For an intake team in New Hampshire, an Aetna card means three layers: Aetna’s national clinical policy, New Hampshire’s autism mandate in RSA 417-E, and the plan’s funding type, which decides whether the mandate applies at all. This guide stacks them in order.
Aetna covers ABA for autism spectrum disorder under CPB 0648, which CPB 0554 names as the policy “for Applied Behavior Analysis for autism”; CPB 0554 (last review 10/14/2026) considers ABA experimental for Down syndrome without co-occurring ASD and for all other non-ASD indications. Its behavioral health precertification list names all ten ABA codes, 97151 through 97158, 0362T and 0373T, and ABA precertification runs on form GR-69017-4 through Availity or the number on the card. We checked Aetna’s ABA medical necessity guide: its state exhibits do not include New Hampshire, so the national criteria apply unchanged. Aetna runs no New Hampshire Medicaid plan.[1][2][4][3]
New Hampshire’s autism mandate sits inside its mental-illness parity statute. RSA 417-E:1 requires every insurer, nonprofit health service corporation and HMO issuing or renewing accident or health coverage in the state to cover "pervasive developmental disorder or autism" on terms "no less extensive than the coverage provided for any other type of health care for physical illness." RSA 417-E:2 then defines the treatment: "applied behavioral analysis, necessary to produce socially significant improvements in human behavior or to prevent loss of attained skill or function," plus pharmaceuticals, psychiatric, APRN, psychologist and social-work services, and speech, occupational and physical therapy. Two conditions bind ABA specifically. It "must be provided by a person professionally certified by the national Behavior Analyst Certification Board or performed under the supervision of" one. And the insurer "may require submission of a treatment plan, including the frequency and duration of treatment," signed by the primary care provider or a listed specialist (child psychiatrist, developmental-behavioral pediatrician, child neurologist, or a psychologist trained in child psychology), updated "no more frequently than on a semi-annual basis." Coverage "shall not be denied on the basis that services are habilitative in nature." The age and dollar question has changed since enactment: HB 569 as passed in 2010 let a policy "limit coverage for applied behavior analysis to $36,000 per year for children 0 to 12 years of age, and $27,000 from ages 13 to 21." That paragraph does not appear in the current RSA 417-E:2, whose source note lists amendments in 2011 and 2022, and no other age or dollar limit appears in the section. Autism Speaks’ New Hampshire summary (last updated December 2019) still describes the caps, so expect some plan documents and benefit summaries to lag. The mandate reaches fully insured plans only; self-funded employer plans answer to ERISA and federal parity.[6][7]
New Hampshire does not license behavior analysts. The BACB’s state licensure table (updated 2026) lists no New Hampshire law or board, and the practical credential is therefore BACB certification, which the mandate itself requires. That shapes credentialing in two ways. First, carriers credential BCBAs on certification rather than a state license number, even where a form asks for one (WellSense’s New Hampshire ABA form has a "BCBA license #" field). Second, the state credentialing clock in RSA 420-J:4 does help: a carrier must tell you an application is incomplete within 15 business days and must "act upon and finalize the credentialing process within 30 calendar days" of a clean and complete application for primary care physicians and mental health providers (45 days for specialists). The statute does not say which bucket a BCBA falls in, so ask. The provisional-pay rule in RSA 420-J:8-c is keyed to "a valid license from the respective state licensing board," which New Hampshire BCBAs do not hold, so do not plan on being paid before credentialing completes. On rates: commercial ABA rates are negotiated and unpublished. RSA 417-E:1, V-b requires carriers’ contracts to pay mental health and substance use treatment services, on average, at least as favorably as non-hospital primary care, measured against relative Medicare reimbursement; the statute does not say whether ABA codes are in that comparison. The public benchmark is the NH Medicaid fee-for-service schedule, which is low (97153 $17.79 and 97155 $16.43 per 15-minute unit).[10][8][6][14][19]
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, NH Medicaid’s 2026 fee-for-service schedule pays 97153 at $17.79 per 15 minutes; commercial contracts are negotiated separately.[12][14]
New Hampshire’s RSA 420-J:8-a makes health carriers pay clean claims for services rendered in New Hampshire "within 30 calendar days upon receipt of a clean non-electronic claim or 15 calendar days upon receipt of a clean electronic claim," with 1.5% interest per month on overdue claims. A carrier is not in violation for a claim submitted more than 90 days after the service.[16][12][17][18]
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 business days. 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.[16][12][17][18]
Aetna’s behavioral health precertification list (eff. 8/1/2024) identifies ABA as CPT 97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T and 0373T, and CPB 0648 lists 97151–97158, “Adaptive Behavior Assessments and treatment”, among the CPT codes covered when its criteria are met. Neither lists a HCPCS H-code such as H0031, H0032 or H2019 for ABA. Aetna’s provider manual (6/26) defines a clean claim as one with all the data elements of the CMS-1500, including the member ID, NPI, dates of service and “a complete and accurate breakdown of services”, plus “a corresponding referral (whether in paper or electronic format), if required for the applicable claim”. A claim that involves coordination of benefits is not a clean claim. The manual does not mention a taxonomy code, a corrected-claim deadline or electronic visit verification. Benefits are coordinated under the NAIC order-of-benefit rules, including the birthday rule for a child whose parents are not separated or divorced, where state or federal law allows; otherwise by the member’s plan.[4][2][12][3]
For continued authorization, Aetna’s ABA medical necessity guide requires a standardized scale of functioning from the past 12 months (for instance the Vineland-3, ABAS, VB-MAPP or ABLLS), target behaviors with recorded baseline measures and quantifiable criteria for progress, and documentation that the target behavior has improved, or, if it has not, documentation of treatment modification, added assessments or consultation. A member’s progress is evaluated every six months. The guide does not require graphs.[4][2][12][3]
Aetna's provider manual (6/26) uses transition of care (TOC) and continuity of care rather than the term single case agreement. TOC “allows certain qualifying members the ability to request to continue receiving care from their current out-of-network provider at in-network cost level for a defined period of time,” typically at plan enrollment or renewal; continuity of care does the same when a provider leaves the network mid-treatment. The member must be in “an active course of covered treatment,” and the treating provider must be an individual practitioner (the manual's examples are a specialist, physical therapist or speech therapist) or home care agency that is not contracted in the member's plan. Steps: the member gets a Transition Coverage Request Form from Member Services or the employer, completes it with the non-participating provider's help, faxes it to Aetna, and Aetna sends a decision letter stating how long the transition benefits last. The process does not apply to Traditional Choice plans. Aetna publishes no ABA rate for this; ask Aetna behavioral health whether the ABA agency qualifies before the first session.[12]
The questions that decide whether a family can start with Aetna in New Hampshire, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the ASD diagnosis itself, but medical necessity requires functional impairment shown on a standardized scale administered in the past 12 months (at least one standard deviation below the mean) or a significant risk of harm.[3]
A DSM-5 ASD diagnosis by an appropriate provider: a licensed psychologist or psychiatrist, a physician, or another professional qualified to diagnose within scope. CPB 0648 lists the professionals appropriate to an ASD evaluation, from developmental pediatricians and neurologists to psychologists and speech-language pathologists. LCSW: not named. The test turns on licensure and diagnostic scope, so an LCSW's diagnosis is accepted only if the plan agrees it is within the LCSW's licensed scope; confirm with the plan before relying on one.[3][2]
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).[2][3]
Aetna’s national ABA policies require no physician referral or prescription; what they require is precertification of all ten ABA codes, on form GR-69017-4 through Availity or the number on the card. For a fully insured New Hampshire plan, RSA 417-E:2, II lets the insurer require a treatment plan, with frequency and duration, signed by the primary care provider or a listed specialist, updated no more than every six months. Self-funded ERISA plans sit outside the statute.[4][3][6]
Aetna’s national ABA policies set no age cap; the guide describes typical, not limiting, age ranges. For fully insured New Hampshire plans, the current RSA 417-E:2 carries no age or dollar limit on ABA (the 2010 caps of $36,000 a year for ages 0–12 and $27,000 for 13–21 are no longer in the text). Self-funded ERISA plans are outside the statute, so plan funding type decides whether that binds.[3][6][7]
Ask the plan: Live benefits verification on the member ID: establish fully insured vs. self-funded ERISA, then the plan’s own age terms.
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. Aetna’s provider manual (6/26) says Aetna Behavioral Health “offers telehealth services to all commercial fully insured members and to all commercial self-insured plan sponsors, unless those self-insured plan sponsors opt out,” and that providers “must act within the scope of their license and ensure that they have the proper licensure based on state requirements.” For a fully insured New Hampshire plan, RSA 415-J:3 says an insurer “may not deny coverage on the sole basis that the coverage is provided through telemedicine” and must cover and reimburse it “on the same basis” as in person, with “no restriction on eligible originating or distant sites,” for “all modes of telehealth.” Its list of providers who may use all modes includes “Professionals certified by the national behavior analyst certification board or persons performing services under the supervision of” a BACB certificant “as required by RSA 417-E:2.” Self-funded employer plans are outside the state statute.[20][12][13]
Ask the plan: Availity or the precertification line on the card: ask whether the plan is fully insured in New Hampshire 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. Fully insured New Hampshire plans fall under RSA 420-J:6. For requests sent through the carrier’s electronic prior-authorization process, a non-urgent decision is due "within 7 calendar days of obtaining all information necessary to make the determination"; for paper or fax requests the limit is 14 calendar days; urgent requests are decided within 72 hours. Any request for more information must come within 7 calendar days of the request date, and information supplied in a peer-to-peer counts. A missed deadline means the request "shall be considered approved." Once approved, the carrier may not revoke or limit it "if care is provided within 60 business days" of the approval, and a peer-to-peer must be offered within 2 business days of a request. 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 New Hampshire-specific ABA turnaround or reauthorization lead time.[8][11]
Ask the plan: At benefits verification ask whether the plan is fully insured (New Hampshire-regulated) or self-funded (ERISA), whether you are submitting electronically, and what reauthorization lead time Aetna expects.
For a child on two group plans, New Hampshire follows the birthday rule: when parents are married or living together, "the plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (Ins 1904.05(d)(2)); for separated parents a court decree controls, and otherwise the custodial parent’s plan pays first. That rule binds group plans regulated by the state; a self-funded plan sets its own order. When both plans require precertification, RSA 420-J:3-b says the member "shall obtain pre-certification from the primary plan," and the secondary plan "shall not refuse payment for such services solely on the basis that the services were not pre-certified by the secondary plan" (it can still apply its own criteria). If the child also has NH Medicaid, Aetna pays first: Medicaid is payer of last resort (42 CFR 433.139), and NH Medicaid will not pay a balance the primary denied for "incorrect billing, non-eligible provider, or lack of medical necessity." TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[9][8][21][22][23][24]
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 New Hampshire 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 licensure laws), board-certified behavior analysts, or licensed psychologists where ABA is within scope, unless mandates, plan documents or contracts say otherwise; where others deliver services, there must be supervision "in line with practice standards." Aetna publishes no numeric ratio. The NH mandate requires ABA to be provided by, or supervised by, a BACB certificant. 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."[15][3][6]
No per-day or per-week cap is published. Hours come from the guide’s severity assessment, with typical intensities of 10–25 hours a week for comprehensive and 1–20 for focused programs (typical, not caps). Progress is re-evaluated every six months.[3]
Outpatient ABA is setting-neutral in Aetna’s guide; inpatient, residential or partial hospitalization settings use that level of care’s criteria. Aetna expects coordination with the school and is not required to provide services under an IEP. RSA 417-E:2 likewise leaves school districts’ IEP obligations untouched.[3][6]
Services must be provided directly or billed by the appropriately licensed or certified provider (licensed behavior analyst where a state licenses them, BCBA, or licensed psychologist where in scope), unless mandates, plan documents or contracts say otherwise. New Hampshire has no behavior-analyst license, so the BCBA is the billing credential.[3][10]
Possibly, through Aetna's transition-of-care or continuity-of-care process. The member must be in an active course of covered treatment; the member requests a Transition Coverage Request Form, completes it with the provider and faxes it to Aetna, which issues a time-limited decision. Aetna's manual names individual practitioners and home care agencies as eligible, so confirm with Aetna behavioral health that an ABA agency qualifies.
Aetna’s precertification list and CPB 0648 identify ABA by CPT 97151–97158, 0362T and 0373T. No H-codes are listed for ABA.
The ABA medical necessity guide does not say graphs. It requires a standardized functioning scale from the past 12 months, baseline measures with quantifiable progress criteria, and documentation of improvement or of how treatment changed. Progress is evaluated every six months.
Yes, under its national policy for ASD, with New Hampshire’s RSA 417-E mandate layered on for fully insured plans. Self-funded employer plans follow their own documents.
Coverage of autism treatment including ABA by or under a BACB-certified provider, on terms no less extensive than physical illness, without denial because services are habilitative. The current statute carries no age or dollar cap.
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. The only public benchmark is NH Medicaid’s fee-for-service schedule (97153 $17.79 per 15 minutes).
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.
Fifteen calendar days for a clean electronic claim and 30 for paper (RSA 420-J:8-a), on plans subject to the Managed Care Law. Claims filed more than 90 days after service lose that protection.
180 calendar days from the initial claim decision to request a reconsideration, then 60 calendar days from the reconsideration decision to appeal.
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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