For an intake team in Washington, an Aetna card means three layers: Aetna’s national ABA policy, Washington’s mental health parity law, which is how ABA reaches state-regulated plans here, and the plan’s funding type, which decides whether state law applies at all. Washington also licenses behavior analysts, so the clinician’s DOH license matters for billing.
Aetna’s ABA medical necessity guide requires a DSM-5 ASD diagnosis 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 time-limited treatment plan with measurable targets; progress is evaluated every six months. Typical intensity is 10–25 hours a week for comprehensive programs (typical age 0–7) and 1–20 hours for focused programs, as guidance rather than caps. Its only state exhibit covers Maryland, so the national criteria apply in Washington. All ten ABA codes, 97151 through 97158, 0362T and 0373T, are on Aetna’s behavioral health precertification list, submitted through Availity. Aetna is not an Apple Health managed care plan in Washington.[1][2][27]
Washington has no stand-alone autism insurance statute. ABA reaches state-regulated plans through the mental health parity laws instead. Until January 1, 2027, RCW 48.44.341 (health care service contractors), RCW 48.46.291 (HMOs) and RCW 48.21.241 (group disability insurers) require a plan that covers medical and surgical services to cover "mental health services," defined for plans issued or renewed on or after January 1, 2021 as "medically necessary outpatient and inpatient services provided to treat mental health and substance use disorders covered by the diagnostic categories listed in" the DSM. Autism spectrum disorder is a DSM diagnosis. Cost sharing for mental health services may be no more than for medical and surgical services, and "Treatment limitations or any other financial requirements on coverage for mental health services are only allowed if the same limitations or requirements are imposed on coverage for medical and surgical services." The statutes name no ABA-specific age, hour or dollar limit. For individual and small-group plans, the Insurance Commissioner’s essential health benefit rule (WAC 284-43-5642, effective January 19, 2026) lists "Behavioral treatment for a DSM category diagnosis" among the mental health services every plan must include, and says that when habilitative services treat a DSM diagnosis, "the mental health parity requirements apply." The law changes on January 1, 2027: Chapter 227, Laws of 2025 (E2SHB 1432) repeals those parity sections and replaces them with RCW 48.43.766, which covers DSM diagnoses plus the mental, behavioral and neurodevelopmental chapters of ICD and DC:0-5, and bars utilization review and clinical review criteria that "deviate from generally accepted standards of mental health and substance use disorder care." Regence’s own ABA policy names "Washington’s Mental Health Parity Act (RCW 48.44)" as the Washington basis for its coverage. None of this reaches self-funded employer plans, which answer to ERISA and federal parity law.[7][8][9][10][11][12][28]
Washington licenses ABA practitioners at three levels under chapter 18.380 RCW, administered by the Department of Health: licensed behavior analyst (LBA), licensed assistant behavior analyst (LABA) and certified behavior technician (CBT). The BACB’s licensure table lists Washington (2015, WA State Department of Health). "No person may engage in the practice of applied behavior analysis unless he or she holds a license or a temporary license under this chapter," and no one may practice as a technician without DOH certification (RCW 18.380.020). The exemptions in RCW 18.380.030 cover holders of another Washington credential practicing within their own scope (psychologists, for example), federal employees, school employees working only for their school, supervised students and trainees, and supervised family members; none of them exempts a BCBA licensed in another state. DOH may accept national certification in lieu of the education and exam requirements (RCW 18.380.050(3); WAC 246-805-100 accepts current certification from an approved credentialing entity). An out-of-state LBA has two quicker routes: reciprocity where the other state’s standards are "substantially equivalent" (WAC 246-805-510), and a 180-day temporary license for applicants who do not live in Washington and hold an active, unrestricted behavior analyst license elsewhere, which "will not be renewed, reissued, or extended" (WAC 246-805-520). Telehealth does not get around this. Washington’s Uniform Telehealth Act lets an out-of-state practitioner treat a patient located in Washington only with a Washington license, or for a consultation with the treating practitioner, a specialty assessment or recommendation "This does not include the provision of treatment," or follow-up for an established patient temporarily in the state (RCW 18.134.050). Supervision rules come from DOH: a CBT works "under close, ongoing supervision," with at least two face-to-face contacts a month (in person or by video) and direct supervision and observation of at least five percent of the CBT’s hours each month, including seeing the CBT with each client at least once every three months (WAC 246-805-330).[13][14][15][16][1]
For Aetna this matters directly: its guide requires services to be "provided directly or billed by licensed behavior analysts (in states with behavior analyst licensure laws)," and Washington is such a state.[13][14][15][16][1]
Washington sets the claim-side floor for state-regulated plans. Prompt pay: participating-provider contracts must require the carrier to pay 95 percent of the monthly volume of clean claims within 30 days of receipt and to pay or deny 95 percent of all claims within 60 days; clean claims more than 61 days old earn interest at one percent a month (WAC 284-170-431). A denial must give "the specific reason," and a medical necessity denial must, on request, disclose how the claim failed the guidelines. Prior authorization: for health plans issued or renewed on or after January 1, 2024, a carrier must decide an electronic standard request within three calendar days (excluding holidays) and an electronic expedited request within one calendar day; non-electronic requests get five and two calendar days. A request for missing information must come within one calendar day of an electronic submission (five days for a non-electronic standard one), only a licensed physician or licensed health professional may deny on medical necessity, and since 2026 artificial intelligence "shall not be the sole means used to deny, delay, or modify health care services" (RCW 48.43.830). Members can take an adverse decision to a certified independent review organization (RCW 48.43.535). Timely filing limits and appeal windows for providers are set by each carrier’s contract; get them from your agreement.[5][17][18][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.[5][17][18][20]
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 a member who has exhausted benefits cannot be charged "more than the contracted rate." Get rates from your Aetna agreement or Aetna provider services. For a public benchmark, Washington Apple Health’s fee-for-service ABA schedule (effective July 1, 2026) pays 97153 at $12.40 and 97155 at $14.09 per 15-minute unit; commercial contracts are negotiated separately.[5][23]
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."[5]
So box 17 is not a published condition of an Aetna ABA claim in Washington. If a plan design does require a referral, the eligibility-and-benefits response shows it; enter the referring provider only when one exists.[5]
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."[25][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.[25][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).[25]
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.[25]
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 Washington, 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 administered 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).[3][1]
Aetna’s ABA guide requires no physician referral or prescription; what it requires is precertification of all ten ABA codes. Washington’s parity statutes add no referral requirement of their own; they allow a plan to require medical necessity and to manage mental health services only where it applies "a comparable requirement" to medical and surgical services (RCW 48.44.341(3)–(4)). Self-funded ERISA plans sit outside the statute.[2][1][7]
Aetna’s guide sets no age cap; its age ranges (0–7 for comprehensive, all ages for focused) are typical, not limiting. For fully insured Washington plans, the parity statutes allow treatment limitations on mental health services "only if the same limitations or requirements are imposed on coverage for medical and surgical services," and they name no ABA-specific age or dollar limit. Self-funded ERISA plans are outside the statute, so plan funding type decides whether that 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 age terms.
Aetna’s Telemedicine and Direct Patient Contact Payment Policy lists, for commercial plans, 97151, 97153, 97155, 97156 and 97157 as eligible by telehealth 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 manual says 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 Washington plan, RCW 48.43.735 requires reimbursement of a covered, medically necessary service delivered by telemedicine "the same amount" as in person (groups of 11 or more providers may negotiate otherwise), counts the home as an originating site, and lets the carrier apply its usual prior authorization. Self-funded plans are outside the statute.[6][5][19]
Ask the plan: Availity or the precertification line on the card: ask whether the plan is fully insured in Washington or self-funded, and which ABA codes, POS and modifier Aetna pays by telehealth.
Depends on how the plan is funded. Fully insured Washington plans issued or renewed on or after January 1, 2024 fall under RCW 48.43.830: an electronic standard prior-authorization request must be decided "within three calendar days, excluding holidays," an electronic expedited request within one calendar day, a non-electronic standard request within five calendar days and a non-electronic expedited one within two. If information is missing, the carrier must ask within one calendar day of an electronic request (five days for a non-electronic standard 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," with one 15-day extension. Aetna publishes no Washington-specific ABA turnaround.[18][22]
Ask the plan: At benefits verification ask whether the plan is fully insured in Washington or self-funded (ERISA), whether you are submitting through Aetna’s electronic prior-authorization process, and what reauthorization lead time it expects.
For a child on two plans, Washington’s coordination-of-benefits rule is the birthday rule: unless a court decree says otherwise, "The plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (if both parents share a birthday, the plan that has covered a parent longer); a court decree assigning health coverage controls, and with no decree the custodial parent’s plan pays first (WAC 284-51-205). That binds state-regulated plans; a self-funded plan sets its own order. If the child also has Apple Health, Aetna pays first: Apple Health requires providers to bill known third parties and does not pay when third-party benefits are available (WAC 182-501-0200; 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).[21][29][30][31][32]
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 Washington 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: 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, with "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 Washington that means DOH’s rule too: two face-to-face contacts a month with each CBT and direct supervision of at least 5 percent of the CBT’s monthly hours (WAC 246-805-330).[4][14]
No per-day or per-week cap is published. Typical intensities are 10–25 hours a week (comprehensive) and 1–20 (focused), typical rather than limits; 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, and ABA does not need separate authorization there. Aetna expects coordination with existing providers and 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," unless mandates, plan documents or contracts say otherwise. Washington licenses behavior analysts, so the billing credential is the DOH license (LBA), or a licensed psychologist.[1][13]
Not addressed in Aetna’s published ABA documents (the medical necessity guide, the 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 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’s 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, under its national ABA guide for ASD. For fully insured Washington plans, the state’s mental health parity law requires coverage of medically necessary treatment for DSM conditions on par with medical care; self-funded employer plans follow their own documents.
Not a stand-alone one. ABA is required through Washington’s mental health parity statutes and, for individual and small-group plans, the essential health benefit rule that lists behavioral treatment for a DSM diagnosis. A new parity statute, RCW 48.43.766, takes over on January 1, 2027.
Only with Washington authorization. Washington requires a DOH license (or a 180-day temporary license for nonresidents licensed elsewhere, or reciprocity) to practice ABA, and its telehealth act lets an out-of-state practitioner treat a patient in Washington only with a Washington license, apart from consultations, assessments without treatment, and short continuity-of-care follow-up.
For fully insured plans, Washington requires carriers to pay 95 percent of clean claims within 30 days and pay or deny 95 percent of all claims within 60 days, with 1 percent monthly interest on clean claims older than 61 days (WAC 284-170-431).
Aetna publishes no ABA rates; payment follows your participation agreement. The public benchmark is Apple Health’s fee-for-service schedule (97153 $12.40 per 15 minutes from July 1, 2026).
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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