---
title: "Aetna ABA coverage in Georgia: the intake guide."
url: "https://carelu.com/payers/aetna-georgia"
markdown_url: "https://carelu.com/payers/aetna-georgia.md"
state: GA (Georgia)
payer: Aetna in Georgia
kind: Commercial insurance
description: "How Aetna covers ABA for Georgia families — the national clinical policy, prior authorization, the O.C.G.A. § 33-24-59.10 (Ava’s Law) mandate (ages, caps, exemptions), Georgia behavior-analyst licensure, and what intake should verify."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Aetna ABA coverage in Georgia: the intake guide.

_Payer Guide · Aetna · Georgia · Last updated September 2026 · 7 primary sources_

> CPB 0554 (ABA) + CPB 0648 (ASD) + the O.C.G.A. § 33-24-59.10 (Ava’s Law) mandate layer.

For an intake team in Georgia, a Aetna card means three layers at once: the carrier's national clinical policy, Georgia's autism insurance mandate (O.C.G.A. § 33-24-59.10 (Ava’s Law)), and the plan's funding type deciding which of the two actually binds. This guide stacks them in order.

## 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 [7][6]
- **Prior auth for treatment**: Required — precertification; reauthorization commonly ~6 months (verify per plan) [7][6]
- **Autism diagnosis required?**: Yes — ASD only (F84.0–F84.9); ABA for other diagnoses considered experimental [1]

## At a glance

- **Covers ABA?:** Yes — for ASD, per the national Aetna policy
- **State mandate:** O.C.G.A. § 33-24-59.10 (Ava’s Law)
- **Mandate age:** Age 20 and under (mandate); parity may extend in practice
- **Mandate caps:** $35,000/yr nominal ABA cap; no visit limits allowed
- **Exempt from mandate:** ≤10-employee groups; self-funded ERISA plans
- **Licensure:** Licensed Behavior Analyst (GA Behavior Analyst Licensing Board)

## The national policy, applied in Georgia

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 Georgia is the legal floor underneath it: the state mandate below governs what fully-insured 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 Georgia. [1][2]

## The Georgia mandate: what it guarantees (and doesn't)

Ava’s Law requires state-regulated accident and sickness plans (including the state employee health plan) to cover ASD treatment for individuals 20 years of age or under, with ABA nominally cappable at $35,000 per year — and no limits allowed on the number of visits. The statute exempts employers with 10 or fewer employees, and insurers can seek a one-year opt-out if an actuary certifies the mandate raises average premiums more than 1%. Self-funded ERISA plans are exempt by federal preemption. Federal mental-health parity (MHPAEA) generally makes the dollar and age caps hard to enforce against covered large-group plans — a payer applying the $35K cap to a large-group member is a red flag to escalate, not accept. [3][4]

## No Georgia-specific Aetna policy exists

We checked: Aetna publishes no Georgia-specific ABA policy, form, or supplement — the national policy plus the state mandate is the whole picture. That’s worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where Georgia-specific answers come from, not a carrier document. [1]

## Licensure & rates in Georgia

Georgia now licenses behavior analysts: HB 412 (2022) created the Georgia Behavior Analyst Licensing Board under the Secretary of State, with licensure built on BCBA certification. Confirm your supervising analysts hold the Georgia license when credentialing with any commercial plan. On rates: Aetna does not publish commercial ABA fee schedules for Georgia (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement, so treat rate expectations as a contracting conversation, not a lookup. [5]

## Intake gates

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

- **Diagnosis recency**: Aetna sets no expiry on the ASD diagnosis itself, but it puts a 12-month clock on the functional evidence: “there is demonstration of functional impairment on a standardized scale of functioning in the past 12 months… the impairment must be at least one standard deviation below the population mean OR represent a significant risk of harm to self or others.” That is the recency rule intake must schedule around — a current standardized functional score, not a fresh diagnostic report. Reauthorization commonly runs on a roughly six-month cadence. [6]
- **Who may diagnose**: Broad and scope-tied: the ASD diagnosis must be “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).” CPB 0648 names who Aetna expects to be involved in an ASD evaluation — “board certified behavioral analyst; developmental pediatrician; neurologist; occupational therapist; physical therapist; primary care provider; psychiatrist; psychologist; or speech-language pathologist and audiologist” — evaluated by “the appropriate certified/licensed health care professional.” The diagnosis must be DSM-5 ASD (ICD-10 F84.0, F84.3–F84.9); ABA for other indications is considered experimental, investigational or unproven. Georgia adds a licensure layer on the treating side: since HB 412 (2022), behavior analysts must hold a Georgia Behavior Analyst Licensing Board licence. [6][2]
- **Diagnostic tools required**: Two layers, and intake needs both. For the diagnosis, CPB 0648 names the instruments Aetna expects alongside clinical assessment: “Autism Diagnostic Interview-Revised (ADI-R), Autism Diagnostic Observation Schedule-2nd edition (ADOS-2), Childhood Autism Rating Scale 2nd edition (CARS-2) and Asperger Syndrome Diagnostic Scale.” For medical necessity, the ABA Medical Necessity Guide requires a standardized scale of functioning administered in the past 12 months — “for instance, the Vineland Adaptive Behavior Scales 3 (VABS-3), the Adaptive Behavior Assessment Scale (ABAS), VB-MAPP or ABLLS” — scoring at least one standard deviation below the population mean, or documenting a significant risk of harm to self or others. [6][2]
- **Age limit** _(plan-dependent)_: Aetna publishes none. The ABA Medical Necessity Guide gives a “typical age range” of 0–7 years for comprehensive ABA and “all ages” for focused ABA — planning guidance, not a benefit boundary — and CPB 0554/0648 set no age criterion. The age term in Georgia comes from Ava’s Law, which reaches individuals 20 years of age or under on state-regulated plans, with employers of 10 or fewer employees exempt and self-funded ERISA plans preempted. Federal parity generally makes that age cap hard to enforce against covered large-group plans, so treat an age-based decline on a large-group member as an escalation rather than an answer. [6][3]
  - Ask the plan: Plan funding type and employer size, then a live benefits verification — the mandate, not the carrier policy, is what carries the age term.
- **Referral required?** _(plan-dependent)_: Aetna gates ABA with precertification rather than a referral: form GR-69017-4, via Availity or phone, for both the assessment and treatment. Neither CPB 0554, CPB 0648 nor the ABA Medical Necessity Guide publishes a referral or physician-order requirement — the Guide mentions “involvement of, or referrals to, appropriate health care, community or supplemental resources” as a quality element, not an entry condition. Whether the member’s plan requires a PCP referral is a benefit-design question. [6][1]
  - Ask the plan: The member’s benefit document and Aetna precertification at the number on the ID card — ask whether a PCP referral is required in addition to precertification.
- **Prior-auth decision time** _(plan-dependent)_: It depends on how the plan is funded. A fully insured Aetna plan sold in Georgia follows the Ensuring Transparency in Prior Authorization Act. A standard request gets notice "within 7 calendar days of obtaining all necessary information to make such authorization or adverse determination" (O.C.G.A. 33-46-26). Urgent requests get notice "no later than 72 hours after receiving all information needed" (33-46-27). A missed deadline means "automatic authorization" of the service (33-46-29), with a narrow de minimis exception. Both clocks start only once the plan has everything it needs, so send a complete packet. The Act also binds DCH contracts under the State Health Benefit Plan. A self-funded employer plan is governed by ERISA instead: "not later than 15 days after receipt of the claim," with one 15-day extension, and 72 hours for urgent care. No reauthorization lead time is published for Aetna ABA in Georgia. [8][9][10]
  - Ask the plan: Benefits verification with Aetna: ask whether the plan is fully insured (Georgia prior-authorization law), self-funded (ERISA), or the State Health Benefit Plan, and the plan's reauthorization lead time.
- **Other insurance (who pays first)** _(plan-dependent)_: Between two parents' group plans, Georgia's coordination-of-benefits rule uses the birthday rule: "The benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year." "Birthday" means month and day only. If the birthdays match, the plan that has covered the parent longer pays first. For separated or divorced parents, the order is the custodial parent's plan, then the step-parent's, then the non-custodial parent's, unless a court decree assigns health costs to one parent. That rule governs fully insured group plans. A self-funded employer plan sets its own order in its plan document. The Aetna plan pays before Georgia Medicaid, which is payer of last resort and still wants its own ABS PA when secondary. It also pays before TRICARE, which pays only after other coverage. When the child also has CHAMPVA, the Aetna plan pays first: "If you have any other type of other health insurance, CHAMPVA will pay secondary." [11][12][13][14]
  - Ask the plan: Aetna member services / benefits verification: confirm funding type and the COB order in the plan document, and collect the other parent's plan, each parent's date of birth and any custody decree at intake.
- **Telehealth** _(ask the plan)_: Not published. Aetna’s ABA materials — CPB 0554, CPB 0648 and the ABA Medical Necessity Guide — say nothing about telehealth delivery of ABA: no code list, no place-of-service codes, no modifiers and no limits.
  - Ask the plan: Aetna’s telemedicine policy and provider services at the number on the member’s ID card — confirm which ABA codes pay by telehealth on that specific Georgia plan before scheduling remote sessions.

## Delivery and billing rules

Coverage decides whether Aetna in Georgia 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. [6]
- **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. [6]
- **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. [6]
  - 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.
  - 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 Georgia

- **Plan funding type:** Fully insured (mandate applies) vs. self-funded ERISA (exempt) — it decides which rulebook governs. Ask for the employer and check the card.
- **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.
- **Age:** Where the mandate carries age terms, flag edge cases for the parity analysis rather than turning families away.

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

## Verification of benefits (VOB) data

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

### EDI routing

- **Payer ID (pVerify):** 00001
- **Payer ID (Availity):** 60054 — QA re-check (2026-07-23): the cited Availity list carries an "As of 08/08/2012" footer — 60054=AETNA is confirmed present in that snapshot, but downgraded from verified to inferred pending reconfirmation against a current Availity export (same treatment already applied to aetna-florida for the identical staleness finding).
- **Payer ID (Change Healthcare / Optum):** 60054 — Same staleness finding as payerId.availity — this value was carried over from the same 2012 Availity snapshot.
- **Supports 270/271 eligibility:** Yes

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Required — precertification (specific form number not confirmed in either cited CPB) | — | — | — | — |
| 97152 | Yes | Required — precertification (specific form number not confirmed in either cited CPB) | — | — | — | — |
| 97153 | Yes | Required — precertification (specific form number not confirmed in either cited CPB) | — | — | — | — |
| 97154 | Yes | Required — precertification (specific form number not confirmed in either cited CPB) | — | — | — | — |
| 97155 | Yes | Required — precertification (specific form number not confirmed in either cited CPB) | — | — | — | — |
| 97156 | Yes | Required — precertification (specific form number not confirmed in either cited CPB) | — | — | — | — |
| 97157 | Yes | Required — precertification (specific form number not confirmed in either cited CPB) | — | — | — | — |
| 97158 | Yes | Required — precertification (specific form number not confirmed in either cited CPB) | — | — | — | — |
| 0362T | Yes | Required — precertification (specific form number not confirmed in either cited CPB) | — | — | — | — |
| 0373T | Yes | Required — precertification (specific form number not confirmed in either cited CPB) | — | — | — | — |

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/reimbursement policy could be located this pass. QA re-check (2026-07-23): form "GR-69017-4," previously cited here, does not appear in either CPB 0554 or CPB 0648 — removed pending a source that actually states it.

### Contacts

- **Provider services phone:** 1-888-632-3862
- **Hours:** 8 a.m.–5 p.m. Monday–Friday (normal business hours); same toll-free number staffed 24/7 for coverage discussions
- **Portal:** [Availity](https://www.availity.com)

Questions to ask on a verification call:

- Does ABA administer in-house at Aetna or through a separate behavioral-health carve-out — and if carved out, what's the administrator and payer ID for eligibility checks?
- Is the ABA cost share a copay or coinsurance, and is it charged per visit or per day?
- What's the daily unit cap and cap period for 97153, 97155, and the rest of the ABA code set?
- What form or process do you use for ABA precertification, and how often is continued treatment reviewed?
- What POS codes and telehealth modifiers do you accept for ABA billing?
- What licensure-tier modifiers do you require on ABA claims?
- Does eligibility checking return real-time or batch-only 271 responses, and can you confirm the correct Availity/Change Healthcare payer ID (our cited list is a 2012 snapshot)?

### 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/document-library/healthcare-professionals/documents-forms/bh-provider-manual.pdf (accessed 2026-07-23)
- https://www.aetna.com/document-library/healthcare-professionals/documents-forms/bh_precert_list.pdf (accessed 2026-07-23)

## Common questions

### Does Aetna cover ABA therapy in Georgia?

Yes — under the carrier's national policy for ASD, layered on Georgia's mandate (O.C.G.A. § 33-24-59.10 (Ava’s Law)) for fully-insured plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.

### What does the Georgia autism mandate require?

Ava’s Law requires state-regulated accident and sickness plans (including the state employee health plan) to cover ASD treatment for individuals 20 years of age or under, with ABA nominally cappable at $35,000 per year — and no limits allowed on the number of visits. See the mandate section above for ages, caps, and exemptions — and remember federal parity limits how hard the numeric caps can be enforced against group plans.

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

Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against the Georgia Medicaid fee schedule where one exists, 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. [Georgia Code § 33-24-59.10 (Ava's Law)](https://codes.findlaw.com/ga/title-33-insurance/ga-code-sect-33-24-59-10/)
4. [Autism Speaks — Georgia state-regulated coverage](https://www.autismspeaks.org/georgia-state-regulated-insurance-coverage)
5. [Georgia Association for Behavior Analysis — licensure (HB 412)](https://www.georgia-aba.org/licensure)
6. [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)
7. [Aetna — Participating provider behavioral health precertification list (eff. 8/1/2024)](https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/healthcare-professionals/documents-forms/bh_precert_list.pdf)
8. [Georgia SB 80 (2021) — O.C.G.A. 33-46-26, -27, -29, -30 (Ensuring Transparency in Prior Authorization Act)](https://gov.georgia.gov/document/2021-signed-legislation/sb-80/download)
9. [O.C.G.A. 33-46-26 — prior authorization notice within 7 calendar days (FindLaw)](https://codes.findlaw.com/ga/title-33-insurance/ga-code-sect-33-46-26/)
10. [29 CFR 2560.503-1 — ERISA claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
11. [Ga. Comp. R. & Regs. 120-2-48-.05 — Group Coordination of Benefits, order of benefits](https://www.law.cornell.edu/regulations/georgia/Ga-Comp-R-Regs-R-120-2-48-.05)
12. [GA DCH — Part I Policies and Procedures for Medicaid/PeachCare for Kids (version date July 1, 2026), 104.3 and 303 (GAMMIS copy retrieved via web.archive.org)](https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Part%201%20Policies%20and%20Procedures%20for%20Medicaid%20PeachCare%20for%20Kids%20Q3%20July%202026%2020260706155614.pdf)
13. [10 U.S.C. 1079(i)(1) — TRICARE pays after other coverage, Medicaid excepted](https://www.govinfo.gov/content/pkg/USCODE-2023-title10/html/USCODE-2023-title10-subtitleA-partII-chap55-sec1079.htm)
14. [CHAMPVA Guidebook (updated Jan. 1, 2025) — Other Health Insurance](https://www.va.gov/COMMUNITYCARE/docs/pubfiles/programguides/CHAMPVA-Guide.pdf)

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.