For an intake team in Missouri, a Aetna card means three layers at once: the carrier's national clinical policy, Missouri's autism insurance mandate (RSMo § 376.1224), and the plan's funding type deciding which of the two actually binds. This guide stacks them in order.
Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. Aetna publishes no Missouri-specific ABA policy, form, or supplement — we checked — so the national policy plus the state mandate is the whole picture, with Missouri's statutory constraints (the 6-month treatment-plan review cadence, the ABA cap) applying to fully-insured business by operation of law rather than via a carrier document. Plan funding type is therefore the first fact to establish on every benefits check. The full national policy breakdown lives in our Aetna guide; this page covers what changes in Missouri.[1][2]
Missouri's mandate — enacted by 2010's HB 1311, with the current version applying to plans delivered, issued, continued, or renewed on or after January 1, 2020 (which added developmental and physical disability coverage) — reaches unusually far: beyond ordinary individual and group policies, it covers the state consolidated health care plan, self-insured governmental plans, MEWAs, and self-insured school district health plans established after 1/1/2020. ABA must be ordered by the treating licensed physician or psychologist in a treatment plan, supervised by a board-certified behavior analyst licensed under Chapter 337, and insurers may review the ABA treatment plan no more than once every 6 months unless the provider agrees otherwise. The headline number: ABA carries a $40,000-per-calendar-year cap for individuals through age 18 — statutory base value. Three things soften it: the cap may be exceeded with prior plan approval when additional ABA is medically necessary; it is CPI-indexed (carriers must adjust at least triennially, with the current adjusted figure published annually in the Missouri Register — don't quote $40K as the live number without checking); and other autism treatments (OT/PT/speech, psychiatric, pharmacy) sit outside the cap entirely. Self-funded private ERISA plans remain federally preempted.[3]
Missouri requires behavior-analyst licensure: RSMo 337.315 prohibits practicing applied behavior analysis without an LBA (or Licensed Assistant Behavior Analyst) license or an enumerated exception — supervised trainees, licensed psychologists within scope, IDEA school personnel, and students among them. The Behavior Analyst Advisory Board within the State Committee of Psychologists (Division of Professional Registration, RSMo 337.300–337.345) reviews applications, and the mandate itself requires BCBA-supervised, Chapter 337-licensed delivery — so licensure is a coverage requirement, not just a credentialing one. On rates: Aetna does not publish commercial ABA fee schedules for Missouri (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement. Benchmark against MO HealthNet's published fee schedule ($20.13/unit on 97153 at the analyst tier) when modeling.[4]
Aetna sets the content of the plan, not a DSM-5 template. Its ABA Medical Necessity Guide (©2026) requires a DSM-5 ASD diagnosis and a treatment plan whose "specific identified target behaviors related to the condition" are "clearly defined: frequency, rate, symptom intensity or duration, or other objective measures of baseline levels are recorded, and quantifiable criteria for progress are established," with the intervention techniques, reinforcers, generalization strategies, and transition, titration and discharge criteria spelled out. Hours are sized from severity in three areas — maladaptive behavior, social communication and self-care — rather than from DSM criteria. Precertification form GR-69017-4 (7-26) asks for a "time-limited, individualized treatment plan" with "baseline, interim and current data for all goals." Neither document asks for goals to be grouped under DSM-5 criteria. Missouri's mandate adds only that a plan, when the carrier requests it, must include the elements needed to pay claims — "a diagnosis, proposed treatment by type, frequency and duration of treatment, and goals" (RSMo § 376.1224.4(2)).[7][6][3]
Caregiver participation is a criterion, but Aetna publishes no hour minimum. The Medical Necessity Guide requires "engagement and commitment from parent(s) (or guardians) to participate in treatment to generalize gains," and says that, based on impairment and severity, additional authorization may be provided "for QHP protocol modification and direction at 1 to 2 hours per 10 hours of treatment by protocol, as well as authorization for caregiver training" — no caregiver-training amount is stated. Form GR-69017-4 asks you to request 97156 and 97157 in hours per week and to show that "Primary caregiver(s) have measurable goals that work to reinforce interventions and generalize gains." The approved caregiver-training hours are whatever the precertification letter grants.[7][6]
Missouri law sets the floor for health carriers, which the statute defines to include self-insured plans "to the extent allowed by federal law". A carrier must "Permit participating health care providers to file a claim for reimbursement for a health care service provided in this state for a period of up to six months from the date of service, unless the contract between the health carrier and health care provider specifies a different standard," and must give nonparticipating providers up to one year (RSMo 376.384). So the filing window in your Aetna agreement controls, and without one it is six months.[10][11]
On payment, the carrier acknowledges an electronic claim within 48 hours and, within 30 processing days, tells you whether it is clean or what additional information it needs. Once it has the information it has ten processing days to pay or deny (or make a final request), then five more. A claim still unpaid on the 45th processing day earns "one percent interest per month and a penalty in an amount equal to one percent of the claim per day" (RSMo 376.383). Processing days stop counting while the carrier waits for your answer, and the 2003 electronic-filing rule means a paper claim falls outside these protections.[10][11]
Aetna publishes no ABA-specific referring-provider rule. Its provider manual defines a clean claim as including "A corresponding referral (whether in paper or electronic format), if required for the applicable claim" plus all CMS-1500 data elements, and it treats behavioral health as direct access: members "may access behavioral health care" "Through direct access to the behavioral health provider," through a PCP recommendation, or through an EAP referral. PCP referrals are a feature of plans "that require the issuance of referrals for specialist care," and even there they apply "other than for direct-access services."[9]
So box 17 is not a published condition of an Aetna ABA claim in Missouri. If a plan design does require a referral, the eligibility-and-benefits response shows it; enter the referring provider only when one exists.[9]
Aetna publishes no rule on ABA delivered at the same clock time as speech, OT or PT. What it asks for is coordination. Precertification form GR-69017-4 (7-26) asks whether the member gets physical, occupational or speech therapy, mental health services or school services, and "Do you collaborate with all the providers above?" (if not, explain why). The Medical Necessity Guide expects "ongoing collaboration and coordination with existing providers and/or the school district."[6][7]
Report the other therapies and their schedule on the precertification request, and ask Aetna's precertification line before billing ABA minutes that overlap another therapy.[6][7]
Start on Availity with the Authorization (Precertification) Add transaction, or call the precertification department. Form GR-69017-4 (7-26) is not used to start a request. It supplies the clinicals when a case pends, attached on Availity or faxed to FaxHub 833-596-0339. Since August 1, 2026 it "replaces all other Applied Behavior Health Analysis (ABA) precertification information request documents and forms" (not for Maryland or Massachusetts plans).[6]
For the assessment, request 97151, 97152 and 0362T in hours per authorization period. Treatment codes are requested in hours per week. The form also asks for the current DSM-5 diagnosis codes, the "Diagnosing Provider (name and credentials)," who will supervise, whether any hours fall during class, and the child's other services (PT, OT, speech, mental health, PCP, school). Supporting documents, "where applicable," include a standardized assessment (Vineland, ABAS, VB-MAPP) "completed within the past 12 months," the treatment plan with baseline data, caregiver goals, and titration and discharge criteria. Questions: 1-800-424-4047.[6]
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.[5][6][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.[7][6]
Aetna’s precertification information request (GR-69017-4, effective August 1, 2026, used outside Maryland and Massachusetts) spells out the reauthorization package. It asks for a standardized assessment within the past 12 months, re-evaluation of interventions and progress “every 6 months,” “a repeat validated assessment … every 6-12 months to demonstrate response to intervention,” and a treatment plan that includes “baseline, interim and current data for all goals.” It also asks for measurable caregiver goals and titration and discharge criteria. Data, not graphs, is what the form names.[7][6]
The questions that decide whether a family can start with Aetna in Missouri, and what they have to bring. Each maps onto something intake should ask on the first call.
Twelve months, and it runs on the functional measure rather than the diagnosis. Aetna's ABA Medical Necessity Guide requires "demonstration of functional impairment on a standardized scale of functioning in the past 12 months" (for instance Vineland-3, ABAS, VB-MAPP or ABLLS), at least one standard deviation below the mean or a significant risk of harm. Precertification form GR-69017-4 (7-26) asks for "Results of a standardized assessment (i.e. Vineland, ABAS, VB-MAPP) completed within the past 12 months," a re-evaluation every 6 months and a repeat validated assessment every 6–12 months. The ASD diagnosis itself has no stated shelf life. Aetna's provider manual expects "a comprehensive diagnostic evaluation prior to the initiation of treatment" and diagnoses on claims that are "current and consistent with the most recent" DSM. RSMo § 376.1224 adds no recency rule; its six-month clock governs plan review of the treatment plan.[7][6][9][3]
Two lists, and the narrower one is the statute's. Aetna requires the diagnosis to come from a provider qualified to diagnose within their scope — a licensed psychologist, psychiatrist or physician — and its precertification form (GR-69017-4 (7-26), eff. 8/1/2026) asks for the DSM-5 diagnosis code, the diagnosing provider and their credentials. On a plan the Missouri mandate reaches, the ABA itself must additionally be ordered by the treating licensed physician or psychologist, so a diagnosis from a nurse practitioner will not by itself satisfy the ordering requirement.[1][2][3]
No Aetna referral, but the state mandate wants an order. Aetna's provider manual treats behavioral health as direct access: members "may access behavioral health care" "Through direct access to the behavioral health provider," through a PCP recommendation, or through an EAP referral. PCP referrals apply only on plans that require them for specialist care, "other than for direct-access services." Aetna's ABA Medical Necessity Guide asks only for 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)." Form GR-69017-4 (7-26) records the "Diagnosing Provider (name and credentials)" rather than an order. Missouri's mandate requires ABA to be "ordered by the insured's treating licensed physician or licensed psychologist, pursuant to the powers granted under such licensed physician's or licensed psychologist's license, in accordance with a treatment plan" (RSMo § 376.1224). Keep that order and the treatment plan on file for any plan the statute reaches. It does not reach private self-funded ERISA plans, but it does reach self-insured governmental plans. Aetna publishes no order form and sets no validity period for one. Precertification on Availity is the real gate. The same statute requires the ABA to be supervised by a board-certified behavior analyst licensed under chapter 337, limits the carrier to reviewing the treatment plan once every six months unless the provider agrees otherwise, and puts the cost of any review or treatment plan on the plan.[9][7][6][3]
Aetna: "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" — the manual's order-of-benefits list includes the birthday rule for children whose parents are not separated or divorced. Missouri's COB rule (20 CSR 400-2.030) governs fully insured group plans: when parents are not separated or divorced, "The benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year" (same birthday: the plan that covered the parent longer); for divorced or separated parents a court decree naming the responsible parent controls. Self-funded plans follow their plan document instead, and Aetna notes many use "Maintenance of Benefits (MOB)" rather than the "100% Allowable" method most state laws require, so a secondary payment can be smaller. If the child also has Medicaid, this plan pays first: Medicaid is payer of last resort (42 CFR 433.139) — bill here, then send the EOB or denial to Medicaid, and get Medicaid's own prior auth too if the state requires it. TRICARE is secondary to this plan ("TRICARE shall be last pay," 32 CFR 199.8), and "CHAMPVA is the last payer to OHI" (38 CFR 17.276(d)).[9][15][16][17][18]
The mandate sets no overall age limit on autism coverage — what it ages out is the dollar cap. RSMo § 376.1224 subjects ABA to “a maximum benefit of forty thousand dollars per calendar year for individuals through eighteen years of age,” a statutory base that is CPI-indexed (the Department of Commerce and Insurance publishes the adjusted figure annually). Coverage required under the section other than ABA “shall not be subject to the age and dollar limitations described in this subsection,” so OT, PT, speech, psychiatric and pharmacy care for autism carry no age cut-off and no dollar cap. Self-funded private ERISA plans are preempted from all of it; note Missouri's unusual reach into the state consolidated health care plan, self-insured governmental plans, MEWAs and self-insured school-district plans established on or after 1/1/2020.[3]
Ask the plan: Benefits verification on the specific plan, via the payer portal or the number on the member’s card — ask whether RSMo § 376.1224 reaches this plan (it reaches fully-insured plans, the state consolidated health care plan, self-insured governmental plans, MEWAs and self-insured school-district plans established on or after 1/1/2020, but not private self-funded ERISA plans), and what the plan applies as this year’s dollar cap. The Missouri Department of Commerce and Insurance publishes the CPI-adjusted figure annually — quote that year’s number, never the $40,000 statutory base.
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. But the public copy of the policy shows a last review of June 2021 and a next review of June 2022; the current version sits behind Availity, so this list cannot be treated as today's rule until that copy is checked. Missouri's Medicaid telemedicine rule, which expressly allows technician-delivered ABA by telemedicine, is a different program and does not bind a commercial Aetna plan.[8]
Blocked on: Availity (Payer Spaces > Aetna > Resources) for the current Telemedicine and Direct Patient Contact Payment Policy, or Aetna behavioral health precertification — confirm the payable ABA telehealth codes, modifier and that the member's plan carries a telehealth benefit before scheduling remote hours.
Aetna publishes no commercial decision clock of its own: ABA "services require prior authorization. To get ABA services precertified, call the number on the member's Aetna ID card," and the manual sets no reauthorization lead time (none in the ABA Medical Necessity Guide or the ABA precert form either). The legal ceiling depends on funding. Missouri fully insured plans are bound by RSMo 376.1363: a carrier "shall make the determination within thirty-six hours, which shall include one working day, of obtaining all necessary information," with an approval phoned or sent electronically to the provider within 24 hours; concurrent review (continuing an approved course) is decided "within one working day of obtaining all necessary information." The clock starts when the file is complete, not when the form lands. Self-funded ERISA plans are outside state law and follow 29 CFR 2560.503-1: a pre-service decision "not later than 15 days after receipt of the claim" (one 15-day extension), 72 hours for urgent care, and an urgent extension request decided within 24 hours if made at least 24 hours before the approval expires. Aetna's Missouri supplement adds the peer-to-peer window for fully insured members: request "within 14 calendar days of the denial letter date"; response "within one 24-hour working day of the request."[9][12][13][14]
Ask the plan: Aetna precertification (number on the member ID card): ask whether the plan is fully insured or self-funded (which sets the legal clock) and how far before expiry Aetna wants the ABA reauthorization — Aetna publishes no lead time.
No instrument is named at either level. CPB 0554 does not require or reference a specific diagnostic tool, and the precertification form asks for the diagnosis code, the diagnosing provider and their credentials rather than for an instrument and score; § 376.1224 names none either.[1][3]
Ask the plan: Aetna precertification (Availity or the number on the card) — ask whether a specific instrument is expected for this plan before scheduling testing.
Coverage decides whether Aetna in Missouri 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; Aetna publishes no numeric ratio. Missouri makes licensure a coverage requirement rather than just a credentialing one: § 376.1224 requires ABA to be supervised by a board-certified behavior analyst licensed under chapter 337, and RSMo 337.315 prohibits practising applied behavior analysis without an LBA or LaBA licence outside enumerated exceptions.[1][2][3][4]
Aetna publishes no ABA place-of-service list. On school settings it says two things. CPB 0648: "Many Aetna plans exclude coverage of educational services. For example, speech therapy or ABA services during class would be excluded under these plans. Please check benefit plan exclusions." And precertification form GR-69017-4 asks "Are any ABA hours being requested during class?" and, if so, how many and for which codes. The IEP/IDEA carve-out in Aetna's ABA medical necessity guide sits in its Maryland exhibit, not in the national criteria. Where ABA is payable in a school, the community or a group home is a benefit-document question.[2][6]
Ask the plan: The member's benefit document (educational-services exclusion), and Aetna provider services for whether school-setting ABA is payable on that plan.
Aetna does not publish the rendering-versus-billing NPI convention for ABA. Missouri's mandate does supply one half of the answer for plans it reaches: reimbursement is directed to the autism service provider, or to the entity or group the supervising board-certified behavior analyst works for, and it expressly includes line-therapist services delivered under that supervision when they are in the treatment plan and medically necessary.[3][1]
Ask the plan: Aetna provider services or Availity — confirm the rendering-versus-billing NPI convention and any required degree-level modifiers before the first claim.
Not published. Neither CPB 0554 nor CPB 0648 states whether 97155 and 97153 may be billed for the same clock time, and Aetna publishes no Missouri-specific ABA policy, form or supplement.[1]
Ask the plan: Availity Essentials for the plan's reimbursement and claim-editing policies, or the provider-services number on the member's card.
Not published. CPB 0554 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.
Yes — under the carrier's national policy for ASD, layered on Missouri's mandate (RSMo § 376.1224) for fully-insured plans. Self-funded private employer plans are exempt from the mandate, so always verify plan funding type first.
Coverage of ASD diagnosis and treatment including ABA, with a $40,000-per-year ABA cap through age 18 — a CPI-indexed statutory base that can be exceeded with plan approval when medically necessary. Treatment-plan reviews are limited to once every 6 months, and ABA must be supervised by a Chapter 337-licensed behavior analyst.
Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against the MO HealthNet fee schedule, and treat rate-setting as part of contracting.
Not by name. Aetna's ABA medical necessity guide says services must be provided directly or billed by licensed behavior analysts, BCBAs or licensed psychologists "unless state mandates, plan documents or contracts require otherwise." Where those allow services by unlicensed or non-certified staff, "there must be supervision and direction" in line with practice standards. Your contract and any state licensure law decide the technician credential.
Possibly. The public copy of Aetna's telemedicine payment policy lists 97151, 97153, 97155, 97156 and 97157 for commercial plans with modifier GT, 95 or FR, but it was last reviewed in June 2021; the current policy is on Availity. Confirm the code list and the member's telehealth benefit before scheduling a remote assessment.
No DSM-5 grouping is asked for. Aetna wants a DSM-5 ASD diagnosis and a plan with clearly defined target behaviors, baseline data and quantifiable progress criteria; GR-69017-4 asks for baseline, interim and current data for all goals.
No published minimum or cap. Parent commitment to participate is a medical-necessity criterion; request 97156/97157 in hours per week on GR-69017-4 and show measurable caregiver goals — the authorization sets the hours.
Whatever your Aetna agreement says; without a contract term, Missouri law gives participating providers six months from the date of service and nonparticipating providers one year (RSMo 376.384).
No published rule requires one. Aetna treats behavioral health as direct access, and its clean-claim definition asks for a referral only "if required for the applicable claim." Precertification is the gate.
No published rule either way. Aetna's precertification form asks which PT, OT, speech and other services the child gets and whether you coordinate with them, so disclose them and confirm with precertification before overlapping sessions.
Form GR-69017-4 (7-26), which since August 1, 2026 replaces all other Aetna ABA precertification forms (except in Maryland and Massachusetts). Start the request on Availity or by phone first, then attach the form if the case pends. Request 97151, 97152 and 0362T in hours per authorization period.
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. Its precertification request also asks for baseline, interim and current data for all goals and a repeat validated assessment every 6–12 months.
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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