For an intake team in North Dakota, an Aetna card means three layers: Aetna’s national ABA medical necessity guide and precertification list, North Dakota’s Bulletin 2018-1 (the state has no autism statute), and the plan’s funding type, which decides whether state rules apply at all.
Aetna’s ABA medical necessity guide (©2026) requires a DSM-5 ASD diagnosis (F84.0, F84.3–F84.9) from an appropriate provider, services "provided directly or billed by the appropriately licensed provider," functional impairment on a standardized scale "in the past 12 months" at least one standard deviation below the mean (or a significant risk of harm), and a treatment plan with measurable targets, generalization and discharge planning. Hours follow a severity table, with "QHP protocol modification and direction at 1 to 2 hours per 10 hours of treatment by protocol" and caregiver training authorized on top, and progress "evaluated every six months." The guide’s only state exhibit is Maryland, so the national criteria apply unchanged in North Dakota. Aetna’s behavioral health precertification list names all ten ABA codes, 97151 through 97158, 0362T and 0373T.[1][2][3][4]
North Dakota has no autism insurance statute: chapter 26.1-36 of the Century Code, the accident and health insurance chapter, contains no autism or ABA section (§ 26.1-36-09.15, sometimes cited as the autism mandate, is the telehealth coverage section). The rule that binds insured plans is Insurance Department Bulletin 2018-1, issued July 10, 2018 to "all health insurance carriers choosing to cover Autism Spectrum Disorder," which says "treatments for Autism Spectrum Disorder cannot be excluded from an insurance policy." It rests on federal mental health parity: if a carrier covers autism and "seeks to place QTLs or NQTLs on autism spectrum disorder benefits or treatments, it must show that a similar limitation exists regarding substantially all benefits and treatments on the medical/surgical portion of their insurance coverage," and autism benefits "may not be subject to any separate cost-sharing requirements or treatment limitations that only apply to mental health/substance use disorder benefits." On ABA specifically: "exclusion of Applied Behavior Analysis (ABA) therapy to treat children with autism spectrum disorder on the basis that ABA therapy is experimental or investigative treatment will not be allowed by the Department." Carriers may still review medical necessity and periodically review continuing treatment, "as long as the standards for such reviews are comparable to and not more stringent than reviews conducted for substantially all medical/surgical services in the same classification." The bulletin defines treatment as care "prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician or a licensed psychologist who determines the care to be medically necessary," including behavioral health treatment. It applied to grandfathered and transitional individual, small-group and large-group policies from October 1, 2018, and to non-grandfathered policies and Department-regulated self-funded multiple employer welfare arrangements from January 1, 2019. It sets no age or dollar cap of its own. Ordinary self-funded employer plans are not regulated by the Department and answer to ERISA and federal parity instead.[8][9][10]
North Dakota licenses behavior analysts. Under N.D.C.C. 43-64-02, "Effective January 1, 2020, an individual may not practice applied behavior analysis without a current license issued by the board," the State Board of Integrative Health Care. There are two licenses: licensed behavior analyst (a master’s or doctorate from an ABAI-accredited or BACB-approved program, the BCBA examination, current BACB certification, and the North Dakota professional responsibility examination "once developed and approved by the board") and licensed assistant behavior analyst (bachelor’s, the BCaBA examination, and proof of supervision by a licensed behavior analyst). Anyone who held a license or registration from the Board of Psychologist Examiners under chapter 43-32 on December 31, 2019 was grandfathered. The board’s exemptions include behavior technicians who "deliver applied behavior analysis services under the extended authority and direction of a licensed behavior analyst or a licensed assistant behavior analyst" (titles such as "registered behavior technician"), licensed psychologists practicing within competence, and people providing ABA in a public school setting. A BCBA licensed in another state can apply for license by endorsement: the board grants it when the applicant holds "a verified current valid license in good standing to practice as a behavior analyst professional in another state," passed the BACB examination, and the other state’s requirements are "substantially similar." We read chapter 43-64, chapter 43-57 and the full rule chapter 112-05-01 and found no exemption for an out-of-state behavior analyst treating a North Dakota child, in person or by telehealth, so plan on a North Dakota license before serving North Dakota members and confirm telehealth questions with the board. On rates: commercial ABA rates are negotiated and unpublished. The public benchmark is ND Medicaid’s professional fee schedule (August 1, 2026): 97153 $10.81 and 97155 $31.76 per unit.[13][14][15][16][21]
North Dakota’s claim-payment statute, N.D.C.C. 26.1-36-37.1, gives an insurer 15 business days after receiving a proof of loss to "pay the claim or that portion of the claim that is not contested, deny the claim, or make an initial request for additional information," and another 15 business days after receiving the information to pay or deny; a contested claim must be explained in writing. That binds insured policies, not self-funded ERISA plans. Prior authorization for insured plans runs under chapter 26.1-36.12 (seven calendar days after complete information, 72 hours if urgent, missed deadlines deemed approved; see the turnaround field below). Timely-filing limits and the rendering-versus-supervising NPI rule are set by each carrier’s contract, not by state law.[10][11][6]
Aetna’s Health Care Professional Toolkit (6/26) publishes no claim filing deadline: the limit for initial, corrected and secondary claims is the one in your Aetna participation agreement, and claim disputes "Must be submitted within contractual timeframes." The toolkit defines a clean claim as one "received in a timely manner" with all required data, and says a clean claim "Doesn’t involve coordination of benefits," so secondary claims sit outside the clean-claim clock. It publishes no check-run or weekly cut-off schedule.[10][11][6]
Aetna publishes no ABA rate table. Its provider manual (6/26) treats payment as a contract term: where a provider has both an intermediary contract and a direct agreement, "your direct Aetna rates will apply unless we specifically notify you otherwise," and Aetna "requires that you use your own TIN when billing for services." Get the rates from your Aetna agreement or Aetna provider services. For a public benchmark, ND Medicaid’s August 2026 professional fee schedule pays 97153 at $10.81 per unit; commercial contracts are negotiated separately.[6][21]
Aetna’s ABA medical necessity guide (©2026) sets what a renewal must show: the plan records baseline levels of each target behavior by "frequency, rate, symptom intensity or duration, or other objective measures," with "quantifiable criteria for progress"; where target behaviors have improved, documentation of that improvement is included, and where they have not, documentation of "modification of the treatment, additional assessments that have been conducted, and/or there has been appropriate consultations from other staff or experts." "A member’s progress is to be evaluated every six months," and the guide relies on "Repeated measurement with standardized measures to assess progress." It does not require graphs and sets no data-recency window.[1]
The questions that decide whether a family can start with Aetna in North Dakota, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the ASD diagnosis, but medical necessity requires functional impairment on a standardized scale "in the past 12 months" (at least one standard deviation below the mean) or a significant risk of harm.[1]
An appropriate provider: "licensed psychologist/psychiatrist, physician or other health care professional qualified to diagnose mental health conditions within their scope of practice."[1]
CPB 0648 names ADI-R, ADOS-2, CARS-2 and the Asperger Syndrome Diagnostic Scale as diagnostic tools used with clinical assessment. The ABA guide requires a standardized functional measure from the past 12 months (Vineland-3, ABAS, VB-MAPP or ABLLS as examples).[4][1]
Aetna’s national ABA documents require no physician referral; what they require is precertification of all ten ABA codes. North Dakota has no autism statute requiring a referral. For insured plans, Bulletin 2018-1 defines treatment as "evidence-based care and related equipment prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician or a licensed psychologist who determines the care to be medically necessary." The bulletin sets no order form, contents or validity period, so the practical route is a written order or recommendation for ABA from the diagnosing physician or psychologist (often inside the diagnostic report), kept on file. Single-employer self-funded ERISA plans sit outside the bulletin.[2][1][8]
Aetna’s guide sets no age cap; it describes typical, not limiting, age ranges (comprehensive 0–7 years, focused all ages). North Dakota has no autism statute, and Bulletin 2018-1 sets no age or dollar limit: for insured plans it bars autism-only limits that are more restrictive than those on medical/surgical benefits, and bars excluding ABA as experimental (its ABA paragraph speaks of "children with autism spectrum disorder"). Self-funded ERISA plans are outside the bulletin, so plan funding type decides whether it binds.[1][8]
Ask the plan: Live benefits verification on the member ID: establish insured vs. self-funded ERISA, then the plan’s own age terms.
Aetna’s Telemedicine and Direct Patient Contact Payment Policy lists ABA codes payable by telehealth by line of business; 97151, 97153, 97155, 97156 and 97157 carry marks in both the Commercial and Medicare columns, billed with modifier GT, 95 or FR, while 97152, 97154 and 97158 carry a single mark that, like the Medicare-only G0071 line, reads as 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 providers "must act within the scope of their license and ensure that they have the proper licensure based on state requirements." For an insured North Dakota policy, N.D.C.C. 26.1-36-09.15 requires coverage "for health services delivered by means of telehealth which is the same as the coverage for health services delivered by in-person means," lets payment be negotiated "in the same manner" as in-person rates, and does not require a provider at the originating site. Its definition of "health care provider" lists licensees under named chapters, including psychologists (43-32), but not behavior analysts (43-64), so whether a behavior analyst’s telehealth falls inside the statute is not settled by its text. Self-funded employer plans are outside the statute.[7][6][10]
Ask the plan: Availity or the precertification line on the card: ask whether the plan is insured in North Dakota 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. Insured North Dakota plans fall under N.D.C.C. ch. 26.1-36.12: a non-urgent decision is due "within seven calendar days of obtaining all necessary information," an urgent one within 72 hours, and if the provider or family does not supply requested information within 14 calendar days of a written request the carrier "may make an adverse determination." A prior authorization is valid for at least six months (12 months for "a chronic or long-term care condition"), cannot be revoked "if care is provided within forty-five business days" of approval, and a new carrier must honor a prior plan’s authorization for the first 60 days of coverage. If the carrier misses a deadline, "any health care services subject to review automatically are deemed authorized." Requirement changes need 60 days’ written notice to contracted providers. The chapter does not reach Medicaid or the state employees’ PERS plan. 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 North Dakota-specific ABA turnaround or reauthorization lead time.[11][17]
Ask the plan: At benefits verification ask whether the plan is insured in North Dakota (ch. 26.1-36.12 applies) or self-funded (ERISA), and what reauthorization lead time Aetna expects.
For a child on two group plans, North Dakota follows the birthday rule: for parents who are married or living together, "The plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (N.D. Admin. Code 45-08-01.2); a court decree controls for separated parents, and otherwise the custodial parent’s plan pays first. That rule binds plans regulated by the state; a self-funded plan sets its own order. If the child also has ND Medicaid, Aetna pays first: ND Medicaid is "generally the payer of last resort," pays only the member responsibility up to its allowed amount, and expects providers "to follow TPL payer policy and procedures for payment," so be in the commercial network and get its authorization. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[12][18][19][20]
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 North Dakota 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 Network Participation Criteria require ABA services to be "provided directly or supervised by individuals licensed by the state or certified by the Behavior Analyst Certification Board," with supervised staff a BCaBA "or a paraprofessional," "A minimum of one hour of face-to-face supervision" of an unlicensed or noncertified paraprofessional "for each 10 hours of applied behavior analysis," and the supervisor "onsite with the child at least one hour a month." "All BCBAs, BCaBAs and paraprofessionals must meet state requirements." In North Dakota that means a licensed behavior analyst (or licensed assistant under one) under ch. 43-64, with technicians exempt only while working under a licensee’s "extended authority and direction."[5][1][14]
No per-day or per-week cap is published. Hours come from the guide’s severity table, with typical intensities of 10–25 hours a week for comprehensive and 1–20 for focused programs (typical, not caps), plus 1–2 hours of QHP direction per 10 hours of technician treatment. Progress is re-evaluated every six months.[1]
Outpatient ABA is setting-neutral in Aetna’s guide; inpatient, residential or partial hospitalization settings use that level of care’s criteria instead of a separate ABA authorization. The guide expects coordination with existing providers "and/or the school district."[1]
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," unless mandates, plan documents or contracts say otherwise. North Dakota has a licensure law, so the billing credential is a North Dakota licensed behavior analyst (or licensed psychologist within competence). Aetna requires billing under your own TIN.[1][13][6]
Not addressed in Aetna’s published ABA documents (the medical necessity guide, CPB 0554, CPB 0648, the precertification list).[1][3]
Ask the plan: Aetna provider services, the participating-provider agreement, or a written coding determination from Aetna Behavioral Health.
Not addressed. Aetna sets treatment-plan content requirements but not who signs a session note or by when.[1]
Ask the plan: The participating-provider agreement and the Aetna Behavioral Health provider manual section on documentation.
No. Aetna’s ABA medical necessity guide asks for objective baseline measures, quantifiable progress criteria, standardized re-measurement and a six-monthly progress evaluation, with treatment changes documented where there is no improvement, but it does not require graphs or set a data-recency window.
Aetna’s provider toolkit publishes no filing limit; the participation agreement sets it for initial, corrected and secondary claims, and a claim involving coordination of benefits is not a "clean claim." No check-run schedule is published.
Yes, for autism under its national ABA medical necessity guide. For insured North Dakota plans, Bulletin 2018-1 also bars excluding ABA as experimental; self-funded employer plans follow their own documents.
Yes. Aetna’s behavioral health precertification list includes all ten ABA codes, 97151 and 97152 among them.
Not a statute. North Dakota relies on Insurance Department Bulletin 2018-1, which applies federal parity to insured plans that cover autism and forbids excluding ABA as experimental or investigational.
Aetna publishes no ABA rates; they are in your participation agreement. The only public benchmark is ND Medicaid’s fee schedule (97153 $10.81 per unit in August 2026).
For insured plans, N.D.C.C. 26.1-36-37.1 gives 15 business days to pay, deny or request more information, and 15 business days after receiving the information. Self-funded plans follow their own terms.
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.
Carelu collects all of this automatically.
Every ID, document, and detail this payer requires — gathered conversationally the moment a family reaches out, with insurance verified before your team touches the file.
Get a Demo