Aetna for Behavioral Health Providers

Aetna

Aetna Inc.

Aetna, a CVS Health subsidiary, provides behavioral health coverage to millions through commercial, Medicare, and Medicaid plans.

Quick Reference

Payer Type

National Commercial

Parent Company

CVS Health

Headquarters

Hartford, CT

BH Division

Aetna Behavioral Health

Provider Portal

Open Portal

Portal Guide

View Guide →

Credentialing

CAQH ProView

Timeline

60-120 days

Coverage

1 states

Last Verified

Mar 15, 2026

Published

Mar 15, 2026

Reading Time

11 min

Covered Levels of Care

• Medically Managed Detoxification
• Residential Treatment
• Partial Hospitalization Program (PHP)
• Intensive Outpatient Program (IOP)
• Outpatient Treatment

Medical Necessity Criteria

• ASAM Criteria (for substance use disorders)
• Proprietary Aetna Clinical Policy Bulletins

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Overview

Aetna is one of the largest commercial health insurers in the United States, providing coverage to approximately 27 million medical members as of 2025 through employer-sponsored, individual, Medicare Advantage, and Medicaid managed care plans. Since its acquisition by CVS Health ↗ in 2018, Aetna operates as a subsidiary within the broader CVS Health ecosystem, which also includes CVS Pharmacy, CVS Caremark (pharmacy benefit management), and MinuteClinic.

Aetna manages its behavioral health benefits through its internal Aetna Behavioral Health division, which handles utilization management, precertification, and clinical review for mental health and substance use disorder services. Unlike some other national payers that carve out behavioral health to a separate entity, Aetna maintains direct oversight of its behavioral health operations, though specific functions may vary by plan design.

For treatment center operators, Aetna represents a substantial payer across most geographic markets. The integration with CVS Health has introduced some changes around pharmacy benefit coordination, particularly for medication-assisted treatment programs, making it important to understand how medical and pharmacy benefits interact for patients receiving MAT services.

Behavioral Health Coverage

Aetna covers behavioral health services across multiple levels of care, including medically managed detoxification, residential treatment, partial hospitalization programs (PHP), intensive outpatient programs (IOP), and standard outpatient treatment. Coverage specifics depend on the individual member’s plan design, with employer-sponsored plans, individual marketplace plans, and Medicaid managed care plans all having different benefit structures and cost-sharing arrangements.

Medical necessity determinations for substance use disorder treatment are primarily based on the ASAM Criteria, supplemented by Aetna’s proprietary Clinical Policy Bulletins (CPBs). These bulletins provide Aetna-specific guidelines on coverage criteria, documentation requirements, and length-of-stay expectations for each level of care. For mental health services, Aetna relies primarily on its own CPBs, which outline symptom severity thresholds, functional impairment criteria, and risk assessments required for authorization at each level.

Treatment centers should familiarize themselves with Aetna’s Clinical Policy Bulletins, which are publicly available on Aetna’s website. These documents specify the exact criteria reviewers use when evaluating authorization requests. Documentation that directly addresses the criteria outlined in the applicable CPB is far more likely to result in authorization approval than general clinical narratives.

Credentialing and Provider Enrollment

Aetna uses CAQH ProView as the foundation of its credentialing process. Before applying to join Aetna’s network, ensure your CAQH ProView profile is complete, attested, and up to date. You can then submit a participation request through Aetna’s provider enrollment team or through the Availity portal, which Aetna uses as its primary provider transaction platform.

The credentialing timeline for Aetna typically ranges from approximately 60 to 120 days, though timelines can vary based on application completeness, volume, and regional factors. Delays are most commonly caused by incomplete CAQH profiles, missing documentation, or backlogs in Aetna’s credentialing verification office. Commonly required documents include current state facility licenses, individual clinical staff licenses, professional liability insurance with adequate coverage limits, accreditation documentation (CARF or Joint Commission), DEA registrations for prescribing providers, an organizational NPI, a completed W-9, and a current program description. Verify current requirements with Aetna’s provider enrollment team ↗.

Aetna may conduct site visits as part of facility credentialing, particularly for residential treatment centers and detox programs. Be prepared to demonstrate compliance with state licensing requirements, accreditation standards, and Aetna’s own facility quality standards during any site visit.

Recredentialing generally occurs every 36 months. Maintain your CAQH ProView attestation every 120 days and report any material changes to your facility, licensure, or staffing typically within 30 days, though specific reporting timelines may vary by contract. Lapses in credentialing can result in claims being processed at out-of-network rates or denied entirely.

Verification of Benefits (VOB)

Verification of benefits for Aetna members can be performed through Availity (Aetna’s designated provider portal), by calling the Aetna provider services number on the back of the member’s insurance card, or electronically through EDI 270/271 transactions via your clearinghouse.

When verifying benefits, confirm the following: active coverage status and effective dates, behavioral health benefit availability, covered levels of care for both mental health and substance use disorders, deductible amounts and year-to-date accumulations, coinsurance or copay requirements for each level of care, out-of-pocket maximum and current status, any day or visit limitations, precertification requirements by level of care, whether the member has out-of-network benefits, and whether any benefits are carved out to a separate behavioral health manager.

Aetna plan designs can vary significantly between employers. Some employers purchase broad behavioral health benefits while others may limit residential treatment coverage or exclude certain levels of care. Never rely on assumptions based on previous Aetna patients. Verify benefits individually for every admission and document the verification date, time, reference number, and representative name.

For Medicaid managed care plans administered by Aetna, benefits are determined by the state Medicaid program rather than Aetna’s commercial benefit structures. These plans may have different authorization processes, covered services, and reimbursement methodologies.

Prior Authorization Requirements

Aetna generally requires precertification (Aetna’s term for prior authorization) for residential treatment, partial hospitalization, intensive outpatient programs, and detoxification services, though specific requirements can vary by plan design. Outpatient services generally do not require precertification for in-network providers, though some plan designs may have notification requirements.

Precertification requests can be submitted through the Availity portal, by calling Aetna’s precertification line, or through electronic prior authorization platforms. The request should include a comprehensive clinical assessment, DSM-5 diagnoses, the recommended level of care with clinical justification, a treatment plan with measurable objectives, and documentation addressing all relevant ASAM dimensions for substance use disorder cases or Aetna CPB criteria for mental health cases.

Concurrent review is a standard component of the authorization process. For residential treatment, reviews typically occur approximately every 5 to 7 days. For PHP, concurrent reviews are generally conducted every 7 to 14 days. For IOP, reviews may occur every 2 to 4 weeks. These intervals can vary by plan and clinical circumstances. Each concurrent review requires updated clinical documentation demonstrating the patient’s progress, ongoing medical necessity, and plans for continued treatment or step-down.

Failure to obtain precertification before admission can result in reduced reimbursement or denial of the entire claim. For emergency admissions, notification must be provided within 48 hours. If a precertification request is denied, request a peer-to-peer review promptly so your treating clinician can discuss the case directly with the Aetna medical director. Document all peer-to-peer conversations including the date, participants, and outcome.

Claims and Billing

Aetna accepts claims through electronic submission and paper submission. Electronic claims should be submitted in 837I (institutional) or 837P (professional) format through your clearinghouse or through Availity. Paper claims use the UB-04 form for institutional claims and CMS-1500 for professional claims.

The timely filing limit for Aetna commercial plans is generally 90 to 120 days from the date of service or date of discharge, though this can vary by plan type, state, and contract terms. Medicare Advantage plans may follow CMS timely filing requirements, and Medicaid managed care plans follow state-specific deadlines. Always check the applicable plan’s requirements to ensure compliance, as claims submitted after the timely filing deadline are typically denied without appeal rights.

Common denial reasons for behavioral health claims with Aetna include lack of precertification, medical necessity not established or documentation insufficient, timely filing exceeded, coding errors (incorrect CPT, HCPCS, or revenue codes), coordination of benefits issues, and services rendered by non-credentialed providers. Providers should submit clean claims with accurate coding and complete documentation.

Aetna’s appeal process generally includes two levels of internal appeal. First-level appeals should typically be filed within 180 days of the adverse benefit determination, though timeframes may vary by plan type and state. Appeals must include clinical documentation addressing the specific denial reason. If the first-level appeal is denied, a second-level appeal can generally be filed for review by a different clinical reviewer. External review through an independent review organization is typically available after exhausting internal appeals, as required by applicable state and federal regulations. Always refer to the specific denial notice for current deadlines and procedures.

Payer Operations Quick Reference

The mid-task operational data for Aetna billers: phone numbers, payer IDs, filing limits, and addresses. Unlike payers that carve behavioral health out to a separate company, Aetna manages behavioral health internally, so most contacts stay within the Aetna/Availity ecosystem. Phone numbers and payer IDs change; confirm against aetna.com provider resources ↗ and Availity before relying on any value here.

Provider phone numbers

Phone-tree shortcuts are intentionally omitted: we only publish IVR navigation verified first-hand with a date.

Payer IDs and EDI

• Primary Aetna payer ID: 60054 (professional and institutional, most commercial plans).
• Aetna Better Health (Medicaid) plans use state-specific payer IDs — never default Medicaid claims to 60054; check your clearinghouse payer list for the state plan.
• Aetna transacts through Availity as its designated portal — EDI enrollment, ERA/835 enrollment, and EFT setup all run through Availity or your clearinghouse.

Timely filing limits

A wrong payer ID rejection does not pause the filing clock — resubmit immediately and retain the original clearinghouse acceptance report. Cross-payer comparison: /denial-code-timely-filing.

Claims and appeals addresses

• Electronic first: 837P/837I via clearinghouse or Availity under payer ID 60054; paper is the fallback.
• Paper claims address: plan-specific — use the address on the member ID card.
• Appeals: typically two internal levels; first-level appeals generally due within 180 days of the determination (state/plan variation). The appeals address is on the denial letter. For behavioral health denials at detox/residential/PHP/IOP levels, request a peer-to-peer with the Aetna medical director promptly — expedited review applies when the patient is in active treatment.

Credentialing contacts

• Start with CAQH ProView ↗, then submit a participation request via Aetna provider enrollment or Availity; recredentialing every 36 months. See insurance credentialing.
• Aetna may site-visit residential and detox facilities during credentialing — have licensure and accreditation documentation ready.

Prior-auth quirks for behavioral health levels of care

Operational data last reviewed 2026-06-11; quarterly re-verification cadence applies. See /rcm for how automates Aetna eligibility, precertification tracking, and claim routing.

• Precertification (Aetna’s term) is required for detox, residential, and PHP on nearly all plans, and frequently for IOP; emergency admissions require notification within 48 hours.
• Concurrent review cadence: roughly every 5–7 days for residential, 7–14 days for PHP, 2–4 weeks for IOP.
• Criteria: ASAM Criteria for SUD; Aetna’s proprietary Clinical Policy Bulletins for mental health — documentation should quote the applicable CPB’s criteria language back to the reviewer.
• Facility claims at these levels bill 837I/UB-04; mismatched authorization level vs. billed revenue code is a a commonly reported Aetna denial driver.

Frequently Asked Questions

Aetna generally requires precertification for residential treatment, which typically must be obtained before admission or within 48 hours for emergency admissions, though specific requirements may vary by plan. Requests are typically reviewed against ASAM Criteria for substance use disorders and Aetna's proprietary clinical policy bulletins for mental health. You will generally need to provide a clinical assessment, diagnosis, and documentation supporting the need for residential-level care. Failure to obtain precertification can result in a significant reduction in reimbursement or complete denial of the claim, depending on plan terms. Always verify current precertification requirements with [Aetna provider services](https://www.availity.com).

Aetna generally uses the ASAM Criteria for substance use disorder placements and its own Clinical Policy Bulletins for mental health residential admissions, though criteria may be updated periodically. For SUD, documentation typically must address all six ASAM dimensions and demonstrate why a lower level of care would be insufficient. For mental health, Aetna generally evaluates the severity of symptoms, risk of harm, functional impairment, and the intensity of services required. Treatment plans with clear, measurable goals typically strengthen authorization requests. Refer to [Aetna's current clinical policy bulletins](https://www.aetna.com/health-care-professionals/clinical-policy-bulletins.html) for the most up-to-date criteria.

Aetna generally offers a two-level internal appeal process, though specific procedures may vary by plan type and state. First-level appeals must typically be filed within 180 days of the adverse determination, though this timeframe can vary. Submit the appeal in writing with supporting clinical documentation that addresses the specific reason for denial. If the first-level appeal is denied, you can generally request a second-level appeal reviewed by a different clinical reviewer. After exhausting internal appeals, members and providers may request an external review by an independent review organization as required by applicable state and federal law. Always refer to the specific denial letter for applicable deadlines and procedures.

Aetna credentialing typically takes approximately 60 to 120 days from submission of a complete application, though timelines can vary based on application volume and completeness. The process generally begins with a fully attested [CAQH ProView](https://proview.caqh.org) profile. Commonly required documents include state facility licenses, clinical staff licenses, professional liability insurance, accreditation certificates, DEA registrations for prescribers, and a completed W-9. Facility-level credentialing may also require your organizational NPI, program description, and staffing documentation. Requirements are subject to change, so verify current requirements with Aetna's provider enrollment team.

The CVS Health acquisition has gradually integrated some pharmacy and behavioral health functions, particularly around medication-assisted treatment and pharmacy benefit coordination. Treatment centers should be aware that MAT medications may be managed through CVS Caremark pharmacy benefits rather than the medical benefit, though arrangements can vary by plan. Claims processes and credentialing requirements have generally remained consistent as of 2025, though Aetna continues to update its provider portal and electronic submission tools as integration with CVS Health systems evolves. Contact [Aetna provider services](https://www.availity.com) for the most current process information.

Aetna's main provider services line for commercial plans is 888-632-3862 (1-888-MD-AETNA). Behavioral health precertification and clinical questions may route to a dedicated Aetna Behavioral Health line shown on the member's ID card. Confirm the current number on aetna.com or the member card before calling, as payer phone numbers change.

Aetna's primary electronic payer ID is 60054 for most commercial professional and institutional claims. Some Aetna products — including certain Medicare Advantage and Medicaid managed care plans — use different payer IDs, so match the ID on the member card against your clearinghouse payer list before submitting.

Aetna commercial plans generally require claims within 90 to 120 days from the date of service or discharge, depending on your contract and state. Medicare Advantage and Medicaid managed care products follow different rules. Check your participation agreement and the plan-specific provider manual for the exact window that applies.

Key Billing Concepts

Revenue Cycle Resources

This guide is provided for informational purposes only and does not constitute legal, regulatory, or professional advice. Payer requirements, phone numbers, and portal URLs are subject to change. Always verify current information directly with the payer. is not affiliated with the insurance companies described on this page.

• Provider Portal
• Billing Hub
• Code Directory
• RCM Software

Reference tables

Common questions

Official sources

• aetna.com provider resourcesaetna.com