Aetna prior authorization (precertification) for behavioral health and substance use care

1. Which levels of care need precertification

Aetna's precertification lists page links a separate behavioral health precertification list, which as of October 2026 is the version effective August 1, 2024; the general 2026 list (updated November 1, 2026) points back to it for behavioral health. The list covers commercial plans and Aetna's Medicare Advantage HMO and PPO plans. Aetna updates its lists each year, usually in January and July, and says it may update them at other times.

Level of care	Precertification	What Aetna's list says
Inpatient, including inpatient detox	Required	Inpatient admissions are on the list.
Residential treatment	Required	Residential treatment center or facility stays, with codes H0010, H0011, H0017, H0018, H0019, H2034 and T2048. H0010 and H0011 are the residential detox codes.
Partial hospitalization (PHP)	Required	H0035, H2036 and S0201 (S0201 effective October 1, 2024). Medicare Advantage only: G0410 and G0411.
Intensive outpatient (IOP)	Not required since January 1, 2019	Aetna's list says IOP no longer requires precertification or authorization from January 1, 2019.
Outpatient detox (ambulatory withdrawal management)	Not required since January 1, 2019	Removed from the list with IOP.
Outpatient therapy	Not on the list	Routine office visits and psychotherapy aren't on the behavioral health list.
Psychological and neuropsychological testing	Not required since January 1, 2019	Removed from the list. Aetna still sets coverage rules for testing in Clinical Policy Bulletin 0158.
TMS	Required	CPT 90867, 90868 and 90869. Aetna's TMS request form points reviewers to Clinical Policy Bulletin 0469.
ABA (autism)	Required	97151 to 97158, 0362T and 0373T. Aetna's ABA request form says that from August 1, 2026 it replaces all earlier ABA precertification forms.

Aetna's precertification page says more stringent state requirements may supersede its list, and plans can differ. "Not on the list" isn't "covered": the member still needs the benefit, and you still need to be in network or have an agreement. Ask on the call, and keep the rep's name and a reference number. Our VOB call script has the questions by level of care.

2. The 2026 change: no more concurrent review for PHP, ABA and TMS

Aetna's December 2025 OfficeLink Updates announced that, effective January 1, 2026, it removed concurrent review for in-network and out-of-network outpatient behavioral health services subject to precertification. The notice names ABA (97151 to 97158, 0362T, 0373T), TMS (90867 to 90869) and PHP. In practice:

• When the first precertification runs out, you don't call in a concurrent review. If more care is needed, you submit a new precertification request, and Aetna reviews it for medical necessity and appropriateness.
• Inpatient services aren't affected. Inpatient stays still go through concurrent review.
• The notice doesn't name residential treatment. Ask the care manager at the first review whether the next step is a concurrent review or a new request.
• ABA has a revised medical necessity guide as of January 1, 2026, which Aetna uses for ABA requests.

Either way, the work is the same: before the last approved day, send the clinical update that shows why this level is still needed. Put the end date on a calendar with an owner and a reminder far enough ahead to write it. The continued-stay section of our prior authorization guide lists what reviewers look for.

3. How to request precertification

1. Use Availity. Aetna names Availity as its provider portal for electronic precertification requests. If you start a request by phone, Aetna's request forms say you can open the case in Availity with the reference number and attach the form and the medical records there.
2. Or call the number on the member's ID card. Aetna tells providers to call the precertification number on the card. Its behavioral health request forms list behavioral health provider services at 1-888-632-3862 (TTY: 711).
3. Use the form for the service. TMS and ABA have their own request forms, and out-of-network outpatient behavioral health requests have one too. Each form gives its own fax number; check the date on the form, because Aetna replaces them.
4. Have the request ready: the member ID and date of birth, the diagnosis code, the place of service, the admit or start date, the codes for the service, and the clinical information for the level (see the checklist).
5. Write down the reference or precertification number, the reviewer's name, what was approved and through what date.

4. The criteria Aetna uses

• Substance use disorders: the ASAM Criteria. Aetna's parity disclosure forms say it uses the most current ASAM Criteria to evaluate the medical necessity of substance use levels and types of care. Its utilization management page still names the third edition, so ask the reviewer which edition they're applying and rate the six dimensions to match. The dimensions are in our prior authorization guide.
• Mental health: LOCUS and CALOCUS-CASII, the Level of Care Utilization System for adults and its child and adolescent version. Aetna publishes the CALOCUS-CASII level definitions and anchor points on its site.
• Aetna's own Clinical Policy Bulletins for specific services, such as TMS (CPB 0469) and psychological testing (CPB 0158). Aetna's parity forms list ASAM, LOCUS, CALOCUS-CASII and its behavioral health CPBs together as the basis for its reviews.

If a reviewer applies something you can't see, ask for it in writing. Federal parity rules require a plan to make its mental health and substance use medical necessity criteria available to a contracting provider on request; see mental health parity on a VOB call.

5. How long Aetna has to decide

We didn't find a single published decision time for behavioral health precertification on Aetna's site. The outer limits come from law, by plan type:

Plan type	Deadline	Source
Employer plans (ERISA, including self-funded)	Urgent: no later than 72 hours. Non-urgent before care: no later than 15 days, with one 15-day extension allowed. A request to extend an urgent course of treatment made at least 24 hours before it ends: within 24 hours.	29 CFR 2560.503-1
Aetna Medicare Advantage	From January 1, 2026: 7 calendar days for a standard request for a service subject to prior authorization; 72 hours for an expedited one. The plan can extend by up to 14 days only with written reasons, and a missed deadline counts as a denial you can appeal.	42 CFR 422.568, 422.572
Aetna Better Health (Medicaid managed care)	72 hours expedited, 7 calendar days standard, from 2026, under CMS's prior authorization rule. State contracts can be shorter.	CMS-0057-F
Fully insured plans regulated by a state	State law can set shorter deadlines; Texas's are in our prior authorization guide.	Your state insurance department

Under CMS's rule, Medicare Advantage and Medicaid plans must also give a specific reason for every prior authorization denial starting in 2026, by whatever channel the request came in.

6. Peer-to-peer reviews and appeals

• Peer-to-peer. Aetna's provider manual describes peer-to-peer conversations with the reviewer as part of utilization review, with timing that follows state and federal law, CMS rules and NCQA standards. The denial letter says how to ask and by when. Bring the clinician who knows the client and a one-page summary of the ASAM or LOCUS ratings.
• Claim disputes. Aetna's provider disputes and appeals page allows 180 calendar days from the initial claim decision to ask for a reconsideration, then 60 calendar days from the reconsideration decision to appeal.
• Member appeals. Under federal rules, employer plan members get at least 180 days to appeal, and an urgent appeal must be decided within 72 hours. For Medicare Advantage, a reconsideration must be requested within 60 calendar days of receiving the denial (42 CFR 422.582).

For the letter itself, Cima EHR's guide to appealing an insurance denial has a structure that answers the plan's criteria point by point.

7. Commercial, Medicare Advantage and Aetna Better Health

Product	Precertification rules	What to know
Aetna commercial (fully insured and self-funded)	The behavioral health precertification list above	Self-funded plans follow federal law and their plan documents; fully insured plans add state law, which can be stricter than the list.
Aetna Medicare Advantage (HMO and PPO)	The same list, plus the Medicare-only PHP codes G0410 and G0411	Aetna says it uses CMS benefit policies for Medicare Advantage coverage decisions. CMS's 2024 rule requires plans to follow Medicare's coverage criteria, keep an approved course of treatment approved as long as it's medically necessary, and give new enrollees in active treatment a transition period of at least 90 days without new prior authorization (CMS fact sheet). Medicare has covered IOP since 2024 only from certain provider types, such as hospitals and community mental health centers (Medicare Benefit Policy Manual, chapter 6).
Aetna Better Health (Medicaid and CHIP)	Each state plan's own list	Rules differ by state and are often stricter than commercial. Aetna Better Health of Texas requires prior authorization for PHP and IOP for members with mental health or substance use diagnoses. Aetna Better Health of Kentucky began requiring prior authorization for behavioral health services, including SUD services, for all members on June 25, 2025, with the clinical record, an ASAM assessment and the treatment plan. Use the state plan's own list and portal.

Not sure which Aetna product the card is? The plan name, the phone numbers on the back and the payer ID usually tell you; our guide to reading a 271 shows where the electronic check says it.

8. Before you call: a checklist

• The card: both sides, the member ID, and whether it's commercial, Medicare Advantage or Aetna Better Health.
• Network status: are you in network for this level? Out of network, ask whether precertification still applies and whether a single-case agreement is possible.
• The codes: the HCPCS or CPT code and revenue code for the level (for example S0201 for PHP, H0010 or H0011 for residential detox).
• The clinicals: diagnosis with ICD-10 code; substances, amount, frequency and last use; withdrawal history; medications; risk; treatment history with dates; the recovery environment.
• The ratings: the six ASAM dimensions for substance use, or LOCUS or CALOCUS-CASII for mental health.
• The plan of care: the schedule, the expected length of stay, the goals and the discharge plan.
• Your log: the date, the rep, the reference number and the approved dates. The VOB checklist and the printable VOB form have a box for each.

Quick VOB keeps that log: what the rep said for each level of care, with the reference number, and each authorization tracked to its last day with an email 5 days before it ends. That matters more under Aetna's 2026 change, because a new PHP request has to go in before the first one runs out. Programs that want the reviews drafted on the chart use Cima EHR for IOP and PHP programs. Joining Aetna's network first? See Cima Consulting's Aetna credentialing guide.

Other insurers: Cigna prior authorization · Humana prior authorization · prior authorization for any plan

Questions

Does Aetna require precertification for IOP?

Not on Aetna's behavioral health precertification list: intensive outpatient came off it on January 1, 2019. A stricter state law or the member's plan can still require it, and Aetna Better Health (Medicaid) plans set their own rules; Aetna Better Health of Texas, for example, requires prior authorization for IOP.

Does Aetna require prior authorization for partial hospitalization (PHP)?

Yes. PHP is on the list (H0035, H2036, S0201, and G0410 and G0411 for Medicare Advantage). Since January 1, 2026 Aetna doesn't do concurrent review for PHP; when more days are needed, submit a new precertification request before the first one ends.

Does Aetna require prior authorization for residential treatment or detox?

Yes for residential treatment, including the residential detox codes H0010 and H0011, and for inpatient admissions. Outpatient detox (ambulatory withdrawal management) hasn't needed precertification since January 1, 2019.

How do I submit a prior authorization to Aetna?

On Availity, which Aetna names as its provider portal for electronic precertification, or by calling the precertification number on the member's ID card. If you start by phone, you can open the case in Availity with the reference number and attach the records.

What is Aetna's behavioral health precertification phone number?

Use the number on the member's ID card. Aetna's behavioral health request forms list behavioral health provider services at 1-888-632-3862 (TTY: 711).

Does Aetna require prior authorization for TMS, ABA or psychological testing?

TMS (90867 to 90869) and ABA (97151 to 97158, 0362T, 0373T) need precertification. Psychological and neuropsychological testing came off the list on January 1, 2019, though Aetna's Clinical Policy Bulletin 0158 still sets what testing it covers.

Does Aetna Medicare require prior authorization?

Yes, for the same behavioral health services as the commercial list, which covers Aetna's Medicare Advantage HMO and PPO plans, with G0410 and G0411 added for PHP. From 2026, Medicare Advantage plans must decide standard requests within 7 calendar days and expedited ones within 72 hours.

What is Aetna Better Health prior authorization?

Aetna Better Health is Aetna's Medicaid and CHIP brand, and each state plan has its own prior authorization list, forms and portal. Behavioral health rules are often stricter than commercial: the Texas plan requires prior authorization for PHP and IOP, and the Kentucky plan for behavioral health and SUD services since June 25, 2025.

Sources

1. Aetna, Precertification lists for Medicare and commercial plans; Precertification. aetna.com · aetna.com
2. Aetna, Participating provider behavioral health precertification list (effective August 1, 2024), and its earlier version noting the January 1, 2019 removals. aetna.com · aetna.com
3. Aetna, OfficeLink Updates, December 2025 (concurrent review removed for outpatient behavioral health services subject to precertification, effective January 1, 2026). aetna.com
4. Aetna, Outpatient behavioral health request forms: TMS; ABA. aetna.com · aetna.com
5. Aetna, Clinical Policy Bulletin 0158, Neuropsychological and psychological testing. aetna.com
6. Aetna, Utilization management; MHPAEA summary form (NQTL disclosure). aetna.com · aetna.com
7. Aetna, Provider manual; Provider disputes and appeals overview. aetna.com · aetna.com
8. Aetna Better Health of Texas, Integrated behavioral health for providers; Aetna Better Health of Kentucky, Upcoming changes to behavioral health prior authorization. aetnabetterhealth.com · aetnabetterhealth.com
9. 42 CFR 422.568, 422.572 and 422.582 (Medicare Advantage organization determinations and reconsiderations). ecfr.gov · ecfr.gov · ecfr.gov
10. CMS, Interoperability and Prior Authorization Final Rule (CMS-0057-F); 2024 Medicare Advantage and Part D Final Rule (CMS-4201-F) fact sheet; Medicare Benefit Policy Manual, chapter 6. cms.gov · cms.gov · cms.gov
11. 29 CFR 2560.503-1, Claims procedure (employer group health plans). ecfr.gov

General information, not legal, clinical or billing advice. Quick VOB isn't affiliated with Aetna. Requirements differ by plan and state and change during the year; check the member's plan, Aetna's current lists and your contract before each admission.