For an intake team in West Virginia, an Aetna commercial card means three layers: Aetna’s national ABA policy, West Virginia’s autism mandate for fully insured group plans, and the plan’s funding and size, which decide whether the mandate applies. Aetna also runs Aetna Better Health of West Virginia, a separate Medicaid MCO with its own guide.
Aetna covers ABA for autism spectrum disorder under CPB 0554 and its ABA medical necessity guide, with CPB 0648 for ASD, and considers ABA experimental for other diagnoses. Its behavioral health precertification list names all ten ABA codes, 97151 through 97158, 0362T and 0373T, submitted through Availity or the number on the card. The medical necessity guide’s only state exhibit is Maryland, so the national criteria apply unchanged in West Virginia: a standardized functional measure from the past 12 months, typical intensities of 10–25 hours a week for comprehensive and 1–20 for focused programs, and progress evaluated every six months.[1][2][4][3]
West Virginia’s autism mandate is written into each insurance article separately, with matching text: W. Va. Code § 33-16-3v (group accident and sickness insurers), § 33-24-7k (hospital, medical and health service corporations) and § 33-25A-8j (HMOs), all from HB 2693 (2011) as amended by HB 4260 (2012), plus a parallel paragraph for PEIA in § 5-16-7. Each applies to a "policy of group accident and sickness insurance" issued or renewed on or after January 1, 2012, and requires "coverage for diagnosis, evaluation and treatment of autism spectrum disorder in individuals ages eighteen months to eighteen years." Three gates follow. The child "must be diagnosed with autism spectrum disorder at age eight or younger." Treatment must be "medically necessary and ordered or prescribed by a licensed physician or licensed psychologist and in accordance with a treatment plan developed from a comprehensive evaluation by a certified behavior analyst." And ABA "shall be provided or supervised by a certified behavior analyst," defined as someone "certified by the Behavior Analyst Certification Board or certified by a similar nationally recognized organization." The insurer statutes let ABA be capped: "not to exceed $30,000 per individual, for three consecutive years from the date treatment commences," then "not to exceed $2,000 per month, until the individual reaches eighteen years of age." The PEIA paragraph carries the same age, diagnosis and supervision terms but no dollar cap. To keep treatment going, the analyst must "file progress reports … semiannually," and the plan must receive objective evidence or "a clinically supportable statement of expectation" that the child is improving, has not reached maximum improvement, and can reach the anticipated improvement in a reasonable time. Exemptions: "small employers" (25 or fewer eligible employees), cost-containment once the mandate raises total costs by 1% for a plan year, and any part that exceeds the ACA essential health benefits. The mandate does not reach self-funded ERISA plans, and nothing in it requires payment for services by public school personnel or replaces IDEA obligations. The WVCHIP autism section (§ 5-16B-6e) was repealed in 2022; WVCHIP now covers ABA on Medicaid’s terms.[8][9][10][11][22][23]
West Virginia does not license behavior analysts. The BACB’s state licensure table (2026) lists no West Virginia law or board, and the articles of Chapter 30 of the West Virginia Code (Professions and Occupations) include none for behavior analysts; the psychologists’ article (30-21) does not mention them. The working credential is therefore BACB certification, which both the commercial mandate ("certified behavior analyst") and Medicaid Policy 519.23 ("certification by the Behavior Analyst Certification Board is current and in good standing") require. For an out-of-state BCBA, that means there is no West Virginia license to obtain, but each payer still credentials and enrolls you: Medicaid requires enrollment through the BMS fiscal agent (Chapter 300), and BMS’s telehealth policy expects interstate practitioners to register "with the appropriate board in West Virginia" and enroll "as an Interstate Provider," a step that has no obvious board for a BCBA, so get BMS’s answer in writing. On commercial telehealth, § 33-57-1 defines the covered "health care practitioner" as someone licensed under Chapter 30, which an unlicensed BCBA is not, so the carrier’s own telehealth policy decides. On rates: commercial ABA rates are negotiated and unpublished. The public benchmark is the West Virginia Medicaid ABA fee schedule, which is very low (97153 $9.90 and 97155 $29.14 per 15-minute unit).[15][16][24][25][14][18]
West Virginia’s prompt-pay law, W. Va. Code § 33-45-2, requires an insurer to "either pay or deny a clean claim within 40 days of receipt of the claim if submitted manually and within 30 days of receipt of the claim if submitted electronically," to ask for any missing information within 30 days of receipt, and to pay interest at 10 percent a year on claims paid after the 40-day period. Aetna’s own rule is that payment follows your contract: “The rates and compensation under your agreement are subject to the Aetna coding/claim edit policies,” and a member who has used up benefits cannot be charged “more than the contracted rate.” Aetna’s network criteria make supervision a billing condition: services “must be provided directly or supervised by individuals licensed by the state or certified by the Behavior Analyst Certification Board.” For a public rate benchmark, West Virginia Medicaid pays 97153 at $9.90 per 15 minutes; commercial contracts are negotiated separately.[13][6][5][18]
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.[13][6][5][18]
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.[3]
The questions that decide whether a family can start with Aetna in West Virginia, 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 needs functional impairment on a standardized scale administered in the past 12 months. The West Virginia mandate separately requires the diagnosis to have been made at age 8 or younger.[3][8]
A DSM-5 ASD diagnosis by an appropriate provider: a licensed psychologist or psychiatrist, a physician, or another professional qualified to diagnose within scope.[3]
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 is its example).[2][3]
Aetna’s national policies require precertification of all ten ABA codes, not a physician referral. Aetna publishes no ABA order form or validity period, and its provider manual (6/26) says members "may access behavioral health care … through direct access to the behavioral health provider." A PCP referral matters only on plans that require referrals for specialist care; a clean claim then includes "a corresponding referral (whether in paper or electronic format), if required for the applicable claim." The manual names no ABA-specific referring-provider (box 17) requirement. For a fully insured West Virginia group plan, the mandate requires treatment "ordered or prescribed by a licensed physician or licensed psychologist" and "in accordance with a treatment plan developed from a comprehensive evaluation by a certified behavior analyst," with semiannual progress reports from the analyst. Self-funded ERISA plans sit outside the statute.[4][8][6]
Aetna’s national ABA policies set no age cap. For fully insured West Virginia group plans, the mandate covers ages 18 months to 18 years, requires an ASD diagnosis "at age eight or younger," and lets the insurer cap ABA at $30,000 a year for three consecutive years from the start of treatment and $2,000 a month after that until age 18 (W. Va. Code §§ 33-16-3v, 33-24-7k, 33-25A-8j). Employers with 25 or fewer eligible employees are exempt, and self-funded ERISA plans are outside the statute, so plan funding and size decide whether that binds.[3][8][9][10]
Ask the plan: Live benefits verification: establish fully insured vs. self-funded, employer size, and the plan’s own age terms.
Aetna’s Telemedicine and Direct Patient Contact Payment Policy lists ABA codes payable by telehealth with modifier GT, 95 or FR; on commercial plans 97151, 97153, 97155, 97156 and 97157 are checked. 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 all commercial self-insured plan sponsors, unless those self-insured plan sponsors opt out." For a West Virginia-regulated policy, W. Va. Code § 33-57-1 requires coverage of "health care services provided through telehealth services if those same services are covered through face-to-face consultation," bars excluding a service "solely because the service is provided through telehealth services," and counts the patient’s home as an originating site. The statute defines the practitioner as someone licensed under Chapter 30, and West Virginia does not license behavior analysts, so it is unclear whether it reaches BCBA-delivered ABA. Self-funded employer plans are outside it.[7][6][14]
Ask the plan: Availity or the precertification line: ask which ABA codes, POS and modifier Aetna pays by telehealth on this plan.
Depends on how the plan is funded. West Virginia-regulated plans fall under W. Va. Code § 33-24-7s and its twins (§ 33-16-3dd for insurers, § 33-25A-8s for HMOs), for plans beginning on or after January 1, 2024. Requests go through the carrier’s electronic portal, and once "all of the information as required is provided," the carrier "shall respond … within five business days," or "within two business days" for urgent care. If a request is incomplete, the carrier must identify every deficiency and return it within two business days; you then have three business days to supply the information, and the carrier decides within two business days after that (miss the three days and the request is denied and must be resubmitted). A peer-to-peer must finish within five business days of being requested, and a PA appeal within ten business days. An approved PA "is carried over to all other managed care organizations, health insurers, and the Public Employees Insurance Agency for three months if the services are provided within the state," and a practitioner with a 90% approval rate over six months (and at least 30 procedures a year) earns a six-month gold-card exemption. 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 West Virginia-specific ABA turnaround.[12][26][27][17]
Ask the plan: At benefits verification ask whether the plan is fully insured (West Virginia-regulated) or self-funded (ERISA).
West Virginia regulates coordination of benefits by insurance rule (114 CSR 28), which we could not open this run, so we do not restate its birthday rule here; get the member’s order of benefits from both plans. When the child also has West Virginia Medicaid, the commercial plan pays first: Medicaid is "always the payer of last resort," and "All requirements of the third-party insurance plan must be met before Medicaid will reimburse including use of in-network providers" (BMS Chapter 100), consistent with 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).[19][28][20][21]
Ask the plan: Ask Aetna and any other carrier for the member’s order of benefits, and record every other coverage the child has.
Coverage decides whether Aetna in West Virginia 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): 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," with the supervisor "onsite with the child at least one hour a month." "If state requirements are not defined, all BCBAs, BCaBAs and paraprofessionals must meet Aetna standards." West Virginia’s mandate requires ABA "provided or supervised by a certified behavior analyst."[5][8]
No per-day or per-week cap is published. Typical intensities in the guide are 10–25 hours a week (comprehensive) and 1–20 (focused), typical rather than limits. On mandated West Virginia plans, the dollar cap ($30,000 a year for three years, then $2,000 a month) is the binding limit.[3][8]
Outpatient ABA is setting-neutral in Aetna’s guide; inpatient, residential or partial hospitalization settings use that level of care’s criteria, and the guide expects coordination with the school. West Virginia’s mandate does not require payment for services by public school personnel or replace IDEA obligations.[3][8]
Services must be provided directly or billed by a licensed behavior analyst (where a state licenses them), a BCBA, or a licensed psychologist where in scope, unless mandates, plan documents or contracts say otherwise. West Virginia has no behavior-analyst license, so the BCBA is the billing credential.[3][15]
Not addressed in Aetna’s published ABA policies (CPB 0554, CPB 0648, the medical necessity guide). The medical necessity guide and the provider manual also say nothing about ABA at the same time as speech or occupational therapy.[1][3][6]
Ask the plan: Aetna provider services, the participating-provider agreement, or a written coding determination from Aetna Behavioral Health.
Not addressed in Aetna’s ABA policies.[3]
Ask the plan: The participating-provider agreement and the Aetna Behavioral Health Provider Manual documentation section.
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 ASD policy, with West Virginia’s autism mandate layered on for fully insured group plans with more than 25 eligible employees. Self-funded employer plans follow their own documents.
Mandated insured plans may cap ABA at $30,000 a year for three consecutive years from the start of treatment, then $2,000 a month until age 18. Coverage runs from 18 months to 18 years, and the child must have been diagnosed at 8 or younger.
No. West Virginia does not license behavior analysts; the mandate requires BACB (or similar) certification, and Aetna requires credentialing.
Under W. Va. Code § 33-45-2, within 30 days for electronic claims and 40 days for paper claims, with 10% annual interest after 40 days. 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.
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