Cigna (through Evernorth Behavioral Health) covers ABA for autism with one of the more intake-friendly front doors in the industry: no prior authorization on assessment codes. The rigor arrives at the treatment-authorization step, where policy EN0499 sets detailed requirements for assessments, treatment plans, and progress data. Understanding both halves lets an intake team start families fast without setting up a denial later.
With an autism diagnosis on file, an independently licensed provider or BCBA can run assessment codes 97151, 97152, and 0362T without prior authorization (when the plan covers ABA). For intake, that means the sequence can be: verify benefits → book the assessment immediately → build the treatment request from the assessment. No authorization purgatory between first call and first appointment — if your intake process is fast enough to use it.[2][1]
The treatment PA package is the completed assessment plus treatment plan with Cigna's ABA PA form, which Cigna's autism resource guide encourages providers to submit up to 30 days before or within two weeks after the start of service ("A delay in request may result in a retrospective review"). EN0499 (eff. 5/15/2026) sets the actual retrospective trigger: "A retrospective authorization request for ABA is any request made when more than 90 days have passed since the start date of the requested authorization, or any time after the patient has discharged." Initiation requires a standardized, validated instrument — current edition, e.g., Vineland-3 — administered within 60 days before treatment start, with deficits mapped to DSM-5-TR ASD domains and to the treatment plan's goals.[1][2]
Measurable goals with operational definitions and mastery criteria; dated baseline data per setting; caregiver-training goals with their own baselines and data plans; a named, credentialed supervisor; and defined discharge criteria with a fading plan.[1][2]
Not as such. Neither EN0499 (eff. 5/15/2026) nor Evernorth’s ABA Prior Authorization Form (07/26 edition) asks for graphs. What both require is numbers with dates. For continued treatment EN0499 asks for “Quantitative baseline, interim and current data … with dates reported from when the data were collected for all behaviors and skills previously identified and/or proposed for intervention … across all settings and environments.” The form says: “Ensure treatment goal data are quantitative rather than anecdotal in nature” and “Include baseline, interim, and current goal data, with dates recorded, to demonstrate progress over time.” EN0499 defines interim data as covering “at a minimum … the previous 6 months of treatment” and says it “may be reported as patient data points and/or as a relevant average.” So a graph with dated data points works, and so does a dated table. A narrative summary does not. EN0499 mentions figures in one place only, for the standardized assessment: “Standardized scores and score tables, and/or scoring grids/figures must be provided, when applicable.”[1][3]
How recent: current data must be “collected within no more than 60 days prior to the start date of the continued treatment request, as well as collected within no more than 60 days prior to the date the authorization request is received.” The standardized assessment must be “completed no more than one year prior to the start date of the continued treatment request.” The form puts it as “readministered at least once every year.” After any break in treatment longer than 60 calendar days, a new standardized assessment and updated data are required.[1][3]
What else the reassessment needs: an updated treatment plan covering current deficits and progress; data showing “ongoing and sustained progress”; where progress is not shown, the barriers and a documented plan with adjusted protocols; data reported separately for each setting; dated baseline data within 60 days for any new goal; and caregiver (stakeholder) training data showing that each stakeholder still takes part and is progressing. To ask for more hours, add the clinical rationale and quantitative data showing how the increase would improve the outcome. On the form, tick “Continued stay,” say whether treatment broke since the last request, and list the standardized assessments with their dates. The form also warns that the AFLS, Essential for Living and the PEAK Comprehensive Assessment do not, on their own, show medical necessity. A request counts as continued treatment when the child had ABA with the requesting provider within the last 90 days. Approved treatment is authorized per month under 97155, which can be swapped with 97153–97158 and 0373T. Weekly hours are multiplied by 4.33 to get the monthly figure.[1][3]
ABA isn't covered when delivered at the same time as another therapy (speech, OT) to the same child — so intake should map the family's existing therapy schedule, not just list it. Only one provider can bill a unit of time, with the standard supervision exceptions. And if a family is transitioning from another ABA agency, overlapping authorization periods require documented coordination between agencies — capture the outgoing provider's details up front.[1]
Assessment and case supervision must come from a BCBA, licensed behavior analyst, or independently licensed clinician with documented ABA training, with direct supervision at the standard 1–2 hours per 10 hours of direct treatment. Evernorth doesn't credential non-licensed staff — RBT services bill under the supervising provider.[1]
Evernorth Behavioral Health, which runs Cigna's ABA network, says it "is committed to expanding our network of autism providers." It requires providers to be certified by a national governing body or a state licensing board (BCBA, BCBA-D, BCaBA, licensed behavior analyst or other behavioral health licensure). Individual providers complete the Evernorth Behavioral Provider Information Form; autism clinics and large group practices complete the Evernorth Screening Application for Autism Clinics. An application can take up to 90 days, and once a clinic contract is signed each certified or licensed provider must also be credentialed, which "can take an additional 60 to 90 days." Providers must be fully credentialed to render in-network services. "Evernorth does not credential nonlicensed/noncertified staff": technician services are billed under the supervising provider.[2]
Evernorth, which runs Cigna’s behavioral network, puts the licensing burden on the provider and points to state law. Its Behavioral Health Administrative Guidelines (September 2026) say: “Providers must meet all state requirements to provide virtual behavioral services, including any licenses and certifications. Providers must also comply with their state laws about the use of audio or video-based technology.” Providers are also “expected to follow all regulatory and licensure requirements related to their scope of practice.” A provider who meets the telehealth specialty requirements attests on the Attested Specialty Form, and Evernorth then adds “telehealth” to the provider profile.[4]
The guidelines do not name the member’s state in so many words. Check the child’s state licensing law for whether an out-of-state BCBA may practise there by telehealth before scheduling remote sessions.[4]
Telehealth: Evernorth Behavioral Health lets individual providers and outpatient clinics “permanently use telehealth for outpatient therapy, applied behavior analysis (ABA).” On a CMS-1500 put the CPT code in field 24-D with “Modifier 95,” and “Place of Service (POS) 02 in Field 24-B.” GT is retired by CMS but “still acceptable on claim forms.”[4][2][5][6][7]
Filing limit: Evernorth’s Behavioral Health Administrative Guidelines (September 2026) say “We will only consider claims submitted within 90 days of the date of service or as otherwise defined in your Provider Agreement.” A longer state timely-filing law applies where there is one. For COB claims “the 90-day filing limit is applied based on the primary payer’s processing date as stated on an explanation of benefits [EOB] or explanation of payment [EOP].” A claim sent back to you for more information gets a fresh 90 days from the date of the request. Corrected claims are not stamped “Corrected Claim.” They follow NUBC rules: on a CMS-1500, “Field 22 should include a ‘7’ or ‘8’ to indicate a replacement or voided claim.” Evernorth’s older (2021) electronic claim submission course adds a 180-day limit for “Non-participating provider or patient claims” and says a claim acceptance from Evernorth can serve as proof of timely filing. Payment time: the guidelines publish no national clean-claim payment deadline. Prompt-pay clocks for fully insured plans come from state law and sit in the guide’s state addenda. Evernorth offers ERA (835) to “Shorten the payment cycle.” It publishes no weekly submission cutoff or check-run day. The 2021 course also lists what an electronic claim carries: the billing provider’s name, TIN and NPI, the place of service, the prior authorization number, and the name and NPI of the rendering provider, attending physician and referring physician.[4][2][5][6][7]
Codes and who bills: Evernorth’s autism resource guide is explicit: “All ABA services must be billed with CPT codes 97151–97158, 0362T, and 0373T ONLY.” So HCPCS codes such as H0031, H0032 or H2019 are not used for ABA on Cigna plans. Evernorth’s ABA billing-code table lists 97151 through 97158 plus 0362T and 0373T, all in 15-minute units. Technicians and BCaBAs may provide 97152, 97153 and 97154, but the bill for those codes goes out under the BCBA-D, BCBA or licensed mental health provider; every other code is both provided and billed by the BCBA-D, BCBA or licensed provider. Precertification is not needed for 97151, 97152 or 0362T with an autism diagnosis when the provider is independently licensed or a BCBA, except when a network exception is requested.[4][2][5][6][7]
Appeals: Evernorth’s Behavioral Health Administrative Guidelines (September 2026) say to call Provider Services at 800.926.2273 first. Payment appeals are then “initiated in writing within 180 calendar days of the date of the initial payment or denial decision,” or within 180 days of an adjustment. A clinical appeal is due “within 180 calendar days from the claim denial unless determined otherwise by plan or state regulation.” A second-level appeal is due within 60 days of the first-level decision. “Most appeals are resolved within 60 calendar days of receipt,” with notice within 75 days unless state law differs. A late-filing denial (no claim within 90 days of the date of service) needs proof with the appeal, such as the EDI transmission report or COB evidence. Each appeal has to be submitted by a person; Evernorth does not accept appeals filed by automation. Fee-schedule adjustments can go through the reconsideration feature on Provider.Evernorth.com instead of an appeal.[4]
Fee schedule: Evernorth does not publish ABA rates. “For your fee schedule and a listing of autism spectrum disorder–related services eligible for reimbursement, refer to Exhibit A in your Provider Agreement.” Fee-schedule and contract questions go to Provider Services at 800.926.2273.[4]
Taxonomy and EVV: the 290-page guidelines do not mention a taxonomy code on claims or electronic visit verification. The 837 rule they state is that the billing provider’s TIN and NPI are required, and any rendering or referring provider listed must carry a name and NPI. Ask Provider Services if your contract adds a taxonomy requirement.[4]
Not required. Evernorth’s Behavioral Health Administrative Guidelines (September 2026), which govern Cigna behavioral claims including ABA, say for 837 claims: “The ‘Billing Provider’ Taxpayer Identification Number (TIN) and NPI are required. Any additional provider identification on the claim, such as the ‘Rendering Provider’ or ‘Referring Provider,’ must include the name and NPI when submitted.” So box 17/17b is optional, but if you fill it in, give the referring clinician’s name and NPI together.[4]
The clinical policy above is national, but three state-level layers change what a family's card actually buys: the state autism mandate (what fully-insured plans must cover), the carrier's state Medicaid plans (which follow the state Medicaid rules, not this commercial policy), and plan funding type (self-funded ERISA plans can carve benefits differently). Here's the picture in the states we cover:
Fully-insured Cigna / Evernorth plans issued in Georgia sit under the state mandate above. State Medicaid baseline: Georgia Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in North Carolina sit under the state mandate above. State Medicaid baseline: North Carolina Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in Indiana sit under the state mandate above. State Medicaid baseline: Indiana Medicaid (IHCP) guide →
Fully-insured Cigna / Evernorth plans issued in Virginia sit under the state mandate above. State Medicaid baseline: Virginia Medicaid (DMAS) guide →
Fully-insured Cigna / Evernorth plans issued in Tennessee sit under the state mandate above. State Medicaid baseline: TennCare (Tennessee Medicaid) guide →
Fully-insured Cigna / Evernorth plans issued in Ohio sit under the state mandate above. State Medicaid baseline: Ohio Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in New Jersey sit under the state mandate above. State Medicaid baseline: NJ FamilyCare (New Jersey Medicaid) guide →
Fully-insured Cigna / Evernorth plans issued in Maryland sit under the state mandate above. State Medicaid baseline: Maryland Medicaid (Medical Assistance) guide →
Fully-insured Cigna / Evernorth plans issued in Colorado sit under the state mandate above. State Medicaid baseline: Health First Colorado (Colorado Medicaid) guide →
Fully-insured Cigna / Evernorth plans issued in Utah sit under the state mandate above. State Medicaid baseline: Utah Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in Arizona sit under the state mandate above. State Medicaid baseline: AHCCCS (Arizona Medicaid) guide →
Fully-insured Cigna / Evernorth plans issued in New York sit under the state mandate above. State Medicaid baseline: New York Medicaid (NYS DOH / eMedNY) guide →
Fully-insured Cigna / Evernorth plans issued in New Mexico sit under the state mandate above. State Medicaid baseline: New Mexico Medicaid (Turquoise Care) guide →
Fully-insured Cigna / Evernorth plans issued in Missouri sit under the state mandate above. State Medicaid baseline: MO HealthNet (Missouri Medicaid) guide →
Fully-insured Cigna / Evernorth plans issued in Texas sit under the state mandate above. State Medicaid baseline: Texas Medicaid (THSteps-CCP) guide →
Fully-insured Cigna / Evernorth plans issued in Massachusetts sit under the state mandate above. State Medicaid baseline: MassHealth (Massachusetts Medicaid) guide →
Fully-insured Cigna / Evernorth plans issued in Florida sit under the state mandate above. State Medicaid baseline: Florida Medicaid — Behavior Analysis Services (AHCA) guide →
Fully-insured Cigna / Evernorth plans issued in Kansas sit under the state mandate above. State Medicaid baseline: KanCare (Kansas Medicaid) guide →
Fully-insured Cigna / Evernorth plans issued in Nebraska sit under the state mandate above. State Medicaid baseline: Nebraska Medicaid (Heritage Health) guide →
Fully-insured Cigna / Evernorth plans issued in Idaho sit under the state mandate above. State Medicaid baseline: Idaho Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in Iowa sit under the state mandate above. State Medicaid baseline: Iowa Medicaid (IA Health Link) guide →
Fully-insured Cigna / Evernorth plans issued in Oklahoma sit under the state mandate above. State Medicaid baseline: Oklahoma Medicaid (SoonerCare / SoonerSelect) - Oklahoma Health Care Authority guide →
Fully-insured Cigna / Evernorth plans issued in Michigan sit under the state mandate above. State Medicaid baseline: Michigan Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in Hawaii sit under the state mandate above. State Medicaid baseline: Hawaii Medicaid (Med-QUEST / QUEST Integration) guide →
Fully-insured Cigna / Evernorth plans issued in California sit under the state mandate above. State Medicaid baseline: Medi-Cal (California Medicaid) guide →
Fully-insured Cigna / Evernorth plans issued in Pennsylvania sit under the state mandate above. State Medicaid baseline: Pennsylvania Medicaid (Medical Assistance) guide →
Fully-insured Cigna / Evernorth plans issued in New Hampshire sit under the state mandate above. State Medicaid baseline: New Hampshire Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in Wisconsin sit under the state mandate above. State Medicaid baseline: Wisconsin Medicaid (ForwardHealth) guide →
Fully-insured Cigna / Evernorth plans issued in South Carolina sit under the state mandate above. State Medicaid baseline: South Carolina Healthy Connections Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in Kentucky sit under the state mandate above. State Medicaid baseline: Kentucky Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in Washington sit under the state mandate above. State Medicaid baseline: Washington Apple Health (Medicaid) guide →
Fully-insured Cigna / Evernorth plans issued in Connecticut sit under the state mandate above. State Medicaid baseline: Connecticut Medicaid (HUSKY Health) guide →
Fully-insured Cigna / Evernorth plans issued in Illinois sit under the state mandate above. State Medicaid baseline: Illinois Medicaid (HFS) guide →
Fully-insured Cigna / Evernorth plans issued in Louisiana sit under the state mandate above. State Medicaid baseline: Louisiana Medicaid (Healthy Louisiana) guide →
Fully-insured Cigna / Evernorth plans issued in Oregon sit under the state mandate above. State Medicaid baseline: Oregon Health Plan (Medicaid) guide →
Fully-insured Cigna / Evernorth plans issued in Minnesota sit under the state mandate above. State Medicaid baseline: Minnesota Medical Assistance (EIDBI) guide →
Fully-insured Cigna / Evernorth plans issued in Maine sit under the state mandate above. State Medicaid baseline: MaineCare (Maine Medicaid) guide →
Fully-insured Cigna / Evernorth plans issued in Vermont sit under the state mandate above. State Medicaid baseline: Vermont Medicaid (Green Mountain Care / DVHA) guide →
Fully-insured Cigna / Evernorth plans issued in Alabama sit under the state mandate above. State Medicaid baseline: Alabama Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in South Dakota sit under the state mandate above. State Medicaid baseline: South Dakota Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in Nevada sit under the state mandate above. State Medicaid baseline: Nevada Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in Montana sit under the state mandate above. State Medicaid baseline: Montana Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in Alaska sit under the state mandate above. State Medicaid baseline: Alaska Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in North Dakota sit under the state mandate above. State Medicaid baseline: North Dakota Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in Arkansas sit under the state mandate above. State Medicaid baseline: Arkansas Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in Rhode Island sit under the state mandate above. State Medicaid baseline: Rhode Island Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in Wyoming sit under the state mandate above. State Medicaid baseline: Wyoming Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in West Virginia sit under the state mandate above. State Medicaid baseline: West Virginia Medicaid (BMS) guide →
Fully-insured Cigna / Evernorth plans issued in District of Columbia sit under the state mandate above. State Medicaid baseline: District of Columbia Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in Mississippi sit under the state mandate above. State Medicaid baseline: Mississippi Medicaid guide →
Fully-insured Cigna / Evernorth plans issued in Delaware sit under the state mandate above. State Medicaid baseline: Delaware Medicaid (DMAP / Diamond State Health Plan) guide →
The questions that decide whether a family can start with Cigna / Evernorth, and what they have to bring. Each maps onto something intake should ask on the first call.
Cigna's recency rule attaches to the standardized assessment rather than to the diagnosis, and it is the tightest in this directory. Initiation requires a standardized, validated instrument in its current edition administered within 60 days before treatment start. Continued treatment needs an updated plan with current data no more than 60 days old, sustained progress, a repeat standardized assessment within a year, and a re-assessment after any break in service longer than 60 days. If the family's most recent testing is older than 60 days, plan to administer during the assessment window — which Cigna lets you open without prior authorization.[1]
EN0499 (eff. 5/15/2026) requires a DSM-5-TR autism spectrum diagnosis (F84.0–F84.9, except F84.2 Rett syndrome) made “by a healthcare professional who is licensed to practice independently and whose licensure board considers diagnostics to be within their scope of practice.” The request must give “The name, credentials, and type of licensure” of the person who made the diagnosis and “The date on which the diagnosis was most recently made.” A school (IDEA) eligibility finding “may not meet criteria as a formal diagnosis of ASD” unless it also meets that standard. A diagnosis called “provisional,” “rule out” or “at risk of” does not count as confirmed. Evernorth’s ABA Prior Authorization Form asks for the evaluator’s credential: medical doctor, licensed psychologist or other.[1][3]
A standardized, validated instrument in its current edition — EN0499 gives Vineland-3 as the example rather than a closed list — administered within 60 days before treatment start, with the deficits it measures mapped to DSM-5-TR ASD domains and carried through into the treatment plan's goals. Continued treatment requires a repeat standardized assessment within a year. The instrument is the hinge of the treatment authorization, so pick it before the assessment rather than after. Evernorth’s ABA Prior Authorization Form (07/26) says the AFLS, the Essential for Living and the PEAK Comprehensive Assessment “do not, on their own, sufficiently demonstrate medical necessity.” Where a tool scores on a grid or towers, fill in the bubbles to show each domain was fully assessed.[1][3]
No referral or physician order is required by EN0499, and — the part that makes Cigna the friendliest front door in this directory — no prior authorization is required on assessment codes 97151, 97152 and 0362T when there is an autism diagnosis on file and the provider is independently licensed or a BCBA. Treatment is the gated step: the completed assessment plus a treatment plan on Cigna's ABA PA form, which Cigna's autism resource guide encourages providers to submit up to 30 days before or within two weeks after the start of service. The retrospective line is EN0499's, not that window: a request becomes retrospective "when more than 90 days have passed since the start date of the requested authorization, or any time after the patient has discharged."[1][2]
The most permissive published position in this directory: Cigna's March 2025 autism resource guide states that all ABA CPT codes are covered telehealth services, with the delivery model — in person, telehealth or hybrid — chosen on the individual's needs rather than by code. State Medicaid telehealth restrictions do not reach commercial Cigna business. That includes the 97151 assessment and 97155 protocol modification. EN0499 describes direct case supervision as occurring "concurrently with the delivery of direct treatment," with the BCBA "face-to-face with the individual and either the Registered Behavior Technician® [RBT®] or the Board Certified Assistant Behavior Analyst® [BCaBA®]," at one to two hours per ten hours of direct treatment; it publishes no separate in-person minimum for supervision delivered by telehealth. How to bill it: Evernorth Behavioral Health says individual providers and outpatient clinics “may permanently use telehealth for outpatient therapy, applied behavior analysis (ABA)” and must put the CPT code in field 24-D, “Modifier 95 in Field 24-D to specify telehealth” and “Place of Service (POS) 02 in Field 24-B.” The GT modifier “has been retired by the Centers for Medicare & Medicaid Services (CMS), but it still acceptable on claim forms.” On the authorization side, Evernorth’s ABA Prior Authorization Form (07/26) lists Telehealth as a place of service to tick (with clinic, home and school), so declare remote delivery on the request.[3][2][1][5]
Evernorth follows the NAIC order-of-benefit rules "subject to applicable law and the terms of the benefit plan." Dependent child of married parents living together: the "birthday rule" — "The plan of the parent whose birthday falls earlier in the calendar year is primary" (month and day only; same birthday, the longer-running plan). Divorced or separated parents: a court decree first, otherwise custodial parent, custodial parent's spouse, noncustodial parent, noncustodial parent's spouse. When Cigna is secondary, bill the primary first and submit to Cigna with the primary's explanation of payment; the 90-day filing limit runs from the primary's processing date. Cigna pays ahead of Medicaid (payer of last resort by federal law — the Medicaid program may still require its own PA), TRICARE (secondary to other health insurance by law) and CHAMPVA (pays after other health insurance).[4][9][10][11]
EN0499 publishes no age limit for ABA. The bound on a Cigna card therefore comes from the plan document and, on fully-insured business, from the state autism mandate — Maryland's habilitative mandate runs through the month the enrollee turns 19, Missouri's ABA dollar cap runs through age 18, Indiana's mandate has no age term at all. Establish plan funding type before quoting any bound.[1]
Ask the plan: Benefits verification on the specific plan — confirm the ABA benefit exists, the funding type, and any age or visit limit.
Cigna/Evernorth publishes no clock of its own: "We (or our designees) make coverage determinations in accordance with the time frames required under applicable law." For self-funded employer plans that is the ERISA claims rule — a pre-service decision within 15 days (one 15-day extension) and 72 hours for urgent care; fully insured plans follow the state's utilization-review law. What Cigna does publish on timing is encouragement, not a rule: its autism resource guide says "we encourage providers to request authorizations up to 30 days in advance of or two weeks after the start date of service. A delay in request may result in a retrospective review and could delay the determination for up to 30 days." EN0499 (eff. 5/15/2026) sets the actual retrospective trigger: "A retrospective authorization request for ABA is any request made when more than 90 days have passed since the start date of the requested authorization, or any time after the patient has discharged."[4][1][2][8]
Ask the plan: Benefits verification: fully insured (state UR deadlines) or self-funded/ASO (ERISA)? Confirm the reauthorization window with the Cigna Autism Care Coordinator team (877-279-7603).
Coverage decides whether Cigna / Evernorth pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Assessment and case supervision must come from a BCBA, a licensed behavior analyst, or an independently licensed clinician with documented ABA training, with direct supervision at the standard 1–2 hours per 10 hours of direct treatment. Evernorth does not credential non-licensed staff at all, so the supervising clinician is also the contractual party. The treatment plan must name a credentialed supervisor and define discharge criteria with a fading plan. EN0499 adds that when direct treatment is 10 hours a week or less, “a minimum of one to two hours per week of direct case supervision is provided.” It sets no limit on how many technicians or cases one BCBA may supervise. That cap comes from the BACB and state licensure rules, not from Cigna.[1]
Two rules, and the first one catches more claims than the second. ABA is not covered when delivered at the same time as another therapy — speech, OT — to the same child, which makes the family's existing therapy schedule an intake fact rather than a note. And only one provider can bill a unit of time, with the standard supervision exceptions. Where a family is transitioning from another ABA agency, overlapping authorization periods require documented coordination between the agencies, so capture the outgoing provider's details and get releases signed up front.[1]
EN0499 specifies the note element by element: every session note needs the date, start and end times, location, focus, a detailed description of the intervention, the persons present, the service type, and the rendering provider's name, credential and signature. No countersignature requirement and no signing deadline are published.[1]
Evernorth does not credential non-licensed staff, so RBT-delivered services bill under the supervising provider. The treatment plan must carry a named, credentialed supervisor, and assessment codes are payable only when performed by an independently licensed provider or a BCBA. Evernorth’s ABA billing-code table says the same code by code: 97152, 97153 and 97154 may be provided by a “BCaBA, Technician,” but the provider who can bill for them is the “BCBA-D, BCBA, or licensed mental health provider.”[1][7]
Not published as a per-day unit ceiling. EN0499 bounds the day from a different direction: ABA is not covered when delivered at the same time as another therapy to the same child, and only one provider can bill a unit of time, with the standard supervision exceptions. Requested intensity is set in the treatment plan and authorized on the ABA PA form rather than against a published cap. The limit that does apply is the authorization itself. Evernorth’s ABA Prior Authorization Form (07/26) says an approved authorization “will be written on a per month basis with CPT code 97155 and can be interchanged with ongoing treatment codes 97153–97158 and 0373T. ABA hours requested per week are multiplied by 4.33 to determine monthly averages.” So the cap is a monthly bank of authorized hours, not a daily claim edit.[1][3]
Ask the plan: The treatment authorization itself, and Evernorth Behavioral Health provider services (the behavioral health number on the member's card) — ask whether any per-day MUE is applied to ABA codes on this plan.
Not published as a payable-settings list. Two sourced facts bear on setting nonetheless: the treatment plan must carry dated baseline data per setting, so settings are declared and measured rather than assumed; and every session note must record the location. Whether a given setting is payable is a plan-benefit question.[1]
Ask the plan: Benefits verification on the specific plan — ask which places of service are payable for ABA, and whether school-based delivery is excluded before you write school goals.
In your contract. Evernorth says your fee schedule and the list of reimbursable autism services are in Exhibit A of your Provider Agreement. It publishes no ABA rate table, and fee-schedule questions go to Provider Services at 800.926.2273.
Evernorth’s September 2026 guidelines give 180 calendar days from the initial payment or denial decision for a written payment appeal, and 180 days from the denial for a clinical appeal unless the plan or state law says otherwise. A second-level appeal is due within 60 days of the first decision, and most appeals are resolved within 60 days.
No graph is required as such. EN0499 and Evernorth’s ABA Prior Authorization Form require quantitative baseline, interim and current goal data with dates, for every goal and every setting. Interim data covers at least the last 6 months and may be shown as data points or averages, and current data must be no more than 60 days old. A standardized assessment from the last 12 months is also required. A dated graph or a dated table both meet the requirement; a narrative summary does not.
No. Evernorth’s September 2026 administrative guidelines require only the billing provider’s TIN and NPI; a referring provider is optional, but if you report one it "must include the name and NPI."
Not for assessment codes (97151, 97152, 0362T) when there's an autism diagnosis and the provider is independently licensed or a BCBA. Treatment services do require authorization — assessment plus treatment plan with the PA form.
Yes — its March 2025 provider guide states all ABA CPT codes are covered telehealth services, with delivery (in-person, telehealth, hybrid) based on the individual's needs.
Yes, but not at the same time of day — Cigna doesn't cover ABA delivered concurrently with another therapy session. Intake should capture the existing therapy schedule to plan around it.
Evernorth, which runs Cigna's behavioral network, says it is "committed to expanding our network of autism providers." Individual providers submit the Evernorth Behavioral Provider Information Form and clinics the Screening Application for Autism Clinics; allow up to 90 days for the application plus 60 to 90 days of credentialing per provider.
No. "Evernorth does not credential nonlicensed/noncertified staff. Services for these staff members must be billed under the supervising provider." EN0499 expects the direct work from an RBT or BCaBA under BCBA case supervision.
Only if state law allows it. Evernorth requires providers to meet all state requirements for virtual behavioral services, including licences and certifications, and to attest to the telehealth specialty. Check the child’s state licensing rules before scheduling remote sessions.
Yes. Evernorth Behavioral Health asks for modifier 95 in field 24-D and place of service 02 in field 24-B on telehealth claims, and ABA is on its list of services providers may permanently deliver by telehealth. GT is retired but still accepted.
Evernorth’s September 2026 administrative guidelines give 90 days from the date of service, or whatever your provider agreement says, and a longer state law wins. Secondary (COB) claims get 90 days from the primary payer’s processing date on its EOB. Corrected claims use frequency code 7 or 8 in box 22. An older Evernorth course gives 180 days for non-participating providers.
No. Evernorth’s autism resource guide says all ABA services must be billed with CPT 97151–97158, 0362T and 0373T only.
Evernorth publishes no national clean-claim payment deadline or weekly cutoff. On fully insured plans the state prompt-pay law sets the clock, and Evernorth’s guidelines carry those in their state addenda. Enrolling in ERA (835) shortens the payment cycle.
Evernorth lists 97151–97158, 0362T and 0373T. Technicians and BCaBAs may deliver 97152, 97153 and 97154, but those are billed by the BCBA-D, BCBA or licensed mental health provider; the other codes are delivered and billed by those licensed or certified providers.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 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.
Carelu collects all of this automatically.
Every ID, document, and detail this payer requires — gathered conversationally the moment a family reaches out, with insurance verified before your team touches the file.
Get a Demo