For an intake team in South Dakota, an Aetna card means three layers: Aetna’s national ABA policy, South Dakota’s autism mandate in SDCL 58-17-154 to 58-17-162, and the plan’s type, which decides whether the mandate applies. South Dakota’s mandate also exempts ACA individual and small-group plans, so funding is not the only question. Aetna runs no South Dakota Medicaid plan; South Dakota Medicaid has no managed care 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," 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 defined targets, generalization strategies and discharge criteria. Hours follow the guide’s severity table, with QHP protocol modification authorized at 1 to 2 hours per 10 hours of treatment, and progress reviewed every six months. The guide’s only state exhibit is Maryland, so the national criteria apply in South Dakota. Aetna’s behavioral health precertification list (eff. 8/1/2024) names all ten ABA codes, 97151–97158, 0362T and 0373T, and requests go through Availity.[1][2][3][4]
South Dakota’s autism mandate is SDCL 58-17-154 to 58-17-162 (SL 2015, ch 250), in force for plan years beginning on or after January 1, 2016. Every policy it reaches "shall provide coverage for applied behavior analysis for the treatment of autism spectrum disorders" (58-17-157). "Treatment" means evidence-based care "prescribed or ordered for a person diagnosed with an autism spectrum disorder by a licensed physician or psychologist" (58-17-154(4)). The carrier may use "pre-authorization, prior approval, and other care management requirements," visit limits, deductibles, copayments and coinsurance that apply to other medical services, and it may cap the benefit, but the annual maximum "may not be less than" $36,000 through age 6, $25,000 from age 7 through 13, and $12,500 from age 14 through 18 (58-17-158). The statute sets no benefit floor for anyone 19 or older. Anyone who performs or supervises ABA must be a physician or psychologist licensed in South Dakota with documented ABA training, or a licensed behavior analyst (58-17-159). The carrier may review the treatment "not more than once every three months" unless the insurer and the treating physician or psychologist agree to more frequent review, and the carrier pays for that review (58-17-160). School IEP and family-service-plan obligations are untouched (58-17-161). The reach is narrower than in most states. The mandate covers individual and group policies from health carriers and self-funded non-federal governmental plans, but it does not apply to the State of South Dakota employee plan (58-17-156), to self-funded ERISA plans, or to "nongrandfathered plans in the individual and small group markets that are required to include essential health benefits" under the ACA (58-17-155). In practice it binds fully insured large-group and grandfathered plans and local-government self-funded plans. For an ACA individual or small-group plan, check the plan’s own benefit documents.[8]
South Dakota licenses behavior analysts. Under SDCL 36-38 (SL 2016, ch 199) the license is issued by the Board of Social Work Examiners (36-38-1(3)), advised by a three-member Applied Behavior Analyst Advisory Committee. An applicant needs a master’s or doctoral degree and current BCBA certification (36-38-7). No one may "engage in the practice of, or attempt to practice applied behavior analysis" without the license or an exemption (36-38-6), and practicing without one is a Class 2 misdemeanor (36-38-19). BCaBAs and technicians are exempt if they work "under the extended authority and direction of a behavior analyst" and are supervised under BACB requirements, but each must pass a fingerprint background check, which the supervising analyst pays for (36-38-5(6), 36-38-25). Credentialing is on a state clock. A carrier must send an application within 10 business days of a request (58-17-151). It must flag an incomplete application within 30 days and decide a complete one within 90 days, longer only for a "special review." It must then pay clean claims for covered services delivered during the credentialing period, and its timely-filing clock starts only when you are notified that you are credentialed (58-17-150). Do not submit claims during that period (58-17-150(3)). The rule does not apply to Medicaid (58-17-152). Commercial ABA rates are negotiated and unpublished. The public benchmark is the South Dakota Medicaid ABA fee schedule (97153 $21.73 and 97155 $39.00 per 15-minute unit, effective July 1, 2026).[9][17][11][19]
Can a BCBA licensed in another state treat a South Dakota child? Generally not without a South Dakota license. SDCL 36-38-6 requires the state license to practice ABA here. The only exemption for out-of-state analysts is narrow: a provider "who is not a resident of this state, and who has established an office in this state," authorized in their home state, may practice for no more than an aggregate of 20 days a year, and must report to the board once past 20 consecutive days (36-38-5(2)). Telehealth does not get around this. SDCL 34-52-2 says any health care professional "treating a patient in the state through telehealth" must be "fully licensed to practice in the state" or employed by one of the listed facility types (a licensed health care facility, accredited prevention or treatment facility, community support provider, nonprofit mental health center, or licensed child welfare agency). The carriers say the same thing: Aetna tells providers to "ensure that they have the proper licensure based on state requirements," and Aetna’s ABA guide requires billing by "licensed behavior analysts (in states with behavior analyst licensure laws)." For a remote BCBA, plan on a South Dakota license before the first session.[9][10][6][1]
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 with both an intermediary contract and a direct agreement, "your direct Aetna rates will apply unless we specifically notify you otherwise." A member whose benefits are exhausted cannot be charged "more than the contracted rate." For insured South Dakota plans, a clean claim must be paid, denied or settled within 30 calendar days if electronic and 45 if on paper (SDCL 58-12-20), and recoupment is limited to 18 months after payment except for ERISA plans and fraud (58-17H-30.1). For a public benchmark, South Dakota Medicaid pays 97153 at $21.73 per 15 minutes.[6][13][14][19]
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.[6][13][14][19]
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 South Dakota, 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 on a standardized scale "in the past 12 months" (at least one standard deviation below the mean) or a significant risk of harm.[1]
A DSM-5 ASD diagnosis 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)."[1]
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).[4][1]
Aetna’s national ABA policies require no physician referral; they require precertification of all ten ABA codes through Availity. For a plan subject to the South Dakota mandate, treatment is care "prescribed or ordered" for a child diagnosed with autism "by a licensed physician or psychologist" (SDCL 58-17-154(4)), so keep that order on file. Self-funded ERISA and ACA individual or small-group plans sit outside the statute.[2][1][8]
Aetna’s national ABA guide sets no age cap; it describes typical, not limiting, age ranges. For plans subject to the South Dakota mandate, the coverage duty in SDCL 58-17-157 names no age limit, but the minimum annual benefits in 58-17-158 run only through age 18: $36,000 through age 6, $25,000 from 7 to 13, and $12,500 from 14 to 18. Self-funded ERISA plans, the State employee plan and ACA individual or small-group plans are outside the statute, so the plan type decides whether those floors apply.[1][8]
Ask the plan: Live benefits verification on the member ID: establish plan type, then the plan’s own age and dollar 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, 97153, 97155, 97156 and 97157, billed with modifier GT, 95 or FR; 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. Aetna’s provider manual (6/26) says Aetna Behavioral Health offers telehealth to all commercial fully insured members and to 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 South Dakota plan, SDCL 58-17-168 says no health insurer "may exclude a service for coverage solely because the service is provided through telehealth," and 58-17-169 bars discrimination between in-person and telehealth coverage for services "appropriate to be provided through telehealth" (policies issued or renewed from January 1, 2020). South Dakota’s insurance definition of telehealth is "HIPAA-compliant interactive audio-video" and excludes audio-only (58-17-167(4)). The insurer may still set criteria for a service it does not already pay others to deliver by telehealth, as long as they are not "unduly burdensome or unreasonable." Separately, the clinician must hold a South Dakota license (SDCL 34-52-2).[7][6][12][10]
Ask the plan: Availity or the behavioral health number on the card: ask whether the plan is insured in South 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 South Dakota plans fall under SDCL 58-17H. A prospective (pre-service) decision is due "within a reasonable period of time appropriate to the covered person’s medical condition, but in no event later than fifteen days after the date the health carrier receives the request," with one 15-day extension for matters beyond the carrier’s control. If the extension is for missing information, the family gets "at least forty-five days" to supply it, and the clock stops in the meantime (58-17H-28, -31). An urgent request is decided within 24 hours of receipt (58-17H-43). A request to extend an ongoing course, made at least 24 hours before it ends, is also decided within 24 hours (58-17H-46). Cutting or ending an authorized course early counts as an adverse determination, and the service continues until the internal review is decided (58-17H-29). An appeal (first-level grievance) may be filed within 180 days of the denial notice (58-17I-7) and is decided within 30 days for a pre-service request (58-17I-9). 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," with one 15-day extension. Aetna publishes no South Dakota-specific ABA turnaround or reauthorization lead time.[14][15][18]
Ask the plan: At benefits verification ask whether the plan is insured (South Dakota-regulated) or self-funded (ERISA), and what reauthorization lead time Aetna expects.
For a child on two group plans, South Dakota uses the birthday rule. When the parents are married or living together, "the plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (SDCL 58-18A-70); a court decree controls for separated parents. That binds plans regulated by the state; a self-funded plan sets its own order. If the child also has South Dakota Medicaid, the commercial plan pays first, because Medicaid is generally the payer of last resort (42 CFR 433.139). South Dakota Medicaid also processes the claim "even if the commercial payer denies the claim (i.e., out of network)." A claim filed with the primary insurer’s EOB is timely if it reaches Medicaid within 6 months of the primary’s payment or denial. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)), and CHAMPVA is the last payer (38 CFR 17.270).[16][21][20][22][23]
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 South 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 (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 "A minimum of one hour of face-to-face supervision is required of the 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." In South Dakota that means a licensed behavior analyst (SDCL 36-38-6), and supervised technicians must pass a fingerprint background check (36-38-25).[5][9]
No per-day or per-week cap is published. Hours come from the guide’s severity assessment (typical intensities: 10–25 hours a week comprehensive, 1–20 focused; typical, not caps), with QHP protocol modification at 1–2 hours per 10 hours of treatment. Progress is re-evaluated every six months.[1]
Outpatient ABA is setting-neutral in Aetna’s guide; in inpatient, residential or partial hospitalization settings that level of care’s criteria apply and no separate ABA authorization is needed. The guide expects collaboration with the school district. SDCL 58-17-161 leaves IEP and IFSP obligations untouched.[1][8]
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," unless mandates, plan documents or contracts say otherwise. South Dakota licenses behavior analysts, so the billing credential is the South Dakota license.[1][9]
Not addressed in Aetna’s published ABA policies (CPB 0554, CPB 0648, the medical necessity guide).[3][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 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, under its national ABA guide for ASD, with South Dakota’s mandate layered on for the plans it reaches (insured large-group, grandfathered and local-government plans). Self-funded ERISA plans and ACA individual and small-group plans follow their own documents.
Coverage of ABA for autism, prescribed by a licensed physician or psychologist and performed or supervised by a licensed physician, psychologist or behavior analyst. Plans may use prior authorization and cost sharing and may cap the benefit, but not below $36,000 a year through age 6, $25,000 for ages 7–13 and $12,500 for ages 14–18.
Yes. 97151 and 97152 are on Aetna’s behavioral health precertification list with the other ABA codes.
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. In South Dakota every supervised technician must also pass a state fingerprint background check.
Aetna publishes no ABA rates; payment follows the rates in your Aetna agreement. The public benchmark is South Dakota Medicaid’s 97153 rate of $21.73 per 15 minutes.
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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