemed approved.” Mental-health treatment plans must be accepted on the MIA uniform treatment plan form. If the employer self-funds, ERISA’s floor applies instead: pre-service decisions “not later than 15 days after receipt of the claim” (one 15-day extension allowed), urgent claims within 72 hours. Aetna publishes no reauth lead time; Maryland lets carriers require “An annual review by the prescribing primary care provider or specialty physician.”[21][22][8][23]
Ask the plan: the member services or behavioral health number on the ID card — ask whether the plan is fully insured (and in which state) or self-funded, and for its UM decision timeframes
Aetna says: “We coordinate benefits as allowed by state or federal law following the National Associations of Insurance Commissioners (NAIC) guidelines. If there is no applicable law, then we coordinate according to the member’s plan,” and its order of benefits includes the “Dependent Child/Parents Not Separated or Divorced Rule (Birthday Rule)” — the parent whose birthday falls earlier in the year is primary. Maryland has not yet adopted a COB regulation: the Insurance Administration says contract COB provisions “have historically been reviewed for consistency with the NAIC Model, but the Model has not been formally adopted to date,” and its draft COMAR 31.10.53 (comments closed August 2026) would codify the NAIC birthday rule (“The plan of the parent whose birthday falls earlier in the calendar year is the primary plan”) and exclude Medicaid from the definition of a plan — so Maryland Medicaid always pays after the commercial plan. Self-funded plans often use Maintenance of Benefits when secondary. Bill the primary first and send its EOB with the secondary claim.[10][24][25]
Ask the plan: the carrier’s eligibility response (Availity or the ID-card number) for an other-insurance record, and both parents’ birth dates and custody arrangements at intake; a self-funded plan follows its own plan document
Aetna publishes no recency rule for the ASD diagnostic evaluation. The only currency requirement that binds a fully-insured Maryland plan sits on the prescription rather than the diagnosis: COMAR 31.10.39.03 requires annual review by the prescribing PCP or specialty physician. Capture the evaluation date anyway — the precertification package asks for it.[1][3]
Ask the plan: The precertification call or Availity (not form GR-69017-4, which Aetna says not to use for Maryland) — 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 Aetna's national precertification form (not for Maryland use) asks for the DSM-5 diagnosis code, the diagnosing provider and their credentials rather than for an instrument and score. Where a Maryland-regulated plan applies the mandate, COMAR 31.10.39.03 asks for a comprehensive evaluation without naming instruments either.[1][4]
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.
Aetna publishes no current ABA telehealth code list that we could confirm. CPB 0554 does not address telehealth. The only public copy of Aetna's Telemedicine and Direct Patient Contact Payment Policy shows a last review of June 2021 (next review June 2022), and its code table does cover ABA: on commercial plans 97151, 97153, 97155, 97156 and 97157 are eligible, billed with modifier GT, 95 or FR, while 97152, 97154, 97158, 0362T and 0373T are checked for Medicare only. The current version sits behind Availity, so treat that list as Aetna's last published position, not a confirmed current rule. What Aetna's provider manual (6/26) does say: 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 of telehealth services," and providers must hold the licensure state law requires. For a fully insured Maryland policy, Insurance § 15-139 requires coverage "for health care services appropriately delivered through telehealth regardless of the location of the patient," bars excluding a service "solely because it is provided through telehealth," requires reimbursement "on the same basis and at the same rate" as in person, and allows preauthorization only if appropriateness is judged "in the same manner" for both. Self-funded employer plans are outside the statute. Maryland Medicaid's telehealth floor (25 percent in person on 97155/97156/97157) belongs to a different program and does not apply to a commercial Aetna plan.[10][11][20][1]
Blocked on: Aetna's current Telemedicine and Direct Patient Contact Payment Policy (Availity, Payer Spaces > Aetna > Resources) for the ABA code list, or Aetna BH precertification (1-888-632-3862): ask which ABA codes are payable by telehealth, with which POS and modifier, and whether the plan is fully insured in Maryland.
Coverage decides whether Aetna in Maryland 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 CPB 0554 need BACB national certification or state behavior-analyst licensure, with unlicensed staff working under supervision per practice standards. In Maryland that licensure floor is concrete: the Licensed Behavior Analyst credential from the Board of Professional Counselors and Therapists has been required to practice behavior analysis since January 2015, and the mandate's COMAR criteria likewise expect licensed delivery. Aetna publishes no numeric supervision ratio for ABA. Aetna's Network Participation Criteria (5/26) spell out the technician tier: 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," and Aetna requires "A minimum of one hour of face-to-face supervision" of an unlicensed or noncertified paraprofessional "for each 10 hours of applied behavior analysis," plus the supervisor "onsite with the child at least one hour a month." "All BCBAs, BCaBAs and paraprofessionals must meet state requirements. If state requirements are not defined, all BCBAs, BCaBAs and paraprofessionals must meet Aetna standards."[13][1][2][5]
Under the licensed behavior analyst, not the technician. Aetna’s ABA Medical Necessity Guide (©2026) requires that “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,” and its criteria repeat that services “must be provided directly or billed by the appropriately licensed provider.” Maryland is a licensure state, so a technician’s 97153 is billed by the licensed BCBA (or licensed psychologist) who supervises it. Aetna’s Network Participation Criteria (5/26) credential BCBAs and treat a BCaBA or “paraprofessional” as supervised staff, with at least one hour of face-to-face supervision per 10 hours of ABA. Neither document says whether the technician should also be named in the rendering-provider field, and neither names credential modifiers, so confirm both with Aetna before the first claim. Claim disputes ask for the “Provider NPI that was billed on the claim(s)” and the “Name of servicing individual, provider, group, or facility.”[9][13][10]
Not published. Neither CPB 0554 nor CPB 0648 states whether 97155 and 97153 may be billed for the same clock time; Aetna handles code-pair questions through claim-editing and reimbursement policy rather than through the clinical policy bulletin.[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. Ask specifically about 97153 billed alongside 97155.
Not published. CPB 0554 lists the covered ABA codes but sets no per-day unit ceiling, and Aetna publishes no ABA-specific MUE table. The operative ceiling is the precertification itself, which requires requested hours to be listed code by code — so the authorization, not a policy, is what bounds the day. CPB 0648 references intensive-intervention research norms of 25 hours a week, 12 months a year as clinical context rather than as a limit.[1]
Ask the plan: The authorization letter itself, plus Availity Essentials for the plan's claim-editing and reimbursement policies. Ask whether CMS MUE limits are applied to ABA codes on this plan.
Not published. CPB 0554 and CPB 0648 set coverage criteria and precertification content; neither 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 CPB 0554 does make a submission requirement is adjacent and useful: Aetna's national precertification form (which says not to use it for Maryland) asks for concurrent services — PT, OT, speech and school services — plus how care is coordinated across them, so the school picture is data Aetna collects even though it publishes no school-versus-home rule.[1]
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.
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 the carrier's national policy for ASD, layered on Maryland's habilitative-services mandate (Md. Ins. § 15-835 + COMAR 31.10.39.03) for fully-insured plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.
For fully-insured plans: coverage of habilitative services through at least the month the enrollee turns 19, no denial of ABA solely on prescribed hours up to 25 hrs/week (ages 18 months–5) or 10 hrs/week (ages 6–18), no experimental/investigational denials, and no dollar cap — entered via a comprehensive evaluation plus a physician prescription reviewed annually.
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. Maryland Medicaid's published schedule (97153 $19.17–$24.41 per 15 minutes by credential tier) is the public benchmark.
Aetna's network criteria do not require the RBT credential by name: technicians may be paraprofessionals supervised by a BCBA or licensed provider, 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. Technicians must meet any state requirement, so check the state's licensure or Medicaid rules too.
The supervising licensed behavior analyst. Aetna’s ABA Medical Necessity Guide says 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,” and Maryland licenses behavior analysts. So a technician’s 97153 goes out under the licensed BCBA who supervises it. Aetna credentials BCBAs and treats BCaBAs and paraprofessionals as supervised staff. Its public documents do not say whether to list the technician in the rendering field as well, so confirm that with Aetna provider services before the first claim.
Aetna leaves the claim filing window to your agreement. On a fully insured Maryland plan, Insurance § 15-1005 guarantees at least 180 days from the date of service to file, and payment or a status notice within 30 days, with interest after that. To dispute a payment, file a reconsideration within 180 calendar days of the claim decision, then an appeal within 60 days of the reconsideration decision. For fully insured Maryland members, Aetna allows 365 days to file the initial claim-payment dispute.
Maryland requires a Maryland license to practice behavior analysis (Health Occupations § 17-6A-10). 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 precertification list, its ABA precertification request and CPB 0554 list only CPT 97151–97158, 0362T and 0373T for ABA. No H-code appears in them, so bill the CPT codes unless Aetna tells you otherwise for a specific plan.
Aetna’s documents ask for data, not graphs: a standardized functioning assessment within the past 12 months, baseline and quantifiable progress measures for each target behavior, and documentation of improvement or of treatment changes.
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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