---
title: "Aetna ABA coverage in Utah: the intake guide."
url: "https://carelu.com/payers/aetna-utah"
markdown_url: "https://carelu.com/payers/aetna-utah.md"
state: UT (Utah)
payer: Aetna in Utah
kind: Commercial insurance
description: "How Aetna covers ABA for Utah families — the national clinical policy, prior authorization, the Utah Code § 31A-22-642 mandate (markets, ages, caps, exemptions), Utah behavior-analyst licensure, and what intake should verify."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Aetna ABA coverage in Utah: the intake guide.

_Payer Guide · Aetna · Utah · Last updated September 2026 · 5 primary sources_

> CPB 0554 (ABA) + CPB 0648 (ASD) + the Utah Code § 31A-22-642 mandate layer.

For an intake team in Utah, an Aetna card means three layers at once: the carrier's national clinical policy, Utah's autism insurance mandate (Utah Code § 31A-22-642), and the plan's market segment and funding type deciding which of the two actually binds. This guide stacks them in order — and in Utah, the market-segment question comes first, because the mandate covers individual and large-group plans but not small group.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment:** Not published / unverified. Verify via: Aetna's Utah participating-provider precertification list via Availity. CPB 0554 (read in full 9/17/2026) contains no precertification or prior-authorization language at all — it is a coverage/medical-necessity bulletin — so the “precertification required, form GR-69017-4” answer cannot be sourced to it. [1]
- **Prior auth for treatment:** Not published / unverified. Verify via: Aetna's Utah participating-provider precertification list via Availity. CPB 0554 (read in full 9/17/2026) contains no precertification or prior-authorization language at all — it is a coverage/medical-necessity bulletin — so the “precertification required, form GR-69017-4” answer cannot be sourced to it. [1]
- **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:** Utah Code § 31A-22-642
- **Mandate markets:** Individual + large group only — small group NOT covered
- **Mandate age:** No age limit (plans entered/renewed on or after 1/1/2020)
- **Mandate caps:** No hour limit since 2020; 600 hr/yr floor on legacy pre-2020 plans
- **Exempt from mandate:** Small group plans; self-funded ERISA
- **Licensure:** UT Licensed Behavior Analyst (DOPL, Utah Code 58-61 Part 7)

## The national policy, applied in Utah

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 Utah is the legal floor underneath it: the state mandate below governs what individual and large-group fully-insured plans must cover, while small-group and self-funded plans answer to the plan document and federal parity instead. Market segment and plan funding type are therefore the first facts to establish on every benefits check. The full national policy breakdown lives in our Aetna guide; this page covers what changes in Utah. [1][2]

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

Utah Code § 31A-22-642 requires coverage for the diagnosis and treatment of autism spectrum disorder in the individual and large-group markets — small group plans are not named by the statute, making market segment the load-bearing question in Utah, even ahead of funding type. For plans entered or renewed on or after January 1, 2020 there is no age limit and no cap on covered ABA hours; the older 600-hours-a-year floor and the ages-2-to-under-10 window govern only legacy pre-2020 plans. The statute has operational teeth, too: the treatment plan is due to the insurer within 14 business days of starting treatment, the insurer may review it at most once every 3 months, and plan networks must include both board certified behavior analysts and qualified licensed mental health providers. Its diagnosis definition is strict — a board-certified neurologist, psychiatrist, or pediatrician with ASD experience, or an experienced licensed psychologist. Self-funded ERISA plans are exempt by federal preemption, and MHPAEA supplies the parity floor for group plans. New from the 2026 amendment: beginning before July 1, 2027, every health benefit plan must report autism-assessment wait times, whether it imposes PA on assessment or treatment, and ABA utilization to the Utah Insurance Department annually — with public website disclosure of which plans reimburse non-physician therapists from September 1, 2027. Insurer PA behavior in Utah is about to become public record. [3][5]

## No Utah-specific Aetna policy exists

We checked: Aetna publishes no Utah-specific ABA policy, form, or supplement — CPB 0648 contains no Utah entry, and Aetna's standard language defers to state mandates for fully-insured plans. The national policy plus the state mandate is the whole picture. That's worth knowing in itself: it means benefits verification (market segment, plan funding type, mandate applicability) is where Utah-specific answers come from, not a carrier document. Aetna also holds no Utah Medicaid ACO contract, so there is no Medicaid line of business to confuse an Aetna card with here. [2]

## Licensure & rates in Utah

Utah requires a license to practice behavior analysis: the Licensed Behavior Analyst (LBA) and Licensed Assistant Behavior Analyst (LABA) credentials under the Behavior Analyst Licensing Act (Utah Code Title 58, Chapter 61, Part 7), administered by the Division of Professional Licensing (DOPL). Behavior technicians work as certified paraprofessionals under QHP supervision rather than as licensees. On rates: Aetna does not publish commercial ABA fee schedules for Utah (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement. Utah does give you a public benchmark, though: the Medicaid PRISM rates effective 7/1/2026 pay $19.67 per 15-minute unit on 97153 and $37.51 on 97151/97155/97156. [4]

## Intake gates

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

- **Who may diagnose**: CPB 0648 requires the evaluation to be performed by the appropriate certified or licensed health care professional, naming board certified behavior analyst, developmental pediatrician, neurologist, occupational therapist, physical therapist, primary care provider, psychiatrist, psychologist, and speech-language pathologist/audiologist. The Utah mandate's own diagnosis definition is strict and applies to plans it reaches: a board-certified neurologist, psychiatrist or pediatrician with ASD experience, or an experienced licensed psychologist. [2][3]
- **Diagnostic tools required**: CPB 0648 names the instruments it treats as medically necessary components of testing for the diagnosis of pervasive developmental disorders: the ADI-R, the ADOS-2, the CARS-2 and the Asperger Syndrome Diagnostic Scale. It does not say whether all four or a subset are required. [2]
- **Prior-auth decision time**: Aetna publishes no commercial decision clock of its own: ABA "services require prior authorization. To get ABA services precertified, call the number on the member's Aetna ID card," and the manual sets no reauthorization lead time (none in the ABA Medical Necessity Guide or the ABA precert form either). The legal ceiling depends on funding. Utah requires fully insured plans' procedures to "comply with this rule, 29 CFR 2560.503-1, and 45 CFR 147.136" (R590-261-4), and self-funded plans follow 29 CFR 2560.503-1 directly, so through 2026 the ceiling is the same either way: a pre-service decision "not later than 15 days after receipt of the claim" (one 15-day extension) and 72 hours for urgent care. From January 1, 2027 Utah Code 31A-22-650 tightens insurers (fully insured only) to "no later than seven calendar days after the day on which the insurer receives all necessary information," and 72 hours for urgent care. [6][7][8][9]
- **Other insurance (who pays first)**: Aetna: "We coordinate benefits 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" — the manual's order-of-benefits list includes the birthday rule for children whose parents are not separated or divorced. Utah's COB rule (R590-131-6) governs fully insured plans: for a child whose parents are married or living together, "the plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (same birthday: the plan that has covered the parent longest); a court order stating otherwise controls. Self-funded plans follow their plan document instead, and Aetna notes many use "Maintenance of Benefits (MOB)" rather than the "100% Allowable" method most state laws require, so a secondary payment can be smaller. If the child also has Medicaid, this plan pays first: Medicaid is payer of last resort (42 CFR 433.139) — bill here, then send the EOB or denial to Medicaid, and get Medicaid's own prior auth too if the state requires it. TRICARE is secondary to this plan ("TRICARE shall be last pay," 32 CFR 199.8), and "CHAMPVA is the last payer to OHI" (38 CFR 17.276(d)). [6][10][11][12][13]
- **Age limit** _(plan-dependent)_: Aetna's national policy sets no age limit. In Utah the legal floor is Utah Code § 31A-22-642: no age limit and no cap on covered ABA hours for individual and large-group plans entered or renewed on or after 1/1/2020 (the 600-hours-a-year floor and the ages-2-to-under-10 window govern only legacy pre-2020 plans), the treatment plan due to the insurer within 14 business days of starting treatment, and insurer review at most once every 3 months. Small-group plans are not named by the statute and self-funded ERISA plans are exempt, so market segment is the load-bearing question. [1][3]
  - Ask the plan: A live benefits verification — market segment (individual, small-group, large-group) and funding type decide whether the mandate applies.
- **Diagnosis recency** _(plan-dependent)_: Neither CPB 0554 nor CPB 0648 states a recency window on the ASD diagnosis, and the Utah mandate sets none. Where currency is tested is reauthorization, commonly on a roughly 6-month cadence, and the mandate separately gives the insurer the right to review the treatment plan at most once every 3 months. [1][2][3]
  - Ask the plan: Aetna precertification (form GR-69017-4) via Availity, and the plan document for any plan-specific evaluation-currency rule.
- **Referral required?** _(plan-dependent)_: Aetna imposes no referral or physician order of its own — the gate is precertification on form GR-69017-4 for both assessment and treatment, via Availity or phone. The Utah mandate adds no order requirement, but it does put a clock on the practice: the treatment plan is due to the insurer within 14 business days of starting treatment. [1][3]
  - Ask the plan: The member's plan document and a live benefits verification — HMO products may carry their own referral rules.
- **Telehealth** _(ask the plan)_: Neither CPB 0554 nor CPB 0648 addresses telehealth delivery of ABA, and the Utah mandate is silent on modality. Treat it as a plan and network question. [1][2]
  - Ask the plan: Aetna provider services or the plan document — CPB 0554 and CPB 0648 are silent on remote delivery of ABA codes.

## Delivery and billing rules

Coverage decides whether Aetna in Utah 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)_: No per-day unit ceiling is published. Under the Utah mandate there is no cap on covered ABA hours for individual and large-group plans entered or renewed since 1/1/2020; the 600-hours-a-year floor applies only to legacy pre-2020 plans, and small-group and self-funded plans sit outside the statute entirely. [1][3]
  - Ask the plan: A live benefits verification — hour and dollar maximums are plan-specific outside the mandate.
- **Place of service** _(plan-dependent)_: CPB 0554 describes ABA as evaluating observable behavior within relevant settings including the home, school and community but sets no place-of-service restriction; CPB 0648 notes many Aetna plans exclude coverage of educational services and may exclude developmental or intelligence testing in educational settings, making the school boundary a benefit-exclusion question. [1][2]
  - Ask the plan: A live benefits verification — the educational-services exclusion is written into the plan document, not the clinical policy.
- **Supervision** _(ask the plan)_: CPB 0554 sets no supervision ratio. In Utah the binding floor is licensure: the Licensed Behavior Analyst and Licensed Assistant Behavior Analyst credentials under the Behavior Analyst Licensing Act (Utah Code Title 58, Chapter 61, Part 7), administered by DOPL, with behavior technicians working as certified paraprofessionals under QHP supervision rather than as licensees. The mandate separately requires plan networks to include board certified behavior analysts and qualified licensed mental health providers. [1][4][3]
  - Ask the plan: Aetna provider relations and the participating-provider agreement — CPB 0554 carries no supervision standard.
- **Concurrent billing (97153 + 97155):** Not published / unverified. Verify via: Aetna's commercial reimbursement/code-editing policies via Availity, or provider relations. [1]
- **Session-note signature** _(ask the plan)_: Not addressed in CPB 0554 or CPB 0648. [1][2]
  - Ask the plan: Aetna provider relations or the participating-provider agreement — the clinical bulletins carry no documentation or signature standard.
- **Bill as provider** _(ask the plan)_: Not addressed in Aetna's clinical bulletins. In Utah the licensure structure is the constraint: practising behavior analysis requires a DOPL licence (LBA or LABA) under Utah Code 58-61 Part 7, and technicians work under QHP supervision as paraprofessionals. [4][1]
  - Ask the plan: Aetna provider relations and the participating-provider agreement — rendering-versus-supervising NPI rules are contractual, not in CPB 0554.

## What intake should collect for Aetna in Utah

- **Market segment + funding type:** Individual or large group fully-insured (mandate applies) vs. small group or self-funded ERISA (exempt) — in Utah this decides everything. 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 + diagnosing provider credentials:** The mandate's diagnosis definition names specific credentials (neurologist, psychiatrist, pediatrician with ASD experience, or licensed psychologist) — capture who diagnosed.
- **Treatment start date:** The mandate's treatment plan is due to the insurer within 14 business days of starting treatment — put the clock on the calendar.

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

## Verification of benefits (VOB) data

How Aetna in Utah 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 — Availity "60054 AETNA" is confirmed present but the fetched Availity list carries an "As of 08/08/2012" footer — inferred pending reconfirmation against a current Availity export.
- **Payer ID (Change Healthcare / Optum):** 60054 — Carried from the same 2012 Availity snapshot as the medical payer ID; confirm via the Optum/Change Healthcare payer finder.
- **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. Utah-specific layer is the Utah Code 31A-22-642 mandate (individual + large group only — NOT small group), which governs limits, not coding mechanics.

### Contacts

- **Portal:** [Availity Essentials](https://www.availity.com/)

Questions to ask on a verification call:

- Does this ABA claim require precertification, and if so what form or process do you use for it?
- Are there daily, weekly, or annual unit/hour caps on the treatment codes (97153-97158)?
- What place-of-service settings are allowed for ABA — home, clinic, school, telehealth?
- Is telehealth allowed for any of the ABA codes, and if so which ones?
- Does Aetna administer ABA/behavioral health benefits in-house, or through a separate behavioral-health carve-out for this plan?
- Are licensure-tier modifiers (e.g., HN/HO/HM/HP) required on claims, and if so which apply to which codes?

### 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 Utah?

Yes — under the carrier's national policy for ASD, layered on Utah's mandate (Utah Code § 31A-22-642) for individual and large-group fully-insured plans. Small-group and self-funded employer plans sit outside the mandate, so always verify market segment and funding type first.

### What does the Utah autism mandate require?

For individual and large-group plans entered or renewed since 1/1/2020: coverage for ASD diagnosis and treatment with no age limit and no cap on ABA hours, a treatment plan due within 14 business days of starting treatment, insurer reviews at most every 3 months, and networks that include BCBAs. Small group is not covered by the statute.

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

Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against Utah Medicaid's published PRISM rates ($19.67/unit on 97153, $37.51 on 97151/97155/97156, effective 7/1/2026) 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. [Utah Code § 31A-22-642 (current, eff. 5/6/2026)](https://le.utah.gov/xcode/Title31A/Chapter22/C31A-22-S642_2026050620260506.pdf)
4. [Behavior Analyst Licensing Act — Utah Code 58-61 Part 7](https://le.utah.gov/xcode/Title58/Chapter61/C58-61-P7_2015051220150701.pdf)
5. [Utah Code § 31A-22-642 (prior version, effective 5/4/2022)](https://le.utah.gov/xcode/Title31A/Chapter22/C31A-22-S642_2022050420220504.pdf)
6. [Aetna Provider Manual (form 8102800-01-01, 6/26)](https://www.aetna.com/content/dam/aetna/pdfs/aetnacom/health-care-professionals/office_manual_hcp.pdf)
7. [Utah Admin. Code R590-261-4 — Adverse Benefit Determination Procedure Compliance (Cornell LII mirror; rules.utah.gov blocked)](https://www.law.cornell.edu/regulations/utah/Utah-Admin-Code-R590-261-4)
8. [29 CFR 2560.503-1(f)(2) — Group health plan claim decision timeframes (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
9. [Utah Code 31A-22-650 — Health care preauthorization requirements (version effective 1/1/2027, SB 319 of 2026)](https://le.utah.gov/xcode/Title31A/Chapter22/C31A-22-S650_2026050620270101.html)
10. [Utah Admin. Code R590-131-6 — Determining Order of Benefits (Cornell LII mirror)](https://www.law.cornell.edu/regulations/utah/Utah-Admin-Code-R590-131-6)
11. [42 CFR 433.139 — Medicaid third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
12. [32 CFR 199.8 — TRICARE double coverage (eCFR)](https://www.ecfr.gov/current/title-32/subtitle-A/chapter-VII/subchapter-M/part-199/section-199.8)
13. [38 CFR 17.276(d) — CHAMPVA last payer to other health insurance (eCFR)](https://www.ecfr.gov/current/title-38/section-17.276)

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.