Aetna Behavioral Health Prior Authorization: 2026 Guide
Aetna behavioral health precertification in 2026: levels of care on the list, Availity submission, LOCUS and ASAM criteria, peer-to-peer, and appeals.
On this page: Direct answer
Direct answer
Aetna behavioral health prior authorization: what operators need to know
Aetna behavioral health precertification in 2026: levels of care on the list, Availity submission, LOCUS and ASAM criteria, peer-to-peer, and appeals. Aetna's behavioral health list covers inpatient, PHP, residential, ABA, TMS, and out-of-network-at-in-network requests; IOP and psychological testing are not on it.
Aetna calls prior authorization precertification, and it keeps a separate behavioral health precertification list for participating providers. The version Aetna's precertification page links in September 2026 (last updated August 1, 2024) names inpatient confinements, partial hospitalization, residential treatment, applied behavior analysis, transcranial magnetic stimulation, and requests to cover out-of-network care at in-network benefit levels.
Aetna Behavioral Health is an internal business unit of Aetna, and behavioral requests go through Availity like medical ones, but the criteria differ: LOCUS and CALOCUS-CASII for mental health, The ASAM Criteria (third edition) for substance use, and Aetna's own guides for ABA and custodial care. Last verified: September 2026, against Aetna's June 2026 provider manual and current precertification pages.
Marsa Health is not affiliated with, endorsed by, or a partner of Aetna; the name identifies the payer only. Requirements vary by plan, state, and product, so confirm each one on the member's plan.
Key takeaways
The short version
- Aetna's behavioral health list covers inpatient, PHP, residential, ABA, TMS, and out-of-network-at-in-network requests; IOP and psychological testing are not on it.
- Stepping down to a less restrictive level in the same facility still requires a new prior authorization.
- Aetna uses LOCUS (18 and older), CALOCUS-CASII (6 to 17), and ASAM third edition, with LOCADTR for New York SUD and CMS criteria for Medicare Advantage.
- Provider appeals of pre-service or concurrent medical-necessity decisions run through the member appeal process.
- Claim reconsiderations are due within 180 calendar days, and appeals within 60 days of the reconsideration decision.
Take the template with you
Free to copy · no email required
A pre-submission checklist built from Aetna's behavioral health list and June 2026 manual. It contains no patient information; keep PHI in your EHR or Availity.
1. What is on Aetna's behavioral health precertification list
Intensive outpatient and psychological testing do not appear on that list. That is not a coverage promise: Aetna says services without precertification remain subject to the member's plan terms, that review of listed items may vary, and that outpatient care inconsistent with evidence-based practice may be subject to prior authorization. Aetna usually updates its precertification lists in January and July.
| Service | Codes on the list | Notes |
|---|---|---|
| Inpatient confinements | Stays in a hospital, psychiatric hospital, SUD facility, or RTC/RTF | Listed by setting rather than by code |
| Partial hospitalization | H0035, H2036, S0201; Medicare Advantage only: G0410, G0411 | S0201 added effective October 1, 2024 |
| Residential treatment center or facility | H0010, H0011, H0017, H0018, H0019, H2034, T2048 | A separate line from inpatient confinements |
| Applied behavior analysis | 97151 to 97158, 0362T, 0373T | Precertify by calling the number on the member's ID card |
| Transcranial magnetic stimulation | 90867, 90868, 90869 | Aetna posts a TMS request form |
| Out-of-network care at in-network benefits | Any service, unless emergent | Some plans have limited or no out-of-network benefits |
2. Submitting a request
- 01
Use Availity first
Aetna directs most precertification requests to Availity. Offices can also send electronic requests from their own EMR (Aetna explains the process at AetnaElectronicPrecert.com) or use an approved electronic transaction vendor.
- 02
Or call the behavioral health line
The June 2026 manual also lists the Provider Service Center and the toll-free behavioral health or prior authorization number on the member's ID card.
- 03
ABA goes through Member Services
To precertify ABA, call the number on the member's Aetna ID card and speak with a Member Services representative.
- 04
Answer every section
Aetna says the attending physician must complete all sections of a submission; missing requested records can delay review or lead to a denial.
- 05
Treat step-down as a new request
Moving to a less restrictive level within the same facility, such as inpatient detox to inpatient rehabilitation, requires prior authorization even within the same unit.
3. The criteria Aetna applies
Aetna's manual says only licensed medical directors, psychiatrists, psychologists, and pharmacists make medical-necessity denial decisions, and that it does not reward reviewers for denials. Hard copies of behavioral health UM criteria or Clinical Policy Bulletins are available from the Provider Service Center. As of September 2026 Aetna still names the ASAM third edition, so if a rationale uses fourth-edition language, ask which edition was applied.
| Review | Criteria | Detail from Aetna |
|---|---|---|
| Adult mental health level of care | LOCUS | Used for patients 18 and older |
| Child and adolescent mental health | CALOCUS-CASII | Used for ages 6 to 17 |
| Substance use disorder | The ASAM Criteria, third edition | Named in both the manual and the utilization management page |
| New York chemical dependency | LOCADTR | State-specific tool for SUD treatment in New York |
| ABA | Aetna ABA Medical Necessity Guide | Practitioners need BACB certification or a state behavior analyst license |
| Custodial care | Aetna Custodial Care Guidelines | Care deemed custodial is no longer eligible for coverage |
| Medicare Advantage | CMS NCDs and LCDs, then Clinical Policy Bulletins | CMS criteria govern organization determinations |
4. Concurrent review and peer-to-peer
Aetna conducts concurrent review by phone, fax, or on site, builds a discharge and continuing-care plan early in the stay, and revisits it during the stay.
Peer-to-peer is built into Aetna's utilization review: providers can present additional information and discuss the case with a peer-to-peer reviewer, and Aetna says the timing follows state, federal, CMS, and NCQA requirements. Its utilization management page frames it as the physician's request to discuss a precertification determination made by an Aetna medical director.
- Current LOCUS or CALOCUS-CASII ratings, or ASAM third-edition dimensional ratings for SUD
- What changed since the last review, with dates
- The step-down plan and the specific reason it is not safe yet
- Co-occurring medical or psychiatric conditions from the diagnostic evaluation Aetna expects before treatment
- Evidence that treatment is active and aimed at improvement, which answers a custodial-care rationale
5. Appeals: pre-service decisions go through the member process
Aetna's manual separates two tracks. Provider appeals cover payment decisions on claims. A provider may also appeal a pre-service or concurrent medical-necessity decision, but Aetna handles that through the member appeal process. A post-service appeal counts as filed on the member's behalf only if it says so explicitly or includes the member's written authorization.
| Track | Deadline | Aetna response time |
|---|---|---|
| Claim reconsideration | Within 180 calendar days of the initial claim decision | Within 30 business days in most cases |
| Claim appeal after reconsideration | Within 60 calendar days of the reconsideration decision | Within 60 business days |
| Pre-service or concurrent medical-necessity appeal | The member appeal deadline in the denial letter | Plan- and state-specific; Medicare Advantage follows CMS timelines |
| Expedited handling | Post-service appeals are not eligible | Urgent pre-service timelines come from the plan and federal rules |
6. Federal timelines by Aetna product
| Product | Rule | Clock or requirement |
|---|---|---|
| Aetna Medicare Advantage | CMS-0057-F | 72 hours expedited, 7 calendar days standard, and a specific denial reason from January 1, 2026 |
| Medicaid managed care products | CMS-0057-F plus the state contract | The same 72-hour and 7-day clocks and specific denial reasons |
| Individual plans on a Federally Facilitated Exchange | CMS-0057-F | A specific denial reason; the new decision clocks do not apply |
| Employer plans | ERISA claims rule | 72 hours urgent, 15 days pre-service, at least 180 days to appeal |
| Group MH/SUD benefits | MHPAEA | Medical-necessity criteria available on request to contracting providers |
7. Residential or PHP precertification packet for Aetna
- The Aetna product and plan sponsor, and whether the behavioral health list applies (not Traditional Choice or indemnity)
- Requested level and the matching codes from the list, such as H0035 or S0201 for PHP or the residential treatment codes
- LOCUS or CALOCUS-CASII ratings, or ASAM third-edition ratings for substance use
- A current diagnostic evaluation that addresses co-occurring psychiatric or SUD conditions
- Every record Aetna requested, since missing records can delay review or cause a denial
- A discharge and continuing-care plan, and a note to submit a new request before any step-down within the facility
Common questions
Answers before you build.
Does Aetna require precertification for IOP?+
IOP is not on Aetna's current behavioral health precertification list, which was last updated August 1, 2024. Services not on the list are still subject to the member's plan terms, so confirm on the member's plan, especially for self-funded employers and state-specific products.
Does Aetna require precertification for psychological testing?+
Psychological testing does not appear on the current behavioral health precertification list. Confirm the member's benefits before testing, because plan terms still govern coverage.
Which ASAM edition does Aetna use?+
Aetna's June 2026 provider manual and its utilization management page name The ASAM Criteria, third edition. In New York, Aetna uses LOCADTR for chemical dependency treatment.
Who can appeal an Aetna pre-service behavioral health denial?+
The member or a physician acting on the member's behalf. Aetna's manual says providers may appeal pre-service or concurrent medical-necessity decisions, but those appeals are handled through the member appeal process.
Does Aetna precertification guarantee payment?+
No. Aetna says approvals are valid for the authorized period if the member's eligibility and plan coverage have not changed, and approval covers only the service or supply approved. In Texas, Aetna notes its use of the term differs from the state's legal definition of prior authorization.
Practical closeout
Use this operator checklist.
- Aetna's behavioral health list covers inpatient, PHP, residential, ABA, TMS, and out-of-network-at-in-network requests; IOP and psychological testing are not on it.
- Stepping down to a less restrictive level in the same facility still requires a new prior authorization.
- Aetna uses LOCUS (18 and older), CALOCUS-CASII (6 to 17), and ASAM third edition, with LOCADTR for New York SUD and CMS criteria for Medicare Advantage.
- Provider appeals of pre-service or concurrent medical-necessity decisions run through the member appeal process.
- Claim reconsiderations are due within 180 calendar days, and appeals within 60 days of the reconsideration decision.
Continue through the cluster
Verified customer case studies are added only with customer permission and supporting evidence; none is implied by these operational examples.
Sources & methodology
Trace the operational claims.
Marsa Health Editorial reviewed the primary and research sources below on September 21, 2026. We translate them into workflow controls, distinguish proposals from final rules, and flag where plan, program, state, contract, or clinical requirements vary.
- 01Participating Provider Behavioral Health Precertification List for Aetna AetnaBehavioral health precertification list last updated August 1, 2024 and still linked as current in September 2026: inpatient, PHP, RTC, ABA, TMS, and out-of-network-at-in-network requests.Accessed or rechecked September 21, 2026
- 02Precertification Lists for Medicare & Commercial Plans AetnaAetna's index of current precertification lists, including the behavioral health list and the 2026 national list updated September 1, 2026.Accessed or rechecked September 21, 2026
- 03Provider and Behavioral Health Manual (June 2026) AetnaAetna Behavioral Health criteria (LOCUS, CALOCUS-CASII, ASAM third edition, LOCADTR), peer-to-peer, prior authorization channels, step-down rule, ABA precertification, and complaint and appeal tracks.Accessed or rechecked September 21, 2026
- 04Utilization Management AetnaAetna's utilization management criteria list and the physician's option to request a peer-to-peer review of a precertification determination.Accessed or rechecked September 21, 2026
- 05LOCUS, CALOCUS-CASII, ABA, ASAM & Custodial Care AetnaAetna's behavioral health criteria page, including LOCUS for commercial reviews, CMS criteria for Medicare Advantage organization determinations, and custodial care.Accessed or rechecked September 21, 2026
- 06Concurrent Review Process & Resources AetnaHow Aetna conducts concurrent review (phone, fax, or on-site) and plans discharge early in the stay.Accessed or rechecked September 21, 2026
- 07Disputes and Appeals Overview AetnaProvider reconsideration and appeal deadlines, response times, and submission channels for claim disputes.Accessed or rechecked September 21, 2026
- 08CMS Interoperability and Prior Authorization Final Rule (CMS-0057-F) Fact Sheet Centers for Medicare & Medicaid ServicesImpacted payers, 72-hour expedited and seven-calendar-day standard decision timeframes (not applicable to FFE QHP issuers), specific denial reasons beginning in 2026, and January 1, 2027 API requirements.Accessed or rechecked September 21, 2026
Organizational author. Editorial review covers source accuracy, search intent, workflow boundaries, and human-oversight requirements. This material is educational and does not provide clinical, legal, coding, or coverage advice.
No named clinical or legal expert reviewer is attributed to this version. Marsa Health does not invent reviewer credentials.
Read our editorial methodRevision history
What changed and when
September 21, 2026
Initial publication, source review, and operational editing.