For an intake team in Oregon, an Aetna card means three layers: Aetna’s national ABA criteria, Oregon’s ABA mandate (section 2 of chapter 771, Oregon Laws 2013) together with the ORS 743A.168 parity law, and the plan’s funding type, which decides whether state law applies at all.
Aetna’s ABA medical necessity guide (©2026) requires a DSM-5 ASD diagnosis "obtained by an appropriate provider," services "provided directly or billed by the appropriately licensed provider," functional impairment on a standardized scale "in the past 12 months" (Vineland-3, ABAS, VB-MAPP or ABLLS) at least one standard deviation below the mean or a significant risk of harm, and a treatment plan with measurable targets, titration and discharge criteria; progress is evaluated every six months. Its only state exhibit is Maryland’s, so Oregon plans get the national criteria plus Oregon law. Aetna’s behavioral health precertification list names all ten ABA codes, 97151–97158, 0362T and 0373T; requests go through Availity.[1][2]
Oregon’s ABA mandate is not in the numbered ORS. It is section 2 of chapter 771, Oregon Laws 2013 (SB 365), printed as a note after ORS 743A.264 and set to be repealed January 2, 2030. It requires a health benefit plan to cover screening for and diagnosis of autism spectrum disorder "by a licensed neurologist, pediatric neurologist, developmental pediatrician, psychiatrist or psychologist, who has experience or training in the diagnosis of autism spectrum disorder," and "medically necessary treatment for autism spectrum disorder and the management of care, for an individual who begins treatment before nine years of age." Treatment "includes applied behavior analysis for up to 25 hours per week," and the section "applies to coverage for up to 25 hours per week of applied behavior analysis for an individual if the coverage is first requested when the individual is under nine years of age." It is not a ceiling: the section "does not limit coverage for any services that are otherwise available" under ORS 743A.168 or 743A.190, including ABA "for more than 25 hours per week" or ABA first requested at age nine or older. ORS 743A.168, Oregon’s behavioral health parity law, requires group and non-grandfathered individual plans to cover medically necessary behavioral health treatment "at the same level as, and subject to limitations no more restrictive than," other medical conditions; ORS 743A.190 separately requires coverage of medically necessary services for a child under 18 diagnosed with a pervasive developmental disorder. Under the 2013 law an insurer may require prior authorization "for coverage of a maximum of 25 hours per week" of ABA recommended in a treatment plan approved by one of the listed professionals, "as long as the insurer makes a prior authorization determination no later than 30 calendar days after receiving the request," may require an updated treatment plan "not more than once every six months," and must continue approved ABA while the child "continues to make progress toward the majority of the goals" and it remains medically necessary. It does not require coverage of services under an IEP, services by a family or household member, or "telemedicine" (a separate statute, ORS 743A.058, now requires telemedicine coverage generally). Covered settings include "the individual’s home or a licensed health care facility" or a setting approved by the licensed provider. The mandate reaches state-regulated plans only; self-funded employer plans answer to ERISA and federal parity.[7]
Oregon licenses behavior analysts. ORS 676.806 creates the Behavior Analysis Regulatory Board within the Health Licensing Office; under ORS 676.810 it licenses behavior analysts and assistant behavior analysts (a fingerprint-based records check is required, and BACB certification may be), and under ORS 676.815 the Office registers behavior analysis interventionists, who must be 18, hold a diploma or equivalent, pass the fingerprint check, complete "at least 40 hours of professional training," and "receive ongoing training and supervision" by a licensed behavior analyst, licensed assistant behavior analyst or licensed health care professional. A provisional interventionist registration must issue within five business days of a complete application. Only licensees and registrants may use the titles "licensed behavior analyst," "licensed assistant behavior analyst" or "registered behavior analysis interventionist." OAR 824-040-0010 sets the interventionist supervision floor: direct and indirect supervision "for at least 5 percent of the interventionist’s service hours," with direct supervision at least once per calendar month. What that means for an out-of-state BCBA: the Oregon license rule (OAR 824-030-0010) has no reciprocity, temporary-permit or telehealth exemption; it asks applicants for "an affidavit of licensure from any state where the individual holds or has held a license." The payers’ own definitions point the same way. The commercial mandate defines ABA as provided by an Oregon-licensed health care professional, a behavior analyst or assistant licensed under ORS 676.810, or a registered interventionist; OHP pays directly only a Licensed Behavior Analyst, a licensed health care professional, or a declarant; and the telemedicine statute defines a "health professional" as one "licensed, certified or registered in this state." So plan on an Oregon license before treating an Oregon member, including by telehealth. The Health Licensing Office says it does not give individualized advice on how the law applies to a practice. ORS 676.830 lets each health plan set its own ABA credentialing requirements.[9][10][11][12][13][7][24]
Claims timing in Oregon’s commercial market is set by statute. ORS 743B.450 requires an insurer to "pay a clean claim or deny the claim not later than 30 days after the date on which the insurer receives the claim" (or within 30 days of receiving requested additional information), and ORS 743B.452 adds "simple interest of 12 percent per annum" on late payments. For utilization review, ORS 743B.423 generally requires a determination on a non-emergency request "no later than two business days after receipt," but the ABA mandate lets an insurer take up to 30 calendar days on an ABA prior authorization "notwithstanding ORS 743B.423." Approved treatment (other than drugs) is binding for the later of its reasonable duration or "Sixty days after the date that the treatment begins," and an insurer must give participating providers 60 days’ notice before adding new utilization review requirements. Self-funded employer plans follow ERISA instead.[4][8][7][16][4][20]
Aetna publishes no ABA rate table. Its provider manual (6/26) says "The rates and compensation under your agreement are subject to the Aetna coding/claim edit policies," and that where you have both an intermediary contract and a direct agreement "your direct Aetna rates will apply unless we specifically notify you otherwise." For a public benchmark, Oregon’s OHP fee-for-service schedule pays 97153 at $14.70 per 15 minutes.[4][8][7][16][4][20]
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.[4][8][7][16][4][20]
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."[4]
So box 17 is not a published condition of an Aetna ABA claim in Oregon. If a plan design does require a referral, the eligibility-and-benefits response shows it; enter the referring provider only when one exists.[4]
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."[22][1]
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.[22][1]
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).[22]
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.[22]
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.[1]
The questions that decide whether a family can start with Aetna in Oregon, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the diagnosis itself, but medical necessity requires functional impairment on a standardized scale administered in the past 12 months.[1]
An appropriate provider: a licensed psychologist or psychiatrist, physician, or other professional qualified to diagnose within scope. For fully insured Oregon plans the mandate covers diagnosis by a licensed neurologist, pediatric neurologist, developmental pediatrician, psychiatrist or psychologist experienced in ASD, and lets the insurer require re-diagnosis by one of them.[1][7]
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][1]
Aetna’s national ABA documents require no physician referral; they require precertification of all ten ABA codes. For a fully insured Oregon plan, the 2013 ABA section lets the insurer require an individualized treatment plan approved by a licensed neurologist, pediatric neurologist, developmental pediatrician, psychiatrist or psychologist, updated no more than once every six months, and a re-diagnosis by one of them if the original diagnosis was made by someone else. Self-funded ERISA plans sit outside the statute.[2][1][7]
Aetna’s guide sets no age cap; its age ranges are typical, not limiting. For a fully insured Oregon plan, the 2013 ABA section (ch. 771, §2) applies to ABA first requested before age nine, up to 25 hours a week, and says it does not limit ABA otherwise owed under ORS 743A.168 parity (including at older ages or above 25 hours). Self-funded ERISA plans are outside the statute, so the funding type decides whether this binds.[1][7]
Ask the plan: Live benefits verification on the member ID: establish fully insured vs. self-funded ERISA, then the plan’s own terms.
Aetna’s Telemedicine and Direct Patient Contact Payment Policy checks these ABA codes in the Commercial column, billed with GT, 95 or FR: 97151, 97153, 97155, 97156 and 97157; 97152, 97154 and 97158 are checked for Medicare only. The posted policy shows a last review of June 2021, so treat the list as perishable. For a fully insured Oregon plan, ORS 743A.058 requires coverage of a health service delivered by telemedicine when the plan covers it in person, it is medically necessary, and it can be "safely and effectively provided using telemedicine"; the plan may not impose different prior authorization requirements or restrict originating sites, and must pay "the same reimbursement" as in person. The statute defines a "health professional" as one licensed, certified or registered in Oregon. Self-funded employer plans are outside it.[5][7]
Ask the plan: Availity or the precertification line: ask whether the plan is fully insured in Oregon or self-funded, and which ABA codes, POS and modifier Aetna pays by telehealth.
Depends on how the plan is funded. For a fully insured Oregon plan, the ABA mandate lets the insurer require prior authorization of up to 25 hours a week of ABA "as long as the insurer makes a prior authorization determination no later than 30 calendar days after receiving the request, notwithstanding ORS 743B.423"; for other utilization review ORS 743B.423 requires a decision "no later than two business days after receipt," with the same two business days to ask for missing information. An approved treatment is binding for the later of its reasonable duration or 60 days after it begins. Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1: 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 Oregon-specific ABA turnaround.[7][8][16]
Ask the plan: At benefits verification ask whether the plan is fully insured (Oregon-regulated) or self-funded (ERISA), and what reauthorization lead time Aetna expects.
For a child on two state-regulated group plans, Oregon’s coordination-of-benefits rule follows the birthday rule: for parents married or living together, "The plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (OAR 836-020-0785); for separated parents a court decree controls when the plan knows of it, and otherwise the custodial parent’s plan pays first, then the custodial parent’s spouse’s, then the non-custodial parent’s. A self-funded plan sets its own order. If the child also has OHP, the commercial plan pays first: OHA "shall be the payer of last resort" and providers "shall make reasonable efforts to obtain payment first from other resources" (OAR 410-120-1280; 42 CFR 433.139). TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[14][15][17][18][19]
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).
Coverage decides whether Aetna in Oregon 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 (5/26): ABA "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," with the supervisor "onsite with the child at least one hour a month." "All BCBAs, BCaBAs and paraprofessionals must meet state requirements," which in Oregon include licensure or interventionist registration and the 5 percent supervision floor in OAR 824-040-0010.[3][11][9]
No per-day or per-week cap. Typical intensities are 10–25 hours a week for comprehensive and 1–20 for focused programs (typical, not caps), with authorized hours tied to the guide’s severity table and QHP protocol modification at 1–2 hours per 10 hours of technician treatment. For a fully insured Oregon plan, the 2013 mandate section covers up to 25 hours a week (first requested before age 9) and does not limit hours above that owed under ORS 743A.168.[1][7]
Aetna’s guide is setting-neutral for outpatient ABA; inpatient, residential or partial hospitalization use that level of care’s criteria. For fully insured Oregon plans, the mandate covers treatment "in the individual’s home or a licensed health care facility" or a setting approved by the licensed provider, and does not require coverage of services under an IEP.[1][7]
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 in scope. Oregon licenses behavior analysts, so the Oregon-licensed behavior analyst (or other Oregon licensee with ABA in scope) is the billing credential.[1][9]
Not addressed in Aetna’s published ABA guide or precertification list.[1]
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, not who signs a session note or by when.[1]
Ask the plan: The participating-provider agreement and the Aetna Behavioral Health Provider Manual documentation section.
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.
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 Oregon’s ABA mandate and ORS 743A.168 parity layered on for state-regulated plans. Self-funded employer plans follow their own documents.
The 2013 law requires coverage of ASD diagnosis and of medically necessary treatment, including ABA up to 25 hours a week, when ABA is first requested before age 9. It does not limit ABA owed under the ORS 743A.168 parity law at older ages or higher hours.
Within 30 calendar days under the ABA mandate (other utilization review decisions are due within 2 business days under ORS 743B.423). Self-funded ERISA plans have 15 days for pre-service claims.
ORS 743B.450 requires payment or denial of a clean claim within 30 days of receipt, with 12 percent annual interest on late payments under ORS 743B.452 (fully insured plans).
Oregon licenses behavior analysts and its license rule has no telehealth or reciprocity exemption; the mandate and the telemedicine statute both key on Oregon licensure. Get an Oregon license first, and confirm Aetna credentialing.
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.
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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