For a Michigan intake team, an Aetna card means three layers: Aetna’s national ABA policy, Michigan’s autism mandate (MCL 500.3406s), and the plan’s funding type deciding which binds. Michigan’s mandate still lets a fully insured carrier stop treatment coverage after age 18 and cap annual benefits by age band. This guide stacks the layers in order.
Aetna covers ABA for autism spectrum disorder under CPB 0554 (with CPB 0648 for ASD) and its ABA medical necessity guide, which requires a DSM-5 ASD diagnosis from an appropriate provider, functional impairment on a standardized scale within the past 12 months, a measurable treatment plan with transition and discharge criteria, parent engagement, and services delivered or billed by licensed behavior analysts, BCBAs or licensed psychologists. Aetna’s behavioral health precertification list (effective August 1, 2024) requires precertification for every ABA code, the assessment included. Progress is reviewed every six months. What changes in Michigan is the legal floor below.[1][2][3][4]
Reauthorization: the medical necessity guide says “A member's progress is to be evaluated every six months,” and continued coverage needs a treatment plan with “frequency, rate, symptom intensity or duration, or other objective measures of baseline levels” recorded and “quantifiable criteria for progress,” plus documentation that target behaviors improved or, if not, that treatment was modified. Graphs are not named as a requirement; objective baseline-to-current data is.[1][2][3][4]
Michigan’s autism mandate has two parallel statutes: MCL 500.3406s for insurers (added by 2012 PA 100, amended by 2016 PA 276, applying to policies delivered, issued or renewed beginning 180 days after its April 18, 2012 enactment) and MCL 550.1416e for health care corporation group and nongroup certificates. Both require coverage "for the diagnosis of autism spectrum disorders and treatment of autism spectrum disorders," including behavioral health treatment such as applied behavior analysis, and bar the carrier from limiting the number of visits, from denying coverage because treatment "is educational or habilitative in nature," and from applying dollar limits, copays, deductibles or coinsurance that do not apply to physical illness generally.[5][6]
Unlike newer mandates, Michigan’s still carries age and dollar ceilings the carrier may choose to apply: coverage for treatment may be limited "through 18 years of age" and to a maximum annual benefit of $50,000 through age 6, $40,000 from 7 through 12, and $30,000 from 13 through 18. Treatment must be "prescribed or ordered" by a licensed physician or licensed psychologist who finds it medically necessary, behavioral health treatment must be "provided or supervised by a board certified behavior analyst or a licensed psychologist," and the diagnosis means assessments "including the autism diagnostic observation schedule, performed by a licensed physician or a licensed psychologist." While a member is in treatment the carrier may require a treatment plan and treatment review, request the ADOS results, request that the ADOS be repeated no more than once every three years, and request an annual development evaluation. Utilization review, medical-necessity review, network requirements and coordination of benefits still apply. Exempt: self-funded ERISA employer plans (outside state insurance law), exchange qualified health plans to the extent the coverage exceeds essential health benefits, and, under 500.3406s, short-term policies of six months or less.[5][6]
Michigan licenses behavior analysts through LARA’s Board of Behavior Analysts under Part 182A of the Public Health Code (Michigan’s licensure law dates from 2016). A license requires current BACB certification in good standing sent directly from the BACB, a criminal background check, human-trafficking and implicit-bias training, and renews every four years; assistant behavior analysts have their own LARA license and supervision verification. Technicians are not licensed by the state. Aetna does not publish commercial ABA rates for Michigan; they are negotiated in the participating-provider agreement.[7][8][9]
Michigan’s prompt-pay statute, MCL 500.2006(8), governs insured health plans (it excludes administrative-services-only arrangements): "A clean claim must be paid within 45 days after receipt of the claim by the health plan," with 12% simple annual interest after that; the plan must flag defects within 30 days, and the provider gets 45 days to fix them. A provider "must bill a health plan within 1 year after the date of service" for the claim to be a clean claim.[19][17][18][20]
Aetna disputes run in two steps: a reconsideration "within 180 calendar days of the initial claim decision," then an appeal "within 60 calendar days of the reconsideration decision," with a written decision within 60 calendar days of receiving the appeal. Aetna’s manual sets no fixed timely-filing number: a clean claim is one "received in a timely manner," and the deadline comes from the participation agreement or state law.[19][17][18][20]
Single case agreements and out-of-network care. Aetna publishes no single-case-agreement policy for ABA. Its provider manual (6/26) describes two routes instead. An out-of-network referral is “a written or oral request that we review”; reasons it may be approved include a preferred professional who “isn’t available in network (and the member’s plan provides coverage for out-of-network services)” and a member “continuing, or returning to, treatment with a nonparticipating health care professional.” Transition of care lets a qualifying member keep “their current out-of-network provider at in-network cost level for a defined period of time,” and the treating provider “must be an individual practitioner” or a home care agency. ABA itself still needs precertification either way. Neither the manual nor the ABA medical necessity guide publishes an out-of-network ABA rate. What a non-participating Michigan provider is paid comes from the member’s plan, so ask Aetna on the member’s benefits line before you start.[17][18][16][3]
Reconsideration and appeal packet. File a reconsideration “within 180 calendar days of the initial claim decision” and an appeal “within 60 calendar days of the reconsideration decision.” Some cases skip reconsideration and go straight to appeal: denials for no precertification, adverse utilization review decisions and retroactive authorizations. For a reconsideration, send “medical records, office notes and other supporting documents” plus a completed dispute and appeal form or an explanation with the member ID, patient name, TIN, claim ID, dates of service and billed amounts, and the procedure codes and modifiers you are disputing. A valid appeal needs the completed dispute and appeal form, “an explanation identifying the denied codes or payments being disputed,” and the medical records. The manual adds that a written dispute must carry the TIN and NPI billed, the servicing provider, the expected reimbursement and your rationale, or “the original claim decision will be deemed final.” Aetna answers appeals within 60 calendar days. For Michigan, Aetna’s state table sends a mailed reconsideration to Aetna Provider Resolution Team, PO Box 981106, El Paso, TX 79998-1106; written commercial appeals go to Aetna Provider Resolution Team, PO Box 14020, Lexington, KY 40512 (fax 1-859-455-8650). Availity is the fastest route for both.[17][18][16][3]
Whose authorization is it? The ABA precertification form identifies the requester as the “Provider/Provider Group” by “TIN or PIN number,” with its network status (Participating or Non-Participating) and the service location. It also names who “is supervising/directing the ABA services.” None of Aetna’s ABA documents (the form, the manual or the medical necessity guide) says an approval follows the child to another agency. A practice taking over a case should request its own precertification.[17][18][16][3]
What the 97151 request must contain. Form GR-69017-4 (7-26) replaced every other Aetna ABA precertification document from August 1, 2026 (“Don’t use this form for Maryland and Massachusetts”). It asks for the DSM-5 diagnosis code and the “Diagnosing Provider (name and credentials)”; hours per authorization period for 97151, 97152 and 0362T; hours per week for each treatment code; and any hours during class. It also asks for the results of a standardized assessment (Vineland, ABAS or VB-MAPP) from the past 12 months, a treatment plan with baseline, interim and current data for every goal, FBA or skills-assessment results, caregiver goals, and titration and discharge criteria. Start the request on Availity or by phone, then attach the form; the form cannot open a request.[17][18][16][3]
Who may bill which code. Aetna’s ABA medical necessity guide requires that services “be provided directly or billed by licensed behavior analysts (in states with behavior analyst licensure laws), board-certified behavior analysts, or licensed psychologists” where ABA is within their scope, “unless state mandates, plan documents or contracts require otherwise.” Unlicensed or uncertified staff must work under supervision “in line with practice standards.” The guide, the precertification form and the manual set no per-code credential table and define no HM/HN/HO/HP credential modifiers, so modifier use comes from your Aetna agreement.[17][18][16][3]
What changes on Jan. 1, 2027. CMS records that at its September 2025 meeting the AMA CPT Editorial Panel "deleted CPT codes 0362T" and "0373T," "revised eight existing CPT codes" (97151 through 97158) and "created six new CPT codes" for adaptive behavior services; the AMA released the CPT 2027 code set on Sept. 9, 2026, with changes in effect on January 1. The ABA Coding Coalition’s 2027 guidance gives the final numbers: 97148 and add-on +97149 (behavior identification supporting assessment of harmful behavior, delivered by two technicians, additional technicians on the add-on), 97159 and add-on +97160 (adaptive behavior treatment of harmful behavior, same two-technician structure), 97173 (adaptive behavior treatment with analysis by a physician or other QHP, face-to-face with one patient) and 97180 (non-face-to-face services personally performed by the QHP, such as data review and modifying protocols). "Protocol modification" becomes "analysis" in the descriptors, and "since there is no grace period, 0362T and 0373T are invalid for dates of service on or after January 1, 2027." No state "approves" the codes themselves: they are Category I CPT codes that HIPAA requires on electronic claims, but, as the Coalition notes, HIPAA "does not, however, govern whether a payer covers a code / service, what a payer pays for a code / service, or what a payer requires to authorize" it, so each payer has to load them, price them and say how authorizations that list 0362T or 0373T carry over.[21][22][23][2]
Aetna had published no 2027 adaptive-behavior code guidance as of Nov. 1, 2026: CPB 0648 (Autism Spectrum Disorders), last reviewed Oct. 20, 2026, still lists the current code set, including 0373T. Ask Aetna how it will load and price the new codes and whether authorizations that list 0362T or 0373T carry over.[21][22][23][2]
The questions that decide whether a family can start with Aetna in Michigan, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the diagnosis itself, but a 12-month clock on function: medical necessity requires "demonstration of functional impairment on a standardized scale of functioning in the past 12 months" at least one standard deviation below the mean or a significant risk of harm; progress is re-evaluated every six months. On fully insured Michigan plans the mandate also lets the carrier request a repeat ADOS no more than once every three years.[3][5]
A DSM-5 ASD diagnosis (ICD-10 F84.0, F84.3–F84.9) "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 fully insured Michigan plans the mandate defines the diagnosis as assessments, including the ADOS, performed by a licensed physician or licensed psychologist.[3][5]
CPB 0648 names the diagnostic instruments: ADI-R, ADOS-2, CARS-2 and the Asperger Syndrome Diagnostic Scale. The ABA guide then requires a standardized measure of functioning within the past 12 months (examples: Vineland-3, ABAS, VB-MAPP, ABLLS) showing impairment at least one standard deviation below the mean or a significant risk of harm.[2][3]
Aetna’s national ABA criteria require no physician referral; what they require is precertification, and the behavioral health precertification list names all ABA codes (97151–97158, 0362T, 0373T). For a fully insured Michigan policy the mandate adds an order requirement: covered treatment is care "prescribed or ordered for an individual diagnosed with 1 of the autism spectrum disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary," and the treatment plan is developed "when the treatment of an autism spectrum disorder is first prescribed or ordered." Self-funded ERISA plans sit outside the statute.[4][3][5]
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.[24]
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.
Aetna’s national ABA policies set no age cap; its guide lists typical, not limiting, age ranges (comprehensive ABA typically 0–7, focused ABA all ages). Michigan’s mandate lets a fully insured carrier limit autism treatment coverage to members "through 18 years of age" and cap it at $50,000 a year through age 6, $40,000 for ages 7–12 and $30,000 for ages 13–18; whether a given plan uses those limits is in its certificate. Self-funded ERISA plans set their own terms.[3][5][6]
Ask the plan: Live benefits verification on the member ID: fully insured vs. self-funded, and whether the certificate applies the mandate’s age-18 and annual-dollar limits.
Turns on how the plan is funded. Fully insured Michigan insurance and HMO plans follow MCL 500.2212e: after May 31, 2024 a non-urgent prior authorization request "is considered granted" if the insurer does not grant it, deny it, or ask for more information "within 7 calendar days after the date and time of submission," and again within 7 calendar days after additional information is submitted; a request the provider certifies as urgent is considered granted if not acted on within 72 hours. An approved authorization "is valid for not less than 60 calendar days or for a duration that is clinically appropriate, whichever is later." The statute’s "health benefit plan" covers individual and group insurance, HMO contracts, and self-funded plans of the state or local governments, not private self-funded employer plans, which follow ERISA: pre-service decisions "not later than 15 days after receipt of the claim," one 15-day extension, urgent claims within 72 hours.[10][11]
Ask the plan: At benefits verification ask whether the plan is fully insured (Michigan-regulated) or self-funded (ERISA), then confirm the Aetna turnaround and reauthorization lead time (precertification via Availity or the number on the member ID card).
Which plan pays first is set by Michigan’s Coordination of Benefits Act for state-regulated plans: for a dependent child whose parents are married or living together, "The plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (same birthday: the plan covering the parent longer); for divorced or separated parents a court order assigning health coverage controls, then the order in MCL 550.253. The autism mandate adds that a member with two policies covering autism gets benefits "subject to the limits of this section when coordinating benefits." If the child also has Michigan Medicaid, Aetna pays first: Medicaid is payer of last resort and "is not liable for payment of services denied because coverage rules of the primary health insurance were not followed," so get Aetna’s authorization even when Medicaid (the PIHP) will pay secondary. TRICARE pays after other coverage except Medicaid (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[12][5][13][14][15]
Ask the plan: Ask Aetna at benefits verification for the member’s coordination-of-benefits order (precertification via Availity or the number on the member ID card); self-funded plans set their own COB terms in the plan document. Record every other coverage the child has.
Coverage decides whether Aetna in Michigan 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.
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 definition, unless state mandates, plan documents or contracts require otherwise." Where unlicensed or non-certified staff are authorized, "there must be supervision and direction of the unlicensed or non-certified providers in line with practice standards." Aetna publishes no numeric supervision ratio. Michigan is a licensure state, so the supervising analyst must hold a LARA license.[3][7]
Aetna publishes no per-day or per-week unit ceiling. Its guide lists typical intensities (comprehensive ABA 10–25 hours a week, typically ages 0–7 for 1–2 years; focused ABA 1–20 hours a week, all ages) and says "Authorized hours will be based on documented severity of impairments"; progress is evaluated every six months. For fully insured Michigan plans the mandate bars visit limits but allows annual dollar maximums of $50,000 (through age 6), $40,000 (7–12) and $30,000 (13–18).[3][5]
Outpatient ABA is setting-agnostic in Aetna’s guide. If treatment is in an inpatient, residential or partial hospitalization setting, that level of care’s criteria apply and "specific authorization for ABA is not needed in addition." The guide expects coordination with existing providers and the school district; its statement that Aetna will not deny ABA solely because the location is a child’s educational setting sits in a state-specific exhibit, not the national criteria.[3]
"Services must be provided directly or billed by the appropriately licensed provider": licensed behavior analysts in licensure states (Michigan is one), board-certified behavior analysts, or licensed psychologists within scope, unless state mandates, plan documents or contracts require otherwise.[3]
Not addressed in Aetna’s published ABA policies — CPB 0554, CPB 0648 and the ABA medical necessity guide are silent on billing 97153 and 97155 for the same clock time.[1][3]
Ask the plan: Aetna provider services / the participating-provider agreement, or a written coding determination from Aetna Behavioral Health.
Not addressed. Aetna’s published ABA policies set treatment-plan content (target behaviors, baselines, quantifiable progress criteria, generalization, transition and discharge planning) but do not say who signs a session note or by when.[3]
Ask the plan: The participating-provider agreement and the Aetna Behavioral Health Provider Manual documentation section.
Aetna’s ABA guide evaluates progress every six months against objective baseline measures and quantifiable progress criteria; it does not name graphs as a requirement.
Yes, for ASD under its national policy, with precertification on all ABA codes. For fully insured plans Michigan’s mandate (MCL 500.3406s) also applies; self-funded employer plans are exempt.
Aetna’s policy sets none, but Michigan’s mandate lets a fully insured plan limit treatment coverage to members through age 18 and cap annual benefits at $50,000 (through 6), $40,000 (7–12) and $30,000 (13–18). Check the certificate.
Commercial rates are not published; they are negotiated in the participating-provider agreement.
Within 45 days of receipt for a clean claim on an insured plan (MCL 500.2006(8)), with 12% interest after that. Self-funded plans are not covered.
180 calendar days from the initial claim decision to request a reconsideration, then 60 calendar days from the reconsideration decision to appeal.
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 publishes no single-case-agreement policy. Its provider manual offers an out-of-network referral request (approved, for example, when no in-network professional is available and the plan has out-of-network benefits) and transition of care for a member already in treatment with an out-of-network individual practitioner. ABA still needs precertification.
Medical records and supporting documents, plus a dispute and appeal form or a letter with the member ID, patient name, TIN, claim ID, dates of service, billed amounts, and the codes and modifiers in dispute. File within 180 days of the claim decision; an appeal follows within 60 days of the reconsideration decision.
The precertification form identifies the provider or group by TIN or PIN, with the supervising clinician named separately. Aetna publishes no rule that moves an authorization to another agency, so a new agency requests its own precertification.
Not as of Nov. 1, 2026. CPB 0648 (last reviewed Oct. 20, 2026) still lists the current codes, including 0373T. CPT 2027 deletes 0362T and 0373T and adds 97148/97149, 97159/97160, 97173 and 97180 from Jan. 1, 2027, so ask Aetna how it will price them and handle existing authorizations.
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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