---
title: "Aetna ABA coverage in Tennessee: the intake guide."
url: "https://carelu.com/payers/aetna-tennessee"
markdown_url: "https://carelu.com/payers/aetna-tennessee.md"
state: TN (Tennessee)
payer: Aetna in Tennessee
kind: Commercial insurance
description: "How Aetna covers ABA for Tennessee families — the national clinical policy, prior authorization, the Tenn. Code Ann. § 56-7-2367 mandate (ages, caps, exemptions), Tennessee behavior-analyst licensure, and what intake should verify."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Aetna ABA coverage in Tennessee: the intake guide.

_Payer Guide · Aetna · Tennessee · Last updated September 2026 · 4 primary sources_

> CPB 0554 (ABA) + CPB 0648 (ASD) + the Tenn. Code Ann. § 56-7-2367 mandate layer.

For an intake team in Tennessee, a Aetna card means three layers at once: the carrier's national clinical policy, Tennessee's autism insurance mandate (Tenn. Code Ann. § 56-7-2367), 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 [1][2]
- **Prior auth for treatment**: Required — precertification; reauthorization commonly ~6 months (verify per plan) [1]
- **Autism diagnosis required?**: Yes — ASD only (F84.0–F84.9); ABA for other diagnoses considered experimental [1][2]

## At a glance

- **Covers ABA?:** Yes — for ASD, per the national Aetna policy
- **State mandate:** Tenn. Code Ann. § 56-7-2367
- **Mandate age:** Statute keyed to under-12 (parity-style, not an ABA mandate)
- **Mandate caps:** No ABA-specific benefit — carrier policy governs
- **Exempt from mandate:** Plans without neurological-disorder benefits; self-funded ERISA
- **Licensure:** TN Licensed Behavior Analyst (Dept. of Health committee)

## The national policy, applied in Tennessee

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 Tennessee 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 Tennessee. [1][2]

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

Tennessee’s statute is the weakest of the states we cover — it’s a parity rule, not an ABA mandate. For insureds under 12, plans that cover neurological disorders must provide ASD benefits at least as comprehensive, with cost-sharing no more stringent; ABA is never named, and the statute explicitly doesn’t expand the type or scope of treatment beyond other neurological disorders. In practice, commercial ABA coverage in Tennessee rides on the carrier’s national medical policy and the plan document — which makes benefits verification, not the mandate, the load-bearing step. Self-funded ERISA plans are exempt where federal law preempts, and MHPAEA supplies the stronger parity floor for group plans. [3]

## No Tennessee-specific Aetna policy exists

We checked: Aetna publishes no Tennessee-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 Tennessee-specific answers come from, not a carrier document. [1]

## Licensure & rates in Tennessee

Tennessee requires the Licensed Behavior Analyst (LBA) credential under Tenn. Code Ann. §§ 63-11-301 through 63-11-311, administered by the Applied Behavior Analyst Licensing Committee at the Department of Health — the same licensure gate that governs TennCare work applies on the commercial side. On rates: Aetna does not publish commercial ABA fee schedules for Tennessee (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. [4]

## Intake gates

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

- **Who may diagnose**: CPB 0648 frames the diagnosis as made by an “appropriate certified/licensed health care professional” and names the professional types it contemplates in an ASD workup — board certified behavior analyst, developmental pediatrician, neurologist, occupational therapist, physical therapist, primary care provider, psychiatrist, psychologist, and speech-language pathologist and audiologist. Tennessee layers a delivery-side credential on top that is not a diagnostic one: direct ABA requires a TN Licensed Behavior Analyst under T.C.A. §§ 63-11-301–311. [2][4]
- **Age limit** _(plan-dependent)_: No age limit in Aetna’s national policy — neither CPB 0554 nor CPB 0648 states an upper or lower age bound for ABA. Tennessee’s mandate does not supply one either in the way most states do: § 56-7-2367 is a parity rule keyed to insureds under 12, requiring plans that cover neurological disorders to provide at least as comprehensive ASD benefits, and it expressly does not expand the type or scope of treatment. So the operative age answer on a Tennessee Aetna card comes from the benefit document, not from either rulebook. [1][2][3]
  - Ask the plan: Live benefits verification on the specific plan, and the summary plan description for a self-funded employer group.
- **Diagnosis recency** _(plan-dependent)_: Aetna’s policies are silent on how recent the diagnostic evaluation must be, and set no re-evaluation interval, so recency is a plan-document and utilization-review question rather than a published rule. Reauthorization is commonly on a roughly six-month cadence, which is the practical clock intake should plan around. [1][2]
  - Ask the plan: Precertification intake at Aetna (form GR-69017-4 via Availity or phone) — ask what evaluation age the reviewer will accept, and get the answer in writing per case.
- **Diagnostic tools required** _(plan-dependent)_: CPB 0648 names four ASD instruments by name — the 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. The policy does not state that any one of them is mandatory for an ABA authorization, so treat the list as the instruments Aetna recognizes rather than a required battery, and confirm per case at precertification. [2]
  - Ask the plan: Aetna precertification (form GR-69017-4) — confirm which instrument results the reviewer requires for the specific plan.
- **Referral required?** _(plan-dependent)_: Aetna’s ABA policies are silent on whether a referral, prescription or physician order is required; what is required is precertification for both assessment and treatment on form GR-69017-4, submitted through Availity or by phone. Tennessee’s statute imposes no ordering requirement either — it names no treatment type at all. Many plans still ask for a physician order as a benefit-document term, so verify per plan rather than assuming none is needed. [1][3]
  - Ask the plan: Live benefits verification and the plan document; Aetna precertification intake for the specific member.
- **Prior-auth decision time** _(plan-dependent)_: It depends on how the plan is funded. A fully insured Aetna plan sold in Tennessee follows the Prior Authorization Fairness Act. A standard request is "deemed approved within seven (7) calendar days" of submission if the carrier fails to approve, deny, or ask for the missing information. If it asks, it gets "an additional five (5) calendar days" after the provider responds, and the whole process "must not exceed seventeen (17) calendar days." An urgent request is deemed approved if not decided within "seventy-two (72) hours plus, if applicable, one (1) additional business day." A self-funded employer plan is governed by ERISA instead: pre-service decisions "not later than 15 days after receipt of the claim," with one 15-day extension, and urgent care "not later than 72 hours." No reauthorization lead time is published for Aetna ABA in Tennessee. [5][6]
  - Ask the plan: Benefits verification with Aetna: ask whether the plan is fully insured (Tennessee Prior Authorization Fairness Act) or self-funded (ERISA timelines), and the plan's reauthorization lead time.
- **Other insurance (who pays first)** _(plan-dependent)_: Between two parents' group plans, Tennessee'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." Only month and day count. If the birthdays match, the plan that has covered the parent longer pays first. A court decree or the divorced/separated-parent rules can change this. That rule governs fully insured group contracts. A self-funded employer plan sets its own order in its plan document, and individual policies are outside the group rule. The Aetna plan pays before TennCare, because Medicaid is payer of last resort. 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." Get the Aetna prior authorization even when a secondary plan will pick up the balance. [7][8][9][10]
  - 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 and each parent's date of birth at intake.
- **Telehealth** _(ask the plan)_: Neither CPB 0554 nor CPB 0648 addresses telehealth delivery of ABA codes, so there is no published Aetna rule to cite for Tennessee — and no Tennessee-specific Aetna ABA policy, form or supplement exists to supply one. Coverage and any place-of-service requirement fall to the member’s benefit plan and Aetna’s general telemedicine terms. [1][2]
  - Ask the plan: Aetna’s telemedicine policy and the member’s benefit document, confirmed at precertification before scheduling remote sessions.

## Delivery and billing rules

Coverage decides whether Aetna in Tennessee 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.

- **Daily limits / MUEs** _(plan-dependent)_: Not published. Aetna states no per-day MUE, unit ceiling or weekly hour maximum for ABA, and Tennessee’s mandate supplies none either — § 56-7-2367 creates no ABA-specific benefit, so any numeric limit a Tennessee family meets is a plan-document term or a medical-necessity determination. Federal parity still constrains how hard a numeric limit can be applied to a group plan. [1][3]
  - Ask the plan: Live benefits verification for the specific plan — ask for visit, hour and dollar limits in writing, and flag any ABA-only limit for a parity review.
- **Supervision** _(ask the plan)_: Not published. Aetna’s ABA policies set no supervision ratio, no supervisor-to-technician cap and no observation cadence. In Tennessee the binding supervision requirement is therefore the state licensure one: direct ABA must be delivered by a Licensed Behavior Analyst under T.C.A. §§ 63-11-301 through 63-11-311, administered by the Applied Behavior Analyst Licensing Committee, with assistant-level LABAs practicing only under LBA supervision — the same gate that governs TennCare work. [1][4]
  - Ask the plan: Aetna provider services and your participating-provider agreement; the TN Applied Behavior Analyst Licensing Committee for the licensure floor.
- **Concurrent billing (97153 + 97155)** _(ask the plan)_: Not published. Neither CPB 0554 nor CPB 0648 addresses whether 97153 and 97155 may be billed for the same clock time, and Aetna publishes no Tennessee-specific ABA reimbursement policy. [1][2]
  - Ask the plan: Aetna’s clinical payment, coding and policy changes pages and your participating-provider agreement; confirm with provider services per case before billing the overlap.
- **Place of service** _(ask the plan)_: Not published. Neither ABA policy names payable settings, and there is no Tennessee-specific Aetna supplement. Worth knowing for contrast: TennCare does pay for school-setting ABA that is not part of an IEP, so a Tennessee family moving between Medicaid and a commercial Aetna plan may find the setting answer changes. [1][2]
  - Ask the plan: Live benefits verification and Aetna’s place-of-service reimbursement guidance for the specific plan.
- **Bill as provider** _(ask the plan)_: Not published in the ABA policies. Aetna sets no rendering-versus-supervising NPI convention for ABA in CPB 0554 or CPB 0648. In Tennessee the constraint that does bind is licensure — direct ABA requires an LBA, with LABAs practicing only under LBA supervision — and rates are contract-negotiated, because no national carrier publishes commercial ABA fee schedules for Tennessee. [1][4]
  - Ask the plan: Your Aetna participating-provider agreement and Aetna’s professional claim submission guidance.

## What intake should collect for Aetna in Tennessee

- **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 Tennessee 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 — 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 georgia.ts and aetna-florida already apply for the identical staleness finding).
- **Payer ID (Change Healthcare / Optum):** 60054 — Same staleness finding as payerId.availity.
- **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 located this pass. tennessee.ts's own prose cites precert form "GR-69017-4," but that number does not appear in either cited CPB — same QA finding georgia.ts made for aetna-georgia (2026-07-23); not restated here as confirmed.

### Contacts

- **Provider services phone:** 1-888-632-3862 (commercial plans; TTY 711) — Aetna's Precertification Department, per Aetna's own participating-provider behavioral health precertification list, which explicitly lists ABA codes 97151-97158, 0362T, and 0373T as requiring precertification
- **Portal:** [Availity](https://www.availity.com)

Questions to ask on a verification call:

- What is the exact precertification form and submission process for ABA under this member's specific plan?
- Is there a numeric unit or hour cap for ABA codes, and what is the authorization period?
- What place-of-service codes and modifiers are required when billing 97151-97158 and 0362T/0373T?
- Is telehealth allowed for any ABA codes under this plan, and if so what modifier/POS applies?
- Is ABA administered on the medical side, or carved out to a separate behavioral health vendor?

### VOB data sources

- 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://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/content/dam/aetna/pdfs/aetnacom/healthcare-professionals/documents-forms/bh_precert_list.pdf (accessed 2026-07-23; source document older than 18 months)

## Common questions

### Does Aetna cover ABA therapy in Tennessee?

Yes — under the carrier's national policy for ASD, layered on Tennessee's mandate (Tenn. Code Ann. § 56-7-2367) for fully-insured plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.

### What does the Tennessee autism mandate require?

Tennessee’s statute is the weakest of the states we cover — it’s a parity rule, not an ABA mandate. 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 Tennessee?

Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against the Tennessee 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. [Tenn. Code Ann. § 56-7-2367 (autism/neurological parity)](https://codes.findlaw.com/tn/title-56-insurance/tn-code-sect-56-7-2367/)
4. [TN Dept. of Health — LBA application (T.C.A. §§ 63-11-301–311)](https://www.tn.gov/content/dam/tn/health/healthprofboards/behavior-analyst/LBA-Application.pdf)
5. [Tenn. Code Ann. 56-7-3705 — Prior Authorization Fairness Act timeframes](https://codes.findlaw.com/tn/title-56-insurance/tn-code-sect-56-7-3705/)
6. [29 CFR 2560.503-1 — ERISA claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
7. [Tenn. Comp. R. & Regs. 0780-01-53 — Coordination of Benefits (group contracts)](https://publications.tnsosfiles.com/rules/0780/0780-01/0780-01-53.pdf)
8. [42 U.S.C. 1396a(a)(25) — Medicaid third-party liability](https://www.govinfo.gov/content/pkg/USCODE-2023-title42/html/USCODE-2023-title42-chap7-subchapXIX-sec1396a.htm)
9. [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)
10. [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.