For an intake team in Colorado, a Cigna card means three layers at once: the carrier's national clinical policy, Colorado's autism insurance mandate (C.R.S. § 10-16-104(1.4)), and the plan's funding type deciding which of the two actually binds. This guide stacks them in order. Note the contrast with Colorado Medicaid: Cigna's commercial policy requires an ASD diagnosis, while Health First Colorado does not — so a family that qualifies for Medicaid ABA without a diagnosis will still need one here.
Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. That clinical policy is national — what changes in Colorado is the legal floor underneath it: the state mandate below governs what fully-insured plans must cover, while self-funded employer plans answer to ERISA and federal parity instead. Plan funding type is therefore the first fact to establish on every benefits check. The full national policy breakdown lives in our Cigna / Evernorth guide; this page covers what changes in Colorado.[1][2]
Code set: the Cigna/Evernorth autism resource guide requires all ABA services to be billed with 97151–97158, 0362T and 0373T only, so HCPCS H-codes such as H0031 or H2019 are not accepted for ABA.[1][2]
Colorado's mandate — C.R.S. § 10-16-104(1.4), originally 2009's SB 09-244 — is one of the stronger ones in our directory: it applies to all health benefit plans issued or renewed in Colorado except short-term limited-duration policies and individual grandfathered plans, carries no age limits, and carries no dollar caps — the historical $34,000/year (birth-8) and $12,000/year (9-18) ABA caps no longer appear in the current statute text, and carriers may not deny or restrict coverage because of an ASD diagnosis or utilization of mandated benefits. The statute also defines "autism services provider" with six qualification pathways reaching down to BACB Registered Behavior Technician. Self-funded ERISA plans are exempt by federal preemption, and MHPAEA parity applies on top for plans covering mental-health benefits — the caps' removal from the statute aligns the mandate with parity rather than fighting it.[3]
Unlike Virginia — where EN0499 explicitly does not apply to fully-insured business — we found no Colorado carve-out in the policy, so the national rules (including the no-assessment-PA fast path) should apply to Colorado members. One honesty note: the current EN0499 PDF could not be fully text-parsed to confirm the state-exceptions list with certainty, so treat "no Colorado carve-out" as high-confidence rather than absolute and confirm the assessment-PA answer on the benefits call before promising families a fast start.[1]
Colorado currently requires no state license to practice behavior analysis — BCBA/BACB certification is the operative credential. That is changing: HB26-1425 (signed June 2, 2026) creates a Colorado Behavior Analyst Licensing Board under DORA's Division of Professions and Occupations, and on and after July 1, 2028 practicing ABA without a behavior analyst or assistant behavior analyst license becomes a class 2 misdemeanor; the law also mandates state licensure of ABA clinics. Practices should put the 2028 licensure conversion on their credentialing roadmap now. On rates: Cigna does not publish commercial ABA fee schedules for Colorado (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement; the Health First Colorado fee schedule (97153 at $17.20/unit for DOS 10/1/2025+) is the published in-state benchmark.[4]
Cigna publishes no ABA fee schedule. In-network ABA is paid at the rates in your Evernorth behavioral-health agreement; the autism resource guide sends "questions about credentialing, contracts, or rates" to your Provider Relations representative, and billing questions to Provider Services at 800.926.2273. Bill only 97151-97158, 0362T and 0373T, in 15-minute units.[2]
Network: Evernorth says it "is committed to expanding our network of autism providers." Individual analysts apply on the Evernorth Behavioral Provider Information Form and autism clinics or large groups on the Evernorth Screening Application for Autism Clinics; processing can take up to 90 days, and after a clinic contract each certified or licensed provider must be credentialed (another 60 to 90 days) before rendering in-network services. Evernorth requires the clinician to hold a national certification or state license (BCBA, BCBA-D, BCaBA, licensed behavior analyst or other behavioral-health licensure). It "does not credential nonlicensed/noncertified staff" such as technicians, whose services "must be billed under the supervising provider."[2]
Colorado does not license behavior analysts yet. HB26-1425 creates a Colorado Behavior Analyst Licensing Board in DORA, and “on and after July 1, 2028, an individual is prohibited from engaging in or offering the practice of applied behavior analysis unless the individual is licensed by the board”; unlicensed practice after that date is a class 2 misdemeanor. Until then there is no Colorado behavior analyst license to hold, and BACB certification is the operative credential.[4][5]
Evernorth, which manages Cigna’s behavioral benefits, frames it as a compliance duty rather than a member-state rule. Its Administrative Guidelines (September 2026): “Providers must meet all state requirements to provide virtual behavioral services, including any licenses and certifications,” must “comply with their state laws about the use of audio or video-based technology,” and providers who meet the telehealth specialty requirements “may deliver services virtually with no additional credentialing” after attesting on the Attested Specialty Form, when Evernorth adds “telehealth” to the provider profile. The guidelines do not say in terms which state’s license a remote BCBA needs, so read “all state requirements” against Colorado’s licensure law above and confirm with Evernorth before a remote start.[4][5]
Cigna’s behavioral benefits, ABA included, are administered by Evernorth Behavioral Health, whose administrative guidelines (revised September 2026) “will only consider claims submitted within 90 days of the date of service or as otherwise defined in your Provider Agreement” — a longer state-law limit overrides it, the clock resets to the date Cigna asks for more information, and Medicaid-secondary claims get three years. Appeals must be started in writing within 180 calendar days of the payment or denial decision.[5]
Corrected and secondary claims: Evernorth applies its 90-day limit to a COB claim “based on the primary payer’s processing date as stated on an explanation of benefits [EOB] or explanation of payment [EOP].” A claim filed on time and returned for more information gets a new 90 days from the date of that request. Mark a replacement or void on the CMS-1500 with code 7 or 8 in field 22, and do not stamp “Corrected Claim” on the form. The guidelines publish no payment-cycle day or submission cutoff.[5]
Evernorth’s guidelines set no EVV requirement and no taxonomy requirement for ABA claims. The complete-claim definition lists names, NPIs and license type, not taxonomy codes.[5]
Colorado’s prompt-pay statute, C.R.S. § 10-16-106.5, requires clean claims to be “paid, denied, or settled within thirty calendar days after receipt by the carrier if submitted electronically and within forty-five calendar days after receipt by the carrier if submitted by any other means.” A claim that needs more information must get a written explanation of what is missing within thirty calendar days, and absent fraud every claim must be paid, denied or settled within ninety calendar days. A carrier that misses the clean-claim deadline owes 10% annual interest on the amount ultimately allowed, and one that misses the ninety-day deadline owes a penalty of 20% of that amount. These statutes bind fully insured plans issued in the state; a self-funded employer plan (ERISA) is not subject to them and follows its plan documents and your contract.[6]
No. Evernorth’s administrative guidelines (September 2026) define a complete CMS-1500 claim as the patient’s ID number, name, address and date of birth; the subscriber’s name and address; release of information and assignment of benefits; diagnosis codes and pointer; date and place of service; CPT/HCPCS code and modifier; billed charge, units, TIN and total charge; the “Rendering provider’s name, NPI, and license type”; and the “Billing provider’s name, address, and NPI.” No referring or ordering provider is on that list. If you do report one on an 837, “Any additional provider identification on the claim, such as the “Rendering Provider” or “Referring Provider,” must include the name and NPI when submitted.”[5][2]
The ABA-specific paper-claim rules sit in the autism resource guide: use Form CMS-1500, “Print your name in box 31,” and “List only a BCBA or other licensed provider in box 33.” Evernorth does not credential non-licensed or non-certified staff, so their services are billed under the supervising provider.[5][2]
The questions that decide whether a family can start with Cigna / Evernorth in Colorado, and what they have to bring. Each maps onto something intake should ask on the first call.
EN0499 puts no expiry on the ASD diagnosis — it requires only that the submission carry "the name, credentials, and type of licensure of the individual who made the diagnosis" and "the date on which the diagnosis was most recently made." The 60-day clocks run on the assessment instead: administration of the standardized assessment instrument must be completed within 60 days prior to the start of treatment, and quantitative baseline data must be collected within 60 days prior to the start of treatment.[1]
"A confirmed diagnosis of autism spectrum disorder (ASD); (ICD-10-CM Diagnosis Codes F84.0 – F84.9, with the exception of F84.2, Rett syndrome) based on the criteria in the DSM-5-TR by a healthcare professional who is licensed to practice independently and whose licensure board considers diagnostics to be within their scope of practice." The ABA assessment itself is then performed by a BCBA, LBA, or an independently licensed mental health clinician with documented ABA training.[1]
EN0499 names no instrument but sets six tests the instrument must pass: it must be reliable, valid and standardized, measure functioning in the DSM-5-TR ASD domains (social communication/interaction; restricted, repetitive behavior), be completed in its entirety and as designed, have established reliability and validity for the population tested, be administered by someone trained to administer and interpret it, and be the most current version — "must be the Vineland-3 vs. Vineland-II." Date of administration, respondent and form type must be recorded.[1]
No referral or physician order is required. Prior authorization is not required on assessment codes 97151, 97152 or 0362T with an autism diagnosis "as long as the provider is independently licensed or a Board Certified Behavior Analyst (BCBA) and the patient's policy covers ABA services"; the authorization gate arrives at the treatment step, with the completed assessment and treatment plan.[2][1]
"All ABA CPT codes are covered telehealth services," subject to EN0499. The policy adds a documentation duty rather than a code restriction: where services are delivered "via telehealth modalities," the record must show the service still meets the definition of direct treatment/direct engagement "regardless of treatment location or modality" and is conducted per the treatment-plan goals. The assessment and supervision codes are included: the resource guide's "All ABA CPT codes" covers 97151 (initial assessment and reassessment) and 97155 (protocol modification / direct supervision) as much as 97153, and neither document caps the share of supervision that may be remote. Neither names a required telehealth POS code or modifier, so confirm claim coding with Evernorth Provider Services (800.926.2273).[2][1]
Colorado's mandate carries no age limit: C.R.S. § 10-16-104(1.4) applies to all health benefit plans issued or renewed in the state except short-term limited-duration policies and individual grandfathered plans, with no age terms and no dollar caps (the cap language was struck effective 1/1/2017). The carrier's national ABA policy adds no age bound of its own, so age comes from the benefit document — and self-funded ERISA plans sit outside the mandate entirely.[3][1]
Ask the plan: Benefits verification on the specific plan — funding type first, then the ABA benefit terms.
Depends on how the plan is funded. Fully insured Colorado plans follow C.R.S. § 10-16-112.5: within five business days after receipt the carrier must say the request is "approved, denied, or incomplete" (naming the missing information), then decide within five business days after receiving it; urgent requests within "two business days but not longer than seventy-two hours." If the carrier misses those deadlines the request "is deemed granted" — but the provider must send any requested information within two business days of the notice or loses that protection. An approval "is valid for at least one hundred eighty days after the date of approval and continues for the duration of the authorized course of treatment." Self-funded (ERISA) plans follow the federal claims rule instead: pre-service decisions within 15 days of receipt (one 15-day extension), urgent within 72 hours. Cigna's ABA policy (EN0499) sets no decision clock; continued-treatment requests need current data "collected within no more than 60 days prior to the start date of the continued treatment request."[7][8][1]
Ask the plan: Benefits verification: fully insured Colorado policy (5-business-day clock, 180-day approvals, deemed-granted rule) vs. self-funded ERISA plan (15 days / 72 hours).
For a child on two parents' plans, Colorado's group coordination-of-benefits regulation (fully insured plans): parents married or living together — "The plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (same birthday → the plan that covered the parent longer); otherwise a court decree controls, and without one the order is custodial parent, custodial parent's spouse, non-custodial parent, then the non-custodial parent's spouse. Self-funded plans set their own order in the plan document. Cigna's ABA documents publish no coordination-of-benefits rule of their own. If the child also has TRICARE, this plan pays first — TRICARE is the secondary payer to other health insurance under its double-coverage rule (Medicaid is the only coverage it pays ahead of). CHAMPVA likewise pays last: "In double coverage situations, CHAMPVA would be the last payer." If the child also has Medicaid, this plan is primary and Medicaid pays last.[9][10][11][12]
Ask the plan: Benefits verification with both plans: funding type, which is primary for the child, and whether the secondary plan requires its own authorization.
Coverage decides whether Cigna / Evernorth in Colorado 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.
One to two hours per ten hours of direct treatment. "Direct case supervision (occurs concurrently with the delivery of direct treatment to the individual and consists of BCBA face-to-face with the individual and either the Registered Behavior Technician or the Board Certified Assistant Behavior Analyst) and indirect case supervision is consistent with the general accepted standard of care of one to two hours per ten hours of direct treatment." When direct treatment is 10 hours per week or less, a minimum of one to two hours per week of direct case supervision is provided, and the supervisor's name and credentials must be documented. EN0499 (effective 5/15/2026) publishes no cap on the number of technicians per supervising BCBA.[1]
Yes — and Evernorth writes it as an explicit carve-out from its general rule: "Only one provider can bill for a unit of time, with the exception of CPT codes 97153, 97154, and 97155 (direct supervision when the BCBA/qualified health care provider directs the technician and both are face-to-face with the patient at the same time)." Both must be with the patient; analyst time away from the patient is not inside the exception. Speech, OT and other therapies are a separate rule: EN0499 says ABA "is not covered or reimbursable when delivered to the same individual, at the same time as any other treatment modality (e.g., ABA and speech therapy, or ABA and occupational therapy)." Schedule ABA and other therapies in separate time blocks. ABA built into a speech or OT session is not billable.[2][1]
The person who delivered the service signs the note. EN0499's Documentation Expectations require "A separate written record ... for each individual receiving ABA intervention corresponding with each service noted through identified CPT® Code." Each record must include at least the start and end date and time, the location, the focus of service, a detailed description of the intervention, the individuals present, the specific service delivered (direct service, supervision, stakeholder training and so on), and the "Name, credential (if applicable), and signature of ABA provider who rendered the service." EN0499 sets no deadline for signing.[1]
Under the supervising provider, because the technician cannot be credentialed: "Evernorth does not credential nonlicensed/noncertified staff. Services for these staff members must be billed under the supervising provider." Practically, the BCBA's credential is what the claim rides on for technician-delivered 97153.[2]
No POS list is published. EN0499 requires the treatment plan to identify the "settings and environments where treatment will occur (e.g., home, clinic, school, community setting)" and to collect data corresponding to each location of service; for settings with competing behavioral expectations — "academic setting, vocational placement, services delivered via telehealth modalities" — the record must show the service still meets the direct-treatment definition. Which of those settings is payable is a benefit-document question.[1][2]
Ask the plan: Evernorth Provider Services at 800.926.2273 for school and community settings, plus the member's benefit document.
Not published. The resource guide sets the code set (97151–97158, 0362T and 0373T only, all in 15-minute increments) but no per-day unit ceiling and no statement of which MUE table Evernorth applies.[2]
Ask the plan: Evernorth Provider Services at 800.926.2273.
Not by name. EN0499 requires dated quantitative baseline, interim and current data for every target, with current data collected within 60 days before the continued-treatment request, plus a standardized assessment no more than a year old. Graphs are a common way to present that data, but the policy asks for the data itself.
Yes — under the carrier's national policy for ASD, layered on Colorado's mandate (C.R.S. § 10-16-104(1.4)) for fully-insured plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.
Per the national EN0499 policy, no — assessment codes 97151, 97152, and 0362T need no PA, and we found no Colorado carve-out from that policy. Confirm on the benefits call, since the current policy PDF could not be fully parsed for the state-exceptions list.
It applies to all Colorado-issued or renewed health benefit plans (short-term limited-duration and individual grandfathered plans excepted), with no age limits and no dollar caps — the historical $34K/$12K annual ABA caps were removed from the statute. Self-funded ERISA plans are exempt by preemption.
Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against the Health First Colorado fee schedule, and treat rate-setting as part of contracting.
Yes. Evernorth's autism resource guide says all ABA CPT codes are covered telehealth services, and EN0499 allows in-person, telehealth or hybrid delivery. No POS code or modifier is published; confirm claim coding with Provider Services (800.926.2273).
Evernorth says it is committed to expanding its autism network. Apply with the Behavioral Provider Information Form (individuals) or the Screening Application for Autism Clinics (groups); allow up to 90 days, plus 60 to 90 days of individual credentialing for a clinic.
EN0499 treats school as a possible treatment setting but excludes educational services. It lists school among the settings where treatment goals may be set ("home, clinic, school, community setting"), requires the record to show that ABA in an academic setting still meets the direct-treatment definition, and excludes services "primarily educational or vocational in nature, or related to academic or work performance." Whether school hours are payable on a given plan is a benefit-document question.
Colorado has no behavior analyst license yet; HB26-1425 makes one mandatory from July 1, 2028. Evernorth (Cigna) requires providers to “meet all state requirements to provide virtual behavioral services, including any licenses”; confirm with Evernorth before a remote start.
Evernorth Behavioral Health, which administers Cigna’s ABA benefit, considers claims submitted within 90 days of the date of service unless your provider agreement or a longer state-law limit says otherwise.
Colorado law (C.R.S. § 10-16-106.5) gives a fully insured plan 30 calendar days to pay, deny or settle a clean electronic claim (45 for paper), 90 days for any claim absent fraud, with 10% interest and a 20% penalty after 90 days. Self-funded employer plans are not bound by the statute.
No. Evernorth’s complete-claim definition for the CMS-1500 lists the rendering and billing providers but no referring provider. If you report a referring provider on an electronic claim, include both the name and the NPI.
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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