For an intake team in Nevada, an Aetna card means three layers: Aetna’s national ABA policy, Nevada’s autism mandate, and the plan’s funding type, which decides whether the mandate applies at all. Nevada’s mandate is narrower than many states’: it covers children under 18 (under 22 while in high school) and caps ABA at the actuarial equivalent of $72,000 a year. Aetna is not one of Nevada’s five Medicaid health plans.
Aetna’s ABA medical necessity guide (©2026) requires a DSM-5 ASD diagnosis (F84.0, F84.3–F84.9) “obtained by an appropriate provider,” functional impairment “on a standardized scale of functioning in the past 12 months” at least one standard deviation below the mean (or significant risk of harm), a measurable treatment plan, and hours matched to a severity table; progress is evaluated every six months. CPB 0554 now only says ABA is experimental for non-ASD indications, and CPB 0648 covers ASD diagnosis and treatment. Aetna’s behavioral health precertification list (effective 8/1/2024) names all ten ABA codes: 97151–97158, 0362T and 0373T. The guide’s only state exhibit is Maryland’s, so the national criteria apply in Nevada unchanged, subject to the mandate below.[4][5][6][7]
Nevada’s autism mandate is written separately into each insurance chapter. For group policies, NRS 689B.0335 says a health benefit plan “must provide coverage for screening for and diagnosis of autism spectrum disorders and for treatment of autism spectrum disorders to persons covered by the policy of group health insurance under the age of 18 years or, if enrolled in high school, until the person reaches the age of 22 years.” HMOs (NRS 695C.1717) and small-employer plans (NRS 689C.1655) carry the same text. Individual policies are different: NRS 689A.0435 only requires the plan to “provide an option of coverage,” with a maximum benefit “of not less than” the same amount. The cap is set in subsection 2: coverage is subject to “A maximum benefit of the actuarial equivalent of $72,000 per year for applied behavior analysis treatment,” plus the policy’s ordinary cost sharing. Inside that cap the insurer “shall not limit the number of visits,” may not charge higher cost sharing or impose a longer wait than for other outpatient care, and “shall accept as dispositive any diagnosis of an autism spectrum disorder that is rendered in accordance with the statewide standard” set under NRS 427A.872. Treatment “must be identified in a treatment plan” prescribed and provided by a provider acting within scope, and the insurer “may request a copy of and review a treatment plan.” The statute defines behavioral therapy as therapy “provided by a licensed psychologist, licensed behavior analyst, licensed assistant behavior analyst or registered behavior technician,” and it does not require an insurer to reimburse a school for school services. The current text was last amended in 2025 and binds policies “delivered, issued for delivery or renewed on or after January 1, 2026.” It reaches state-regulated plans only; self-funded employer plans answer to ERISA.[1][3][13][2]
Nevada licenses behavior analysts. Under NRS Chapter 641D a “behavior analyst” is a person with current BCBA or BCBA-D certification “and is licensed as a behavior analyst pursuant to this chapter”; an assistant behavior analyst is a licensed BCaBA; and a registered behavior technician must be BACB-certified and “registered as such pursuant to this chapter.” The Board of Applied Behavior Analysis (NRS 641D.200) issues those credentials, and the BACB’s licensure table lists Nevada with the NV Applied Behavior Analysis Board. Practicing ABA without the license or registration is prohibited (NRS 641D.900) and is a gross misdemeanor (NRS 641D.910); exemptions cover physicians, psychologists and certain other licensed professionals, family members acting at a behavior analyst’s direction, and school-district employees serving pupils (NRS 641D.110). An assistant behavior analyst or RBT may practice only under supervision by a licensed behavior analyst or a BCBA-certified licensed psychologist (an RBT may also be supervised by a qualified licensed assistant behavior analyst), and supervisors must follow BACB supervision rules (NRS 641D.610). Expect every payer to credential against the Nevada license number, not just the BACB number.[16][18]
Not without a Nevada license. NRS 641D.900 bars anyone from engaging “in the practice of applied behavior analysis unless he or she is licensed or registered as required by the provisions of this chapter.” Telehealth does not get around that: NRS 629.031 counts “A behavior analyst, assistant behavior analyst or registered behavior technician” as a provider of health care, and NRS 629.515 says that before a provider at a distant site “may use telehealth to direct or manage the care or render a diagnosis of a patient who is located at an originating site in this State,” the provider “must hold a valid license or certificate to practice his or her profession in this State.” A BCBA directing a Nevada child’s program from another state is therefore treated as practicing in Nevada and is “subject to the laws and jurisdiction of the State of Nevada.” The fast path is licensure by endorsement under NRS 641D.340: a behavior analyst who holds “a corresponding valid and unrestricted license as a behavior analyst” in another state or D.C. may apply, and unless the Board denies for good cause it must issue the license within 45 days of the application or 10 days after the fingerprint background report, whichever is later. Payers add their own layer: credential the clinician with each plan before billing.[16][17][9]
Aetna’s provider manual (6/26) adds that providers delivering telehealth “must act within the scope of their license and ensure that they have the proper licensure based on state requirements.”[16][17][9]
Claims timing for state-regulated group policies is set by NRS 689B.255: the insurer “shall approve or deny a claim … within 21 days after the insurer receives the claim, if the claim is submitted electronically, or 30 days” on paper, and must pay an approved claim within the same period or owe interest “at a rate of 10 percent per annum.” A request for more information must come “within 20 working days” of receipt, and the clock restarts at 21 or 30 days from the additional information. A denial must state the reasons and the criteria the insurer applied. Self-funded plans follow their own documents and ERISA.[1][9][23]
Aetna publishes no ABA rate table. Its provider manual (6/26) says that where a provider also contracts through an intermediary, “your direct Aetna rates will apply unless we specifically notify you otherwise,” and a member whose benefits run out cannot be charged “more than the contracted rate.” For a public benchmark, Nevada Medicaid’s 07/2026 PT 85 schedule pays 97153 at $30.10 per 15 minutes when billed by a BCBA and $13.01 when billed by an RBT; commercial contracts are negotiated separately.[1][9][23]
Aetna publishes no requirement to report a referring or ordering provider on an ABA claim. Its office manual defines a clean claim as including “A corresponding referral (whether in paper or electronic format), if required for the applicable claim” plus “All the data elements of the UB-04 or CMS-1500 (or successor standard) forms (including but not limited to member identification number, National Provider Identifier (NPI), date(s) of service, and a complete and accurate breakdown of services).”[9][24]
A referral matters only on plans that require PCP referrals for specialist care. Those referrals must be issued before the visit (“Referrals should not be retroactive”), and “In Aetna Open Access® plans, referrals also are not necessary.” Aetna’s behavioral health manual lists direct access as the first way into care: members may reach behavioral health “Through direct access to the behavioral health provider,” through a recommendation from their PCP or another treating provider, or through an EAP referral.[9][24]
Since August 1, 2026, one Aetna form — “Outpatient Behavioral Health (BH) – ABA Treatment Request: Required Information for Precertification” (GR-69017-4) — “replaces all other” ABA precertification information forms. It does not start a request. Start the request on Availity (Authorization Add) or by phone, then attach the form and the records to the case, or fax them to FaxHub 833-596-0339 with the reference number.[25]
Section 1 asks for the member and provider group details; the current DSM-5 diagnosis code(s); the diagnosing provider’s name and credentials; hours per authorization period for the assessment codes 97151, 97152 and 0362T; hours per week for 97153–97158 and 0373T; and whether any hours fall during class. Section 2 asks who supervises the ABA services, and whether the child also gets PT, OT, speech, mental health or school services and whether you coordinate with those providers. It also asks for current impairment areas with supporting severity data.[25]
Attach the results of a standardized assessment (“i.e. Vineland, ABAS, VB-MAPP”) completed within the past 12 months. Also attach a time-limited, individualized treatment plan with baselines and measurable progress criteria, caregiver goals, titration and discharge criteria with an aftercare plan, and baseline, interim and current data for every goal. The form names CPB 0648 and the ABA Medical Necessity Guide as the review criteria.[25]
Nevada sets the payment clock for state-regulated plans. A group or blanket insurer "shall approve or deny a claim ... within 21 days after the insurer receives the claim, if the claim is submitted electronically, or 30 days after the insurer receives the claim, if the claim is not submitted electronically," must pay an approved claim within the same period, and owes interest at 10 percent a year after that (NRS 689B.255; the individual-market rule, NRS 689A.410, is the same). A request for more information must come within 20 working days, and the clock restarts on receipt of it. The HMO section that used to carry the same rule (NRS 695C.185) is shown as repealed in 2025, so for an HMO product check the contract. Self-funded employer plans follow ERISA instead.[1][2][3][9]
Aetna’s provider manual (edition 6/26) publishes no numeric filing deadline: a clean claim is one "received in a timely manner," so the operative limit is the one in your Aetna agreement or state law. The manual says a clean claim "Doesn’t involve coordination of benefits," and that COB, corrected and voided claims can all be submitted through Availity at no charge; it sets no separate deadline for corrected or secondary claims and publishes no weekly payment cycle or submission cutoff.[1][2][3][9]
Aetna’s ABA medical necessity guide (©2026) says "A member's progress is to be evaluated every six months," and a member not making progress "will be transitioned to other appropriate services"; coverage ends when medical necessity is no longer met or when standardized improvement thresholds (for example, two or more standard deviations in multiple domains) are reached. The guide does not specify a graph or data-presentation format for the reassessment; send the updated treatment plan with measurable progress against each goal and the standardized scores the termination criteria are tested against.[4]
The questions that decide whether a family can start with Aetna in Nevada, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the diagnosis itself, but functional impairment must be shown on a standardized scale “in the past 12 months.” Nevada’s mandate requires the insurer to accept as dispositive a diagnosis made under the state’s statewide standard.[4][1]
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).” Nevada’s ABA licensure law excludes diagnosis from the practice of ABA (NRS 641D.080).[4][16]
CPB 0648 names 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).[6][4]
Aetna’s ABA policies require no physician referral; they require precertification of all ten ABA codes. For a state-regulated Nevada plan, autism treatment “must be identified in a treatment plan” and be prescribed by a provider of health care acting within scope, and the insurer “may request a copy of and review a treatment plan” (NRS 689B.0335(5)). Self-funded ERISA plans sit outside the statute.[7][4][1]
Aetna’s guide sets no age cap; it describes typical age ranges only. For state-regulated Nevada group, small-employer and HMO plans, the mandate covers members “under the age of 18 years or, if enrolled in high school, until the person reaches the age of 22 years,” with ABA capped at the actuarial equivalent of $72,000 a year (NRS 689B.0335, 689C.1655, 695C.1717). Individual policies need only offer the coverage as an option (NRS 689A.0435). Self-funded ERISA plans are outside the statute.[4][1][3][13][2]
Ask the plan: Live benefits verification on the member ID: establish fully insured vs. self-funded, then the plan’s own age terms.
Aetna’s Telemedicine and Direct Patient Contact Payment Policy checks 97151, 97153, 97155, 97156 and 97157 for Commercial plans (modifier GT, 95 or FR) and 97152, 97154 and 97158 for Medicare only; the posted policy shows a last review of June 2021, so treat the list as perishable. Aetna’s provider manual 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.” For a state-regulated group policy, NRS 689B.0369 requires coverage of services “provided to an insured through telehealth to the same extent as though provided in person,” bars the insurer from requiring prior authorization for a telehealth service “that is not required for that service when provided in person,” and forbids refusing coverage because of the originating site (the home counts) or the technology used; pay parity in the same amount applies to mental health treatment, including audio-only. NRS 629.515 separately requires the clinician to hold a Nevada license. Self-funded employer plans are outside the state statute.[10][9][1][17]
Ask the plan: Availity or the precertification line on the card: ask whether the plan is Nevada-insured or self-funded (and opted out of telehealth), and which ABA codes, POS and modifier Aetna pays by telehealth.
Depends on how the plan is funded. State-regulated plans fall under Nevada’s prior-authorization statute: unless a shorter period applies, a health carrier must respond “within: (1) Two business days after it receives the request; or (2)” any longer period the CAQH CORE Prior Authorization and Referrals Operating Rules allow, and in any case “within 7 calendar days after receiving the request” (NRS 687B.970). If the carrier violates that section for a particular request, “the request shall be deemed approved” (NRS 687B.990). The procedure “may not discriminate among persons licensed to provide the covered care.” 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, urgent care within 72 hours. Aetna publishes no Nevada-specific ABA turnaround or reauthorization lead time.[15][19]
Ask the plan: At benefits verification ask whether the plan is Nevada-insured or self-funded (ERISA) and what reauthorization lead time Aetna expects.
For a child on two group policies, Nevada uses the birthday rule: when parents are not divorced or separated, “the primary policy is the policy of the parent whose birthday falls earlier in the year”; for divorced or separated parents the custodial parent’s policy pays first, then the custodial parent’s spouse’s, then the non-custodial parent’s, unless a court decree assigns responsibility (NRS 689B.064). A policy that does not coordinate is always primary. That rule binds state-regulated group policies; a self-funded plan sets its own order. If the child also has Nevada Medicaid, Aetna pays first: Medicaid is the payer of last resort (42 CFR 433.139), and Nevada Medicaid tells providers to “Always follow other payers’ billing requirements. If the other payer denies a claim because you did not follow their requirements, Medicaid will also deny the claim.” TRICARE pays after this plan (10 U.S.C. 1079(i)(1)).[1][20][21][22]
Ask the plan: Ask Aetna at benefits verification for the member’s coordination-of-benefits order (and whether a self-funded plan uses the birthday rule), and record every other coverage the child has.
Coverage decides whether Aetna in Nevada pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Aetna’s guide requires services “provided directly or billed by licensed behavior analysts (in states with behavior analyst licensure laws), board-certified behavior analysts, or licensed psychologists,” with supervision of unlicensed staff “in line with practice standards.” Its participation criteria (5/26) require “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,” and say all BCBAs, BCaBAs and paraprofessionals “must meet state requirements.” In Nevada that means NRS 641D.610: BCaBAs and RBTs practice only under a licensed behavior analyst (or qualified psychologist; RBTs also under a qualified licensed BCaBA).[4][8][16]
No per-day cap. Hours follow the guide’s severity table, with typical intensities of 10–25 hours a week for comprehensive and 1–20 for focused programs, plus 1–2 hours of QHP protocol modification per 10 hours of treatment. For state-regulated Nevada plans the mandate caps ABA at the actuarial equivalent of $72,000 a year but bars visit limits within it (NRS 689B.0335).[4][1]
Aetna has a general rule, not an ABA-specific one. Its medical-record standards apply to "all participating practitioners," who "agree to maintain medical records in a current, detailed, organized, and comprehensive manner." The core components are: "All entries are dated," "All entries are legible to someone other than the writer," and "All entries in the record must contain the provider's signature/initials or electronic identifier." Aetna audits records against these at least every two years, with an 85% performance goal. Aetna's ABA documents do not say whether the technician, the supervising BCBA or both sign a session note, or how soon after the session it must be signed. Each person who writes an entry should sign or e-sign and date it.[9][4]
Aetna’s outpatient ABA criteria are setting-neutral and expect coordination with the school district. Nevada’s mandate says nothing in it requires “an insurer to provide reimbursement to a school for services delivered through school services” (NRS 689B.0335(7)).[4][1]
Aetna’s guide requires a progress evaluation every six months but does not prescribe graphs; send measurable progress against each goal and the standardized scores its termination criteria use.
A group or individual insurer must approve or deny within 21 days of an electronic claim (30 days on paper) and pay within the same period, with 10% annual interest after that (NRS 689B.255, 689A.410). Self-funded employer plans follow ERISA instead.
Aetna publishes no numeric filing limit; it comes from your Aetna agreement or state law. COB, corrected and voided claims go through Availity; no weekly payment cutoff is published.
Yes, for ASD under its national ABA guide, with Nevada’s mandate layered on for state-regulated plans. Self-funded employer plans follow their own documents.
Yes. For state-regulated group, small-employer and HMO plans, ABA is capped at the actuarial equivalent of $72,000 a year, and coverage runs to age 18 (22 if still in high school).
For a state-regulated plan, NRS 687B.970 requires a response within 2 business days (or the CAQH CORE rule period) and never more than 7 calendar days; a violation deems the request approved. Self-funded plans follow ERISA’s 15 days.
Aetna’s network criteria allow supervised paraprofessionals, but Nevada law requires anyone practicing as a technician to be a BACB-certified RBT registered with the Nevada Board of Applied Behavior Analysis, and Aetna requires staff to meet state requirements.
Aetna publishes no such requirement for ABA. A referral has to accompany a claim only when the member’s plan requires PCP referrals for specialist care. Behavioral health is a direct-access benefit in Aetna’s behavioral health manual.
Since August 1, 2026, use form GR-69017-4, “ABA Treatment Request: Required Information for Precertification.” Start the request on Availity or by phone first, then attach the completed form plus a standardized assessment from the past 12 months and the treatment plan.
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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