---
title: "Aetna ABA coverage in Arizona: the intake guide."
url: "https://carelu.com/payers/aetna-arizona"
markdown_url: "https://carelu.com/payers/aetna-arizona.md"
state: AZ (Arizona)
payer: Aetna in Arizona
kind: Commercial insurance
description: "How Aetna covers ABA for Arizona families — the national clinical policy, prior authorization, Steven's Law with its dollar caps repealed by SB 1590 (2025), A.R.S. § 32-2091 behavior-analyst licensure, and what intake should verify."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Aetna ABA coverage in Arizona: the intake guide.

_Payer Guide · Aetna · Arizona · Last updated September 2026 · 9 primary sources_

> CPB 0554 (ABA) + CPB 0648 (ASD) + Steven's Law with its caps repealed by SB 1590 (2025).

For an intake team in Arizona, an Aetna card means three layers at once: the carrier's national clinical policy, Arizona's autism insurance mandate (Steven's Law, its dollar caps freshly repealed by SB 1590), and the plan's funding type deciding which of the two actually binds. This guide stacks them in order — plus one Arizona twist: Aetna also administers Mercy Care, so "we have Aetna" often means a Medicaid member.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Required — precertification (form GR-69017-4), per Aetna's behavioral health precertification list (eff. 8/1/2024) — CPB 0554 itself sets no precertification rule [1][2]
- **Prior auth for treatment**: Required — precertification; reauthorization commonly ~6 months (verify per plan) [1][2]

## At a glance

- **Covers ABA?:** Yes — for ASD, per the national Aetna policy
- **State mandate:** Steven's Law (A.R.S. § 20-826.04 and three parallel sections)
- **Mandate caps:** NONE — the $50K/$25K annual caps were repealed by SB 1590 (2025)
- **Mandate age:** No explicit age limit remains — the age tiers lived in the repealed cap subsection
- **Exempt from mandate:** Individual & small-employer policies; self-funded ERISA
- **Licensure:** AZ Licensed Behavior Analyst (A.R.S. § 32-2091, Board of Psychologist Examiners)

## The national policy, applied in Arizona

Aetna covers ABA for autism spectrum disorder under its national clinical policy CPB 0554 (paired with CPB 0648 for ASD), and considers ABA experimental for anything else. Precertification is required for both the assessment and treatment — form GR-69017-4, submitted via Availity or phone — with reauthorization commonly on a roughly 6-month cadence. That clinical policy is national — what changes in Arizona is the legal floor underneath it: the state mandate below governs what fully-insured group plans must cover, while self-funded employer plans answer to ERISA and federal parity instead. Plan funding type is therefore the first fact to establish on every benefits check. The full national policy breakdown lives in our Aetna guide; this page covers what changes in Arizona. [1][2]

## The Arizona mandate: Steven's Law, caps repealed

Steven's Law (HB 2847, 2008) lives in four parallel sections of the insurance code — A.R.S. §§ 20-826.04, 20-1057.11, 20-1402.03, and 20-1404.03 — covering state-regulated group coverage: large-group contracts, HMO plans, and group and blanket disability policies. Plans may not deny or limit treatment based solely on an autism spectrum disorder diagnosis, and may not exclude medically necessary behavioral therapy, which the statute defines to include ABA (discrete trial training, pivotal response training, intensive behavioral intervention), delivered or supervised by a licensed or certified provider. The headline change: SB 1590 (signed May 7, 2025) struck the dollar-cap subsection from all four sections — the old $50,000/year (under age 9) and $25,000/year (ages 9–16) behavioral-therapy maximums are repealed, taking the statute's only age tiers with them, and the ASD definition now tracks the current DSM. No annual dollar ceiling remains on any state-regulated group plan (federal parity had already made the caps largely unenforceable; SB 1590 cleaned the statute to match — do not treat the old $50K/$25K numbers as current). Exemptions: policies issued to an individual or small employer (those reach ABA via the ACA EHB benchmark instead), limited-benefit coverage, and self-funded ERISA plans. Ordinary cost sharing is still permitted. [3][4][5]

## Aetna Medicaid in Arizona: Mercy Care

A family saying "we have Aetna" in Arizona may actually be a Mercy Care member — Mercy Care is administered by Aetna Medicaid Administrators LLC and covers the largest Phoenix-metro Medicaid, DDD, and foster-care books. Mercy Care runs on AHCCCS rules (AMPM 320-S), not this commercial policy: no autism diagnosis required, no PA on assessment codes. Verify which line of business the card belongs to, and use the dedicated Mercy Care guide for the Medicaid plan. Aetna publishes no Arizona-specific commercial ABA policy or supplement — the national policy plus the state mandate is the whole commercial picture. [8]

## Licensure & rates in Arizona

Arizona requires a state license to practice behavior analysis — A.R.S. § 32-2091, administered by the Arizona Board of Psychologist Examiners (behavior analysts sit under the psychology board, not a standalone board) — and BCBA certification alone is not sufficient; AHCCCS itself defines "Behavior Analyst" as a person licensed under § 32-2091. On rates: Aetna does not publish commercial ABA fee schedules for Arizona (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement. Benchmark against the AHCCCS fee schedule (97153 at $17.91–$23.69 per 15-minute unit by credential tier), remembering the ABA codes live on the AHCCCS physician fee schedule, not the behavioral-health one. [6][7]

## Intake gates

The questions that decide whether a family can start with Aetna in Arizona, and what they have to bring.

- **Diagnosis recency**: Aetna puts the recency clock on the functional assessment, not the diagnosis: medical necessity requires "demonstration of functional impairment on a standardized scale of functioning in the past 12 months," and the impairment must be at least one standard deviation below the population mean or represent a significant risk of harm to self or others. The ABA Medical Necessity Guide sets no expiry on the ASD diagnosis itself. [9]
- **Who may diagnose**: "There is a DSM-V diagnosis of Autism Spectrum Disorder (ICD-10/ F84.0; F84.3 - F84.9) obtained 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)." Note the code set the guide actually prints: F84.0 plus F84.3–F84.9, which leaves out F84.1 and F84.2. [9]
- **Diagnostic tools required**: No diagnostic instrument is mandated; the named instruments sit on the functional-impairment test — "the Vineland Adaptive Behavior Scales 3 (VABS-3), the Adaptive Behavior Assessment Scale (ABAS), VB-MAPP or ABLLS" are given as examples of the standardized scale that must show impairment within the past 12 months. [9]
- **Referral required?**: No referral or physician order is required by the national guide — the gate is the diagnosis "obtained by an appropriate provider" plus precertification. The only prescription requirement Aetna publishes is its Maryland exhibit (COMAR 31.10.39), where the child's primary care or specialty physician must perform the evaluation and prescribe the treatment with specific goals; that exhibit does not reach plans outside Maryland. [9]
- **Age limit** _(plan-dependent)_: Steven's Law now carries no explicit age limit: SB 1590 (signed May 7, 2025) struck the dollar-cap subsection from all four sections of the mandate, and the age tiers — under 9, and 9 through 16 — lived inside that subsection. Optum's own state-mandate entry describes the change as repealing "the maximum benefit limitations for behavioral therapy coverage for eligible persons who are 16 years old and younger." The carrier's national ABA policy adds no age bound of its own, so age comes from the benefit document, not the statute. [3][4][9]
  - Ask the plan: Benefits verification on the specific plan — funding type first, then the ABA benefit terms.
- **Prior-auth decision time** _(plan-dependent)_: Aetna publishes no day counts of its own: its 2026 manual says "The timing of the review incorporates state, federal, CMS and NCQA requirements," and ABA services "require prior authorization" by calling the number on the member ID card. So the governing clock depends on funding. For a fully insured plan issued in Arizona, A.R.S. § 20-3404 governs: urgent requests "not later than five days after the receipt of all necessary information", non-urgent "not later than fourteen days after receipt of all necessary information", with the same five/fourteen days again after the provider completes an incomplete request — and "A prior authorization request is deemed granted if a health care services plan or its utilization review agent fails to comply with the deadlines." A granted authorization cannot be rescinded after services are rendered in good faith, absent fraud. A self-funded employer plan sits outside state law and follows ERISA: a non-urgent pre-service decision "not later than 15 days after receipt of the claim by the plan", extendable once by up to 15 days; an urgent one within 72 hours; the clock starts when the request is filed, whether or not it is complete; and an urgent request to extend an approved course is decided within 24 hours if made "at least 24 hours prior to the expiration" of the current authorization. [10][11][12]
  - Ask the plan: At benefits verification, ask whether the plan is fully insured (a policy issued in the state) or a self-funded employer (ERISA) plan — that decides which clock applies — then ask the carrier’s behavioral health precert line its expected ABA turnaround and how early it wants the reauth.
- **Other insurance (who pays first)** _(plan-dependent)_: Arizona’s COB rule for group plans (A.A.C. R20-6-214) sets the order: the plan covering the person other than as a dependent pays first; for a dependent child, "The plan of a parent whose birthday occurs earlier in a calendar year shall cover a dependent child before" the other parent’s plan (month and day only); for separated or divorced parents, the custodial parent’s plan, then the custodial parent’s spouse’s, then the non-custodial parent’s, unless a court decree the plan knows of says otherwise. Self-funded plans follow their own plan document. Aetna says it coordinates "as allowed by state or federal law following the National Associations of Insurance Commissioners (NAIC) guidelines. If there is no applicable law, then we coordinate according to the member's plan" (it names the NAIC birthday and divorced-parent rules); on a secondary claim, send the primary payer’s paid/denied data in the 837 COB loops. Government coverage sorts itself by federal rule: a commercial plan pays before TRICARE, which is secondary to every other health plan but "In any double coverage situation involving Medicaid, CHAMPUS is always the primary payer"; CHAMPVA "is the last payer to OHI"; and Medicaid pays after all of them (42 CFR 433.139), so a child with commercial plus Medicaid needs this plan’s authorization and EOB before Medicaid will pay. [13][10][14][15][16][17]
  - Ask the plan: Collect both parents’ plans, dates of birth, and any custody decree at intake; confirm primary/secondary with each carrier’s COB unit (and whether the plan is self-funded) before the first claim.
- **Telehealth** _(ask the plan)_: Not published. Aetna's ABA Medical Necessity Guide and CPB 0554 set medical-necessity criteria and precertification requirements but say nothing about which ABA codes may be delivered remotely, or with which place-of-service code. [9][1]
  - Ask the plan: Aetna provider services at the number on the member's ID card, and the plan's telehealth/virtual-care policy — confirm before scheduling remote 97155 or 97156.

## Delivery and billing rules

Coverage decides whether Aetna in Arizona pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: Aetna sets a duty, not a number. Where a state mandate, plan document or contract allows services from someone neither state-licensed nor BACB-certified, "there must be supervision and direction of the unlicensed or non-certified providers in line with practice standards." The ABA Medical Necessity Guide publishes no supervision percentage, ratio or caseload cap — the operative standard is professional practice plus whatever the contract adds. [9]
- **Bill as provider**: The claim carries the analyst, not the technician. "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 definition, unless state mandates, plan documents or contracts require otherwise." The escape clause matters: a state mandate or your contract can move the line, so confirm before enrolling technicians. [9]
- **Place of service** _(plan-dependent)_: Aetna does not publish a POS code list for ABA. The one place-of-service boundary it does state is the schools carve-out: pursuant to applicable law Aetna "is not required [to] provide services to a child under an individualized education program or any obligation imposed on a public school by the Individuals with Disabilities Education Act." That is a limit on paying for what the IEP owes, not a blanket ban on the school setting — and it yields to a stronger state mandate. Where ABA is payable in a school, in the community or in a group home is a benefit-document question on Aetna plans. [9]
  - Ask the plan: The member's benefit document, and Aetna provider services for whether school-setting ABA is payable on that plan.
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not published. Neither the ABA Medical Necessity Guide nor Aetna's clinical policy bulletin on ABA addresses whether 97153 and 97155 may be billed for the same clock time; Aetna carries the concurrency question in its claim editing rather than in a public policy.
  - Ask the plan: Aetna precertification/provider services at the number on the member's ID card, and the plan's own reimbursement schedule — ask specifically whether 97155 pays alongside 97153 when analyst, technician and member are all face-to-face.
- **Daily limits / MUEs** _(ask the plan)_: Not published. Aetna's ABA documents set medical-necessity criteria and precertification requirements for 97151–97158, 0362T and 0373T, but no per-day unit ceiling and no statement of which MUE table applies. The guide does publish typical intensity bands — comprehensive ABA 10–25 hours/week, focused ABA 1–20 hours/week — as clinical guidance, not claim edits. [9]
  - Ask the plan: Aetna provider services; confirm before promising a family more than four hours a day of 97153.

## What intake should collect for Aetna in Arizona

- **Plan funding type:** Fully insured group (mandate applies) vs. self-funded ERISA (exempt) vs. individual/small-group (EHB benchmark) — it decides which rulebook governs.
- **Line of business:** Commercial Aetna vs. Mercy Care (Medicaid, Aetna-administered) — different rules, different guide.
- **Member ID + card photo:** Enough to run a live benefits verification — the only reliable answer on limits and cost-sharing.
- **Diagnosis report:** DSM-5 ASD diagnosis, diagnosing provider and credentials, evaluation date — the commercial policy is ASD-only.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How Aetna in Arizona ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00001 — pVerify 00001 = "Aetna" (Elig Y / Claim Y). Note: "we have Aetna" in AZ often means a Mercy Care (Medicaid) member — see mercy-care-arizona.
- **Payer ID (Change Healthcare / Optum):** 60054 — 60054 is Aetna's standard national commercial/EDI ID (Aetna administers ABA in-house on the same ID), but it was not in the required pVerify/Availity/Optum primary PDFs this pass — confirm via Aetna EDI / Availity Essentials.
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** Aetna Behavioral Health (in-house)
- **BH administrator payer ID:** 60054
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required — precertification (assessment and treatment), per national CPB 0554/0648; ASD only. | — | — | — | — |
| 97152 | Yes | Required — precertification (assessment and treatment), per national CPB 0554/0648; ASD only. | — | — | — | — |
| 97153 | Yes | Required — precertification (assessment and treatment), per national CPB 0554/0648; ASD only. | — | — | — | — |
| 97154 | Yes | Required — precertification (assessment and treatment), per national CPB 0554/0648; ASD only. | — | — | — | — |
| 97155 | Yes | Required — precertification (assessment and treatment), per national CPB 0554/0648; ASD only. | — | — | — | — |
| 97156 | Yes | Required — precertification (assessment and treatment), per national CPB 0554/0648; ASD only. | — | — | — | — |
| 97157 | Yes | Required — precertification (assessment and treatment), per national CPB 0554/0648; ASD only. | — | — | — | — |
| 97158 | Yes | Required — precertification (assessment and treatment), per national CPB 0554/0648; ASD only. | — | — | — | — |
| 0362T | Yes | Required — precertification (assessment and treatment), per national CPB 0554/0648; ASD only. | — | — | — | — |
| 0373T | Yes | Required — precertification (assessment and treatment), per national CPB 0554/0648; ASD only. | — | — | — | — |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** Verify via: Aetna provider services / precertification — CPB 0554 & 0648 are medical-necessity policies only; no ABA coding mechanics published. (Commercial only — for Aetna-administered AHCCCS members see mercy-care-arizona.) Steven's Law caps repealed by SB 1590 (2025).

### Contacts

- **Phone menu path:** Precertification is verified via the number on the member’s ID card or submitted through the Availity provider portal — no single AZ-commercial ABA precertification line is published by Aetna.
- **Portal:** [Availity (Aetna secure provider portal)](https://www.availity.com)

Questions to ask on a verification call:

- What POS codes does Aetna accept for ABA sessions (home, clinic, school, community)?
- Is telehealth allowed for ABA codes, and does it require a specific modifier (GT/95)?
- Is there a unit or hour cap per day or week for treatment codes, and over what period?
- What credential-tier modifiers does Aetna require on ABA claims?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23)
- https://www.aetnaseniorproducts.com/ssi/assets/pdf/Aetna%20SSI%20EDI%20270-271%20Companion%20guide.pdf (accessed 2026-07-23)
- https://www.aetna.com/cpb/medical/data/500_599/0554.html (accessed 2026-07-23)
- https://www.aetna.com/cpb/medical/data/600_699/0648.html (accessed 2026-07-23)
- https://www.aetna.com/health-care-professionals/precertification.html (accessed 2026-07-23)

## Common questions

### Does Aetna cover ABA therapy in Arizona?

Yes — under the carrier's national policy for ASD, layered on Steven's Law for state-regulated group plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.

### Does Arizona still cap ABA benefits at $50,000 a year?

No — SB 1590 (signed May 7, 2025) repealed the $50,000/$25,000 annual behavioral-therapy caps from all four Steven's Law sections. No annual dollar ceiling remains on any state-regulated group plan.

### What does Aetna pay for ABA in Arizona?

Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against the AHCCCS physician fee schedule and treat rate-setting as part of contracting.

## Primary sources

1. [Aetna CPB 0554 — Applied Behavior Analysis](https://www.aetna.com/cpb/medical/data/500_599/0554.html)
2. [Aetna CPB 0648 — Autism Spectrum Disorders](https://www.aetna.com/cpb/medical/data/600_699/0648.html)
3. [SB 1590 — chaptered law (Laws 2025, ch. 142)](https://www.azleg.gov/legtext/57leg/1R/laws/0142.pdf)
4. [A.R.S. § 20-826.04 — current text](https://www.azleg.gov/ars/20/00826-04.htm)
5. [Autism Speaks — Arizona state-regulated insurance coverage](https://www.autismspeaks.org/arizona-state-regulated-insurance-coverage)
6. [A.R.S. § 32-2091 — behavior analyst licensure](https://www.azleg.gov/ars/32/02091.htm)
7. [AHCCCS — Final Public Notice, FFS rate changes 11/1/2023 (ABA codes)](https://www.azahcccs.gov/AHCCCS/Downloads/PublicNotices/rates/FinalPublicNotice_RateChanges_20231101_ABA.pdf)
8. [Mercy Care — Applied Behavior Analysis provider page](https://www.mercycareaz.org/providers/applied-behavior-analysis.html)
9. [Aetna — Applied Behavior Analysis Medical Necessity Guide (©2026)](https://www.aetna.com/content/dam/aetna/pdfs/health-care-professionals/applied-behavioral-analysis-necessity-guide.pdf)
10. [Aetna — Provider and behavioral health manual (June 2026)](https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/health-care-professionals/office_manual_hcp.pdf)
11. [A.R.S. § 20-3404 — prior authorization request deadlines (deemed granted if missed)](https://www.azleg.gov/ars/20/03404.htm)
12. [29 CFR 2560.503-1(f) — ERISA claims procedure: group health plan decision timeframes](https://www.ecfr.gov/current/title-29/section-2560.503-1)
13. [Ariz. Admin. Code R20-6-214 — coordination of benefits, order of benefit determination (Cornell LII mirror)](https://www.law.cornell.edu/regulations/arizona/Ariz-Admin-Code-SS-R20-6-214)
14. [Aetna — Coordination of benefits billing tips](https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/healthcare-professionals/documents-forms/COB-billing-tips.pdf)
15. [32 CFR 199.8 — TRICARE double coverage (secondary to other plans, primary to Medicaid)](https://www.ecfr.gov/current/title-32/subtitle-A/chapter-VII/subchapter-M/part-199/section-199.8)
16. [38 CFR 17.276 — CHAMPVA is the last payer to other health insurance](https://www.ecfr.gov/current/title-38/section-17.276)
17. [42 CFR 433.139 — payment of claims involving third-party liability](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)

Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.