For an intake team in Alabama, a Cigna card means three layers: Evernorth’s national ABA policy EN0499 and the Cigna autism resource guide, Alabama’s Riley Ward Act, and the plan’s size and funding. Many Cigna members are on self-funded employer plans, which sit outside the state mandate, so check funding first.
Cigna runs ABA through Evernorth Behavioral Health under EN0499 (effective May 15, 2026). Under the autism resource guide, assessment codes 97151, 97152 and 0362T need no prior authorization with an autism diagnosis when the provider is independently licensed or a BCBA. Treatment needs the completed assessment and treatment plan. Neither EN0499 nor the resource guide mentions Alabama. Evernorth’s September 2026 Administrative Guidelines do carry an Alabama Regulatory Addendum, which repeats the state’s recoupment limits (12 months after payment, or 18 months for coordination of benefits, with 30 days to dispute) and the Ala. Code § 27-1-17.1 right to be paid by ACH. The addendum does not apply to self-funded plans.[1][2][3]
Alabama’s autism mandate is the Riley Ward Act, Ala. Code § 27-54A-2 (Act 2012-298, amended by Act 2017-337). It requires a "health benefit plan" to "cover the screening, diagnosis, and treatment of Autism Spectrum Disorder for an insured 18 years of age or under in policies and contracts issued or delivered in the State of Alabama to employers with at least 51 employees." Coverage "is limited to treatment that is prescribed by the insured’s treating licensed physician or licensed psychologist in accordance with a treatment plan," and the plan must include the diagnosis, treatment by type, frequency and duration, goals, how often it will be updated, and the physician’s or psychologist’s signature. The insurer "may request an updated treatment plan only once every six months" unless both sides agree to more, and it bears the cost of the review. Behavioral health treatment, including ABA, must be "provided or supervised, either in person or by telemedicine, by a Board Certified Behavior Analyst, licensed in the State of Alabama, or a psychologist, licensed in the State of Alabama," and ABA coverage "shall include the services of the personnel who work under the supervision of" that BCBA or psychologist. ABA carries a yearly cap: $40,000 for ages 0–9, $30,000 for ages 10–13 and $20,000 for ages 14–18, which "may be exceeded, upon prior approval by the insurer," when more ABA is medically necessary. There is no visit limit, and dollar limits, deductibles and coinsurance may not be less favorable than for medical and surgical benefits. The plan may still apply coordination of benefits, participating-provider rules, utilization review and medical-necessity review. Since December 31, 2018 the definition includes the State Employees Insurance Board and PEEHIP plans. It does not include non-grandfathered individual and small-group plans that had to carry ACA essential health benefits as of January 1, 2017, and self-funded employer plans answer to ERISA, not state insurance law. The Act does not change any IFSP or IEP obligation.[4]
Alabama licenses behavior analysts. Ala. Code § 34-5A-2 says "the unlicensed practice of behavior analysis is prohibited in this state," with exemptions for licensed psychologists, physicians, other licensed professionals acting within their own scope, and the "applied behavior analysis direct contact technician" working "under the extended authority and direction of a licensed behavior analyst or a licensed assistant behavior analyst." The licensing body changed this year: Act 2026-144 renamed the Alabama Behavior Analyst Licensing Board the Alabama Behavior Analyst Advisory Council from February 26, 2026 and moved its licensing duties to the Department of Mental Health; existing licenses carried over, and statutes, contracts and payer manuals that still name the old Board now legally refer to the Council. To be licensed, a BCBA must keep active BACB certification and pass a criminal background check; a BCaBA must also show ongoing BCBA supervision. DMH says no license is required for Registered Behavior Technicians. For a BCBA based in another state there are two routes: reciprocity, for someone "actively licensed as a behavior analyst in another state" with comparable requirements that offers Alabama reciprocity, and a temporary license for a BCBA "residing and practicing in another state who temporarily provides behavior analysis services in this state or to a resident of this state," which the rules set at 90 days, extendable once. The insurance mandate makes the license matter for payment too: mandated ABA must be provided or supervised, in person or by telemedicine, by a BCBA "licensed in the State of Alabama." Commercial ABA rates are negotiated and not published. The public benchmark is the Alabama Medicaid ABA fee schedule (effective February 5, 2026), which pays 97153 at $10.00 and 97155 at $15.00 per 15-minute unit.[5][6][7][8][4][18]
Alabama’s prompt-pay statute, Ala. Code § 27-1-17, makes insurers, health service corporations and HMOs pay "within 45 calendar days upon receipt of a clean written claim or 30 calendar days upon receipt of a clean electronic claim." Within the same window they must tell you why a claim is denied or pending and what they need. Once you send it, they have 21 calendar days to pay, deny or otherwise decide the claim. Overdue clean claims earn interest of 1.5% a month. The insurer is not in violation for "any claim submitted more than 180 days after the service was rendered," so file well inside 180 days even when your contract allows longer. A paid claim cannot be clawed back after one year (or after your contract’s filing period, if that is shorter), except for fraud, duplicates or coordination of benefits, which have 18 months. You have 30 days to dispute a recoupment notice. The statute binds out-of-state carriers that process claims for Alabama residents. It does not reach self-funded ERISA plans, the Medicaid Agency or traditional Medicare. In 2026 Alabama also passed Act 2026-589 (Ala. Code § 27-1-17.2): when a health plan uses AI in prior-authorization review, a denial, delay or change based on medical necessity "shall always be made by a licensed physician or other health care professional."[9][10][3]
Evernorth’s Behavioral Health Administrative Guidelines (September 2026) set the filing limit: "We will only consider claims submitted within 90 days of the date of service or as otherwise defined in your Provider Agreement," unless "Applicable state law provides for a longer timely filing limit." For a secondary claim the 90 days run from "the primary payer’s processing date as stated on an explanation of benefits [EOB] or explanation of payment [EOP]," Medicaid-primary claims get three years, and a timely claim returned for more information gets a new 90 days from the date of the request. The Alabama Regulatory Addendum adds no filing deadline; it limits retroactive denial or recoupment to 12 months after payment (or the contract’s filing period, if shorter) and gives 30 days to dispute one. State addenda do not apply to self-funded plans. The guidelines publish no check-run or weekly cut-off schedule.[9][10][3]
Cigna publishes no ABA rate table. Evernorth’s Administrative Guidelines (September 2026) say the Provider Agreement terms "include the reimbursement rates applicable to covered services." ABA providers are told: "For your fee schedule and a listing of autism spectrum disorder–related services eligible for reimbursement, refer to Exhibit A in your Provider Agreement." Provider Services is 800.926.2273. Virtual services carry modifier 95, which Evernorth says "will not change the reimbursement." As a public benchmark, Alabama Medicaid pays 97153 at $10.00 per 15 minutes.[3][18]
Evernorth’s EN0499 sets what a continued-treatment request must show: "current data" 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," with collection dates, for every behavior and skill targeted; data showing "ongoing and sustained progress toward mastering the treatment goals"; measurable improvement on "a reliable, valid, and standardized assessment instrument completed no more than one year prior to the start date of the continued treatment request"; an account of barriers and plan changes where progress is not shown; and dated stakeholder (caregiver) training data. EN0499 does not require the data to be graphed.[1]
The questions that decide whether a family can start with Cigna / Evernorth in Alabama, and what they have to bring. Each maps onto something intake should ask on the first call.
The diagnosis does not expire, but the request needs the date it was most recently made. The clocks run on data: the standardized instrument within 60 days before treatment, baseline data within 60 days, and a new standardized assessment after any break in treatment of more than 60 days.[1]
A healthcare professional "licensed to practice independently and whose licensure board considers diagnostics to be within their scope of practice," using DSM-5-TR criteria; their name, credentials and licensure type must be provided.[1]
No single instrument is mandated. It must be reliable, valid and standardized, measure the ASD domains, be given by a trained administrator, and be the current edition (the policy’s example: Vineland-3, not Vineland-II).[1]
EN0499 requires no referral. Assessments need no PA with an autism diagnosis; treatment needs the assessment and plan on the PA request. Evernorth publishes no ABA order form or validity period. On the claim, Evernorth’s administrative guidelines (September 2026) define a complete CMS-1500 claim without a referring provider (they require the rendering provider’s name, NPI and license type and the billing provider’s name, address and NPI); any "Referring Provider" reported on an 837 claim "must include the name and NPI." For a fully insured Alabama large-group plan (51 or more employees), the Riley Ward Act limits mandated ABA to treatment "prescribed by the insured’s treating licensed physician or licensed psychologist in accordance with a treatment plan," and the insurer may ask for an updated plan only once every six months. Self-funded ERISA plans, and ACA individual and small-group plans, are outside the Act.[2][1][4][3]
All ABA CPT codes are covered telehealth services (autism resource guide), and EN0499 allows in-person, telehealth or hybrid delivery. Bill modifier 95. Evernorth says providers "must meet all state requirements to provide virtual" behavioral health, which in Alabama means an Alabama behavior-analyst license.[2][1][3][5]
EN0499 sets no age cap; access to focused intervention "should not be restricted by age." For fully insured Alabama large-group plans, the Riley Ward Act (Ala. Code § 27-54A-2) requires autism coverage for insureds "18 years of age or under," with ABA capped at $40,000 a year for ages 0–9, $30,000 for ages 10–13 and $20,000 for ages 14–18. The insurer may approve more when medically necessary. Self-funded ERISA plans and ACA individual and small-group plans are outside the Act, so the plan’s funding and size decide whether that applies.[1][4]
Ask the plan: Live benefits verification: establish employer size and fully insured vs. self-funded first.
Alabama sets no prior-authorization deadline that reaches most commercial carriers. Ala. Code § 27-3A-5 says a certified utilization review agent must decide "within two business days of the receipt of the request for determination and the receipt of all information necessary," and must decide appeals within 30 days. But § 27-3A-3 exempts licensed insurers reviewing their own plans, HMOs reviewing their own members, and any URAC-accredited entity, which covers most large carriers and behavioral health vendors. Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1: a pre-service decision "not later than 15 days after receipt of the claim," one 15-day extension, urgent care within 72 hours, and 180 days to appeal. 45 CFR 147.136 applies the same claims-and-appeals floor to insured group and individual coverage. Under Ala. Code § 27-1-17.2 (Act 2026-589), any medical-necessity denial of a prior authorization must be made by a licensed physician or other qualified health care professional, even when AI is used. Cigna/Evernorth publishes no Alabama-specific ABA turnaround.[11][12][13][10]
Ask the plan: Evernorth Provider Services, 800.926.2273: ask the plan’s funding type, the decision time and the reauthorization lead time.
Alabama does not set out its group coordination-of-benefits order in any source we could open. Ala. Code § 27-1-17 defines coordination of benefits by reference to "Alabama Insurance Department Regulation No. 56, or any successor regulation," but Ala. Admin. Code ch. 482-1-056 was repealed in 2007, and we could not retrieve its successor to confirm the birthday rule. Treat the order between two parents’ plans as a question for each plan. The federal rules are settled. If the child also has Alabama Medicaid, the commercial plan pays first: Alabama Medicaid calls itself "the payer of last resort" (42 CFR 433.139), will only process a third-party denial on its approved list or with proof of a good-faith effort to collect, and accepts claims filed within 120 days of the other payer’s decision. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)), and CHAMPVA "would be the last payer" (38 CFR 17.270). Alabama limits retroactive recoupment for coordination-of-benefits reasons to 18 months after payment (Ala. Code § 27-1-17(f)).[9][3][15][14][16][17]
Ask the plan: Ask Cigna/Evernorth at benefits verification for the coordination-of-benefits order, and record every other coverage the child has.
Coverage decides whether Cigna / Evernorth in Alabama 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.
Case supervision by a BCBA, Licensed Behavior Analyst, or independently licensed mental health professional with ABA training, at "one to two hours per ten hours of direct treatment." When treatment is 10 hours a week or less, at least one to two hours a week of direct case supervision.[1]
Only one provider may bill a unit of time, except 97153, 97154 and 97155 during direct supervision, when the BCBA or QHP and the technician are both face-to-face with the patient. ABA delivered at the same time as another treatment (such as speech or occupational therapy) is not reimbursable.[2][1]
No per-day cap. All ABA codes bill in 15-minute units; intensity must reflect severity, goals and response. On a Riley Ward plan the annual ABA dollar caps by age band apply unless the insurer approves more.[2][1][4]
Each service record needs date and time, location, who was present, the service delivered, and the "name, credential (if applicable), and signature of ABA provider who rendered the service."[1]
In academic, vocational or telehealth settings the service must still meet EN0499’s definition of direct treatment, and goals and data are reported for each setting. Primarily educational services are not covered.[1]
Evernorth does not credential unlicensed or uncertified staff; their services are billed under the supervising provider. Only a BCBA or other licensed provider goes in box 33, and electronic claims use payer ID 62308. In Alabama that BCBA must also hold an Alabama license (Ala. Code § 34-5A-2).[2][5]
No. Evernorth’s EN0499 requires dated data collected within 60 days before both the requested start date and the request’s receipt, sustained progress, and a standardized assessment from the past year, but it does not require graphs.
90 days from the date of service unless your provider agreement or a longer state limit applies; secondary claims get 90 days from the primary payer’s EOB/EOP date, and a claim returned for more information gets a new 90 days. No check-run schedule is published.
Yes, under EN0499 for ASD. Fully insured large-group plans also carry the Riley Ward Act mandate for children 18 and under; self-funded plans follow their own documents.
No, for 97151, 97152 and 0362T with an autism diagnosis when the provider is independently licensed or a BCBA. PA starts at treatment.
Cigna covers all ABA codes by telehealth (modifier 95), but the provider must meet Alabama’s licensing requirements.
Cigna publishes no ABA rates. Your fee schedule is Exhibit A of your Evernorth Provider Agreement (Provider Services 800.926.2273). Alabama Medicaid’s 97153 rate ($10.00 per 15 minutes) is the only public benchmark.
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.
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