Behavioral Health for Children and Adolescents — Covered Services, Billing Codes, and Authorization Requirements
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Defines covered intermediate and outpatient behavioral health services for children and adolescents, billing codes and authorization requirements, and provider resources; intended for Aetna-contracted behavioral health providers (Massachusetts bulletin referenced).
No material clinical or coverage changes in this revision.
Covered Services and General Coverage Notes
Covered Services
Covered intermediate and outpatient services include but are not limited to the following when medically necessary:
Each service description specifies required components (e.g., functional behavioral assessment, individualized treatment plan, crisis planning, staffing/clinical presence for CBAT/ICBAT) and appropriate settings (home, community, staff-secure/24-hour for CBAT, higher-intensity unlocked setting for ICBAT).
The policy specifies that ICBAT is not used as a step-down placement following discharge from a locked, 24-hour setting. ICBAT programs are described as higher-intensity, unlocked-community alternatives that may admit children directly from the community as an alternative to inpatient hospitalization, but they are not intended to serve as post-discharge step-downs from locked inpatient units.
This portion of the document does not list any services or codes as explicitly "not medically necessary." The billing and authorization section enumerates services and codes that require authorization or do not require authorization and explains authorization request methods, but it does not contain explicit statements declaring particular services or codes to be not medically necessary.
Codes, Units, and Authorization Time Units
| 97151 | Applied Behavior Analysis - Assessment (unit) |
| 97152 | Applied Behavior Analysis - Assessment (unit) |
| 0362T | Applied Behavior Analysis - Assessment (HCPCS/T) |
| 97153 | Applied Behavior Analysis - Treatment (unit) |
| 97154 | Applied Behavior Analysis - Treatment (unit) |
| 97155 | Applied Behavior Analysis - Treatment (unit) |
| 97156 | Applied Behavior Analysis - Treatment (unit) |
| 97157 | Applied Behavior Analysis - Treatment (unit) |
| 97158 | Applied Behavior Analysis - Treatment (unit) |
| 0373T | Applied Behavior Analysis - Treatment (HCPCS/T) |
Authorization Requirements and Provider Actions
Prior authorization and precertification are required as specified below. Contracted providers must obtain authorization prior to rendering the listed services; precertification is implied where prior authorization is required. Authorizations can be requested via the Navinet online portal (Navinet Sign In) or by calling the number on the member's ID card. Provider resources and manuals (including provider billing guidance and authorization procedures) should be consulted for details. Step therapy is not specified for these services.
- Prior authorization required for listed services/codes: H0017 per day; ICBAT (with and without R&B) per day; H0023 per day; ABA assessment and treatment codes (97151-97158, 0362T, 0373T) per 15 minutes; H2019, T1027, 99510 (In-Home Therapy/Family Stabilization Team) per 15 minutes; H2011 per 15 minutes.
- Precertification and prior authorization: Precertification is required where prior authorization is indicated; providers must obtain authorization before services are rendered to avoid claim denials.
- Authorization request methods: Contracted providers may request authorizations via Navinet (online portal) or by calling the number on the member's ID card.
- Provider manuals and resources: Refer to payer provider manuals and online resources for documentation, billing rules, and submission instructions.
- Step therapy: Not specified for these services.
Prior Authorization, Precertification, and Documentation
Obtain prior authorization for listed codes
Prior authorization is required for the listed codes; submit authorization before rendering services for those codes.
Check the behavioral health precertification list before providing services
Consult Aetna's behavioral health precertification list and provider resources to determine which services require precertification or prior authorization prior to service delivery.
- Precertification lists and behavioral health–specific precertification resources are available in provider materials.
- Authorizations can be requested via Navinet or by calling the number on the member's ID card.
Use Navinet or phone to submit authorization requests
Request authorizations through the two available methods listed by Aetna to avoid administrative denials.
- Use the online portal Navinet (requires log‑in) to submit authorization requests for contracted providers.
- Alternatively, call the phone number on the member's ID card to request authorization.
No step therapy specified in this policy
No step therapy or treatment‑sequencing rules are specified in this policy; consult clinical policy bulletins and guideline links for any sequencing requirements.
- See clinical policy bulletins and referenced guideline sources (LOCAT, ABA, ASAM) for treatment sequencing guidance if applicable.
Failure to obtain required authorization may result in claim denial
Services and codes identified in the billing table explicitly 'REQUIRE authorization'—claims for these services may be denied if prior authorization is not obtained.
Follow precertification procedures in provider resources
Follow the precertification procedures referenced in provider resources; although the policy does not list explicit denial triggers, precertification lists indicate required administrative steps to avoid denial.
- Consult the behavioral health specific precertification list in provider materials for programs and codes that require prior authorization.
Document service‑specific clinical elements to support medical necessity
Include service‑specific clinical documentation to demonstrate medical necessity when requesting authorization or submitting claims.
- For in‑home services: functional behavioral assessments, behavior plans, supervision and coordination, and crisis‑response strategies.
- For in‑home therapy: a treatment plan, structured therapeutic relationship documentation, and use of psychotherapeutic techniques.
- For CBAT/ICBAT: staffing and clinical details, psychiatric evaluation, medication monitoring, and discharge planning as applicable.
- Document units/time increments consistent with the code's required authorization unit (per day or per 15‑minute unit).
Refer to Behavioral Health Provider Manuals and resources
Use the Behavioral Health Provider Manuals and referenced resources for administrative, precertification, and clinical policy guidance.
- Provider materials include Behavioral Health Provider Manuals, precertification lists, clinical policy bulletins, and guideline links (LOCAT, ABA, ASAM).
- Most Aetna links in these resources are accessible to both in‑network and out‑of‑network providers.
Service Definitions and Referenced Guidelines
Children and adolescents with serious emotional disturbance or acute behavioral health crises may require a spectrum of intermediate and outpatient services ranging from in-home supports to intensive community-based programs. Covered services include In-Home Behavioral Services and In-Home Therapy that deliver behavior management monitoring, functional behavioral assessment, individualized treatment plans, and family-focused interventions in the child’s residence; Mobile Crisis Intervention for on-site, 24/7 crisis assessment and safety planning; and Intensive Care Coordination (ICC) to provide targeted case management and coordination of services. For more severe presentations, staff-secure 24-hour CBAT programs and higher-intensity, unlocked-setting ICBAT programs provide intensive therapeutic services (psychiatric evaluation, medication monitoring, nursing, therapy, case management and discharge planning) as alternatives to inpatient care.
Criteria for CBAT / ICBAT and In-Home/Outpatient Levels of Care
Applied Behavior Analysis Authorization and Criteria
Applied Behavior Analysis (ABA)
Applied Behavior Analysis entries reference assessment and treatment codes and authorization units.
Specific clinical eligibility criteria are not provided in this excerpt; billing and authorization must follow listed code unit rules and provider precertification procedures.
In-Home Behavioral Services and Therapy Modalities
In-Home Behavioral Services / In-Home Therapy
Documentation should demonstrate the presence of the listed components to support medical necessity and appropriate service delivery.
Authorization Unit and Visit Limit Requirements
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