---
title: "Cigna / Evernorth ABA coverage in the District of Columbia: the intake guide."
url: "https://carelu.com/payers/cigna-district-of-columbia"
markdown_url: "https://carelu.com/payers/cigna-district-of-columbia.md"
state: DC (District of Columbia)
payer: Cigna / Evernorth in the District of Columbia
kind: Commercial insurance
description: "How Cigna / Evernorth covers ABA for District of Columbia families: EN0499, no PA on assessments, D.C. Code § 31-3272 (habilitative coverage under 21), federal-employee and self-funded exclusions, DC licensure, prompt pay and what intake should verify."
last_reviewed: October 2026
---

# Cigna / Evernorth ABA coverage in the District of Columbia: the intake guide.

_Payer Guide · Cigna · District of Columbia · Last updated October 2026 · 16 primary sources_

> EN0499 + autism resource guide + D.C. Code § 31-3272 habilitative mandate; no PA on assessment codes.

For an intake team in Washington, a Cigna card means Evernorth’s national ABA policy EN0499 with the autism resource guide, the District’s habilitative-services mandate in D.C. Code § 31-3272, and the plan’s funding type. Many Cigna members are on self-funded employer plans, which sit outside the DC statute, so check funding first.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Not required for 97151, 97152 and 0362T with an autism diagnosis when the provider is independently licensed or a BCBA and the policy covers ABA (Cigna autism resource guide) [2]
- **Prior auth for treatment**: Required: after the assessment, submit the treatment plan on the Applied Behavior Analysis Prior Authorization Form; requests are encouraged up to 30 days before the start date [2][1]
- **Autism diagnosis required?**: Yes: ASD under DSM-5-TR, made by an independently licensed professional whose board puts diagnosis in scope (EN0499) [1]

## At a glance

- **Covers ABA?:** Yes, for ASD, per national policy EN0499 (eff. 5/15/2026)
- **State mandate:** D.C. Code §§ 31-3271–31-3272 (habilitative services incl. autism; D.C. Law 16-198) + DC EHB benchmark naming ABA
- **Mandate age:** Under 21
- **Mandate caps:** None allowed beyond those for other conditions (parity on deductibles, dollar, visit and durational limits)
- **Exempt from mandate:** Federal employee health plans, Medicare, and self-funded ERISA employer plans
- **Licensure:** DC Board of Psychology licenses behavior analysts (D.C. Law 25-191, 2024); confirm licenses are being issued
- **Fee schedule:** Not public — Exhibit A of your Evernorth Provider Agreement; Provider Services 800.926.2273

## The national policy, applied in the District

Cigna, through Evernorth Behavioral Health, covers ABA under EN0499 (effective May 15, 2026). Per the autism resource guide, prior authorization is not required for assessment codes 97151, 97152 and 0362T with an autism diagnosis "as long as the provider is independently licensed or a Board Certified Behavior Analyst" and the policy covers ABA; treatment needs the Applied Behavior Analysis Prior Authorization Form with the completed assessment and plan. Cigna encourages requests up to 30 days ahead; a late request can trigger retrospective review taking up to 30 days. Neither document mentions the District, so the national criteria apply. DHCF lists no Cigna Medicaid plan in the District. [1][2][16]

## The District mandate: what it guarantees

The District’s autism coverage rule is a habilitative-services statute, not a stand-alone ABA law. D.C. Code § 31-3272 (D.C. Law 16-198, 2007) requires a health insurer to "Provide coverage of habilitative services for children under the age of 21 years and may do so through a managed care system." Section 31-3271 defines habilitative services as "services, including occupational therapy, physical therapy, and speech therapy, for the treatment of a child with a congenital or genetic birth defect to enhance the child’s ability to function," and says a congenital or genetic birth defect "includes: (A) Autism or an autism spectrum disorder." Denying a habilitative request because the condition is not a birth defect is, by statute, an adverse decision. The coverage "shall not be more restrictive than coverage provided for any other illness, condition, or disorder" for deductibles, durational or dollar limits, visit or treatment limits, and cost sharing. An insurer does not have to pay for habilitative services "actually delivered through early intervention or school services." The statute itself never names applied behavior analysis. ABA is named in the District’s essential-health-benefit standard: the DC Health Benefit Exchange Authority’s March 22, 2013 resolution defines the habilitative category as services that help a person "keep, learn or improve skills and functioning for daily living, including, but not limited, to applied behavioral analysis (ABA) for the treatment of autism spectrum disorder." CareFirst’s own ASD policy (3.01.015, updated for March 1, 2026) points DC members to § 31-3272 for mandated coverage. Two exclusions matter in Washington especially: the statute’s definition of a health benefit plan excludes "federal employee health plans, pursuant to contracts with the United States government" and Medicare coverage, and self-funded employer plans answer to ERISA rather than District insurance law. [4][5][6][17][15]

## Licensure, out-of-state BCBAs and rates

The District now licenses behavior analysts, but recently. D.C. Law 25-191 (effective July 19, 2024) gave the Board of Psychology the job of regulating "the practice of behavior analysis" and added a licensed behavior analyst seat to the Board (D.C. Code § 3-1202.11). Under § 3-1207.71 the Board licenses a person who completes a criminal background check, holds "a current certification issued by the Behavior Analyst Certification Board," and has a master’s or higher from a BACB-accredited program, with the education requirement waived for anyone certified by the BACB on or before July 19, 2024. The Mayor was to issue licensure rules (ethics code, education and clinical training, exam, continuing education) within one year. The BACB’s licensure table lists the District (2024, DC Board of Psychology). As of October 2026, though, DC Health’s Board of Psychology page links regulations for psychologists and psychology associates only and shows no behavior-analyst rule or application, so confirm with DC Health whether licenses are being issued before you tell a BCBA they need one. Carriers have not caught up either: CareFirst’s credentialing list still names "Licensed Board-Certified Behavior Analyst (Maryland and Virginia only)" and requires a practitioner to be "licensed in the state where the member receives the service." For telehealth or a BCBA based outside the District, plan on meeting the licensure rule of the place where the child is: DHCF’s telemedicine guidance applies that rule to Medicaid, and ask each commercial plan how it applies it. On rates: commercial ABA rates are negotiated and unpublished. DC Medicaid publishes its ASD fees on the dc-medicaid.com portal, which we could not open. [12][13][14][18][19][20]

## Claims: Evernorth’s 90-day rule meets DC’s 180-day floor

Evernorth’s Administrative Guidelines (September 2026) set a 90-day filing limit but list an exception where "Applicable state law provides for a longer timely filing limit in which case that time limit will apply." D.C. Code § 31-3132 requires a District-regulated insurer to allow "a minimum of 180 days from the date a covered service is rendered" and to pay clean claims within 30 days, with interest of 1.5% a month from day 31, 2% from day 61 and 2.5% after day 120. A self-funded plan is not bound by the District statute, so file within 90 days when in doubt. Rates are in "Exhibit A in your Provider Agreement"; virtual services carry modifier 95, which Evernorth says "will not change the reimbursement." [3][7]

Evernorth’s guidelines also set the secondary and resubmission clocks: 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 District of Columbia Regulatory Addendum adds that after a retroactive denial for coordination of benefits the provider has 180 days from the denial to bill the responsible insurer. No check-run or weekly cut-off schedule is published. [3][7]

## Does Cigna (DC) require a referring provider on ABA claims?

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. [3]

## What a reauthorization must show

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]

## Intake gates

The questions that decide whether a family can start with Cigna / Evernorth in the District of Columbia, and what they have to bring.

- **Diagnosis recency**: No expiry on the diagnosis, but the request needs the date it was most recently made. The standardized instrument and baseline data must be within 60 days before treatment starts. [1]
- **Who may diagnose**: A healthcare professional "licensed to practice independently and whose licensure board considers diagnostics to be within their scope of practice," applying DSM-5-TR. [1]
- **Diagnostic tools required**: No single instrument is mandated; the assessment must use "a reliable, valid, and standardized assessment instrument," with dates and scores reported. [1]
- **Referral required?**: EN0499 requires no referral. Assessments need no PA with an autism diagnosis when the provider is independently licensed or a BCBA; treatment needs the PA form. For a fully insured District plan, D.C. Code § 31-3272 sets no referral or treatment-plan requirement of its own; it lets the insurer deliver habilitative coverage "through a managed care system," which § 31-3271 defines as review and preauthorization of the treatment plan. Federal employee plans and self-funded ERISA plans sit outside the statute. [2][5][4]
- **Telehealth**: "All ABA CPT codes are covered telehealth services" (autism resource guide); bill with modifier 95, which "will not change the reimbursement" (Evernorth Administrative Guidelines). For a District-regulated plan, D.C. Code § 31-3862 says an insurer "may not deny coverage for a healthcare service on the basis that the service is provided through telehealth if the same service would be covered when delivered in person," must reimburse it, and may review telehealth appropriateness only "in the same manner" as in-person care; cost sharing cannot exceed the in-person amount. The statute names no ABA codes, POS or modifiers, and self-funded and federal employee plans are outside it. [2][3][9]
- **Age limit** _(plan-dependent)_: EN0499 sets no age cap; it says access to focused intervention "should not be restricted by age." For fully insured District plans, D.C. Code § 31-3272 requires habilitative coverage (autism included) for children under 21, with no dollar or visit cap allowed beyond what applies to other conditions. Federal employee plans and self-funded ERISA plans are outside the statute, so funding type decides whether that binds. [1][5][4]
  - Ask the plan: Live benefits verification: establish fully insured DC, federal employee or self-funded first.
- **Prior-auth decision time** _(plan-dependent)_: Depends on how the plan is funded. Plans regulated by the District fall under the Prior Authorization Reform Amendment Act of 2023 (D.C. Code ch. 38F). Once it has all required information, a utilization review entity must decide and notify "within … 3 business days of receiving the request via electronic portal or 5 business days of receiving the request via mail, telephone, or facsimile" (24 hours for urgent services), and a request not answered in time "shall be deemed approved." Before an adverse determination it must tell the provider that medical necessity is being questioned and offer a chance to add information. An approval is valid "for at least one year," an approval for a chronic condition stays valid "for as long as medically reasonable and necessary," and it may not be revoked if care is provided within 45 business days. The family gets at least 15 calendar days to appeal. Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1 instead: pre-service decisions "not later than 15 days after receipt of the claim," with one 15-day extension. Cigna/Evernorth publishes no District-specific ABA turnaround or reauthorization lead time. [10][21][22][15]
  - Ask the plan: At benefits verification ask whether the plan is regulated by the District or self-funded (ERISA), and what reauthorization lead time Evernorth expects.
- **Other insurance (who pays first)** _(plan-dependent)_: For a child on two plans, the order of benefits comes from the plans’ coordination-of-benefits provisions; we did not read a District COB regulation, so ask Cigna/Evernorth which plan is primary. When a child changes plans mid-treatment, D.C. Code § 31-3875.07 makes a District-regulated plan "honor an approval granted by a previous utilization review entity for at least the initial 60 days" of new coverage. If the child also has DC Medicaid, Cigna/Evernorth pays first: Medicaid pays after other coverage (42 CFR 433.139), and DC’s Medicaid plans require the primary’s EOB with the claim. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270). If a payer later retracts payment because another carrier was primary, § 31-3133 limits that clawback to 18 months and gives you 180 days to bill the right carrier. [11][8][23][24][25]
  - Ask the plan: Ask Cigna/Evernorth at benefits verification for the coordination-of-benefits order and record every other coverage the child has.

## Delivery and billing rules

Coverage decides whether Cigna / Evernorth in the District of Columbia pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: Direct and indirect case supervision at "one to two hours per ten hours of direct treatment"; when direct treatment is 10 hours a week or less, at least one to two hours a week of direct case supervision (EN0499). [1]
- **Concurrent billing (97153 + 97155)**: "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)." Overlap with other therapies is excluded separately by EN0499: "Provision of ABA treatment 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)." [2][1]
- **Daily limits / MUEs**: No per-day cap is published. All ABA codes are 15-minute units and ABA must be billed only with 97151–97158, 0362T and 0373T. [2]
- **Session-note signature**: EN0499 requires each service to be documented, including the name, credential and signature of the rendering provider. [1]
- **Place of service**: EN0499 asks for goals and data for each setting where treatment occurs; primarily educational services are not covered. D.C. Code § 31-3272 does not require payment for habilitative services delivered through early intervention or school. [1][5]
- **Bill as provider**: "Evernorth does not credential nonlicensed/noncertified staff. Services for these staff members must be billed under the supervising provider." On paper claims list "only a BCBA or other licensed provider in box 33"; electronic payer ID 62308. [2]

## What intake should collect for Cigna / Evernorth in the District of Columbia

- **Plan funding type:** Fully insured DC plan (§ 31-3272 applies), federal employee plan, or self-funded ERISA.
- **Member ID + card photo:** Enough to run a live benefits verification.
- **Diagnosis report:** Diagnosing clinician’s name, credentials and licensure type, and the date of the most recent diagnosis.
- **Standardized assessment timing:** Instrument administered within 60 days before treatment starts.
- **School and EI services:** DC law does not make insurers pay for habilitative services delivered through early intervention or school.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Common questions

### Does Cigna require graphs for ABA reassessments?

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.

### What are Cigna (Evernorth)’s claim filing deadlines for District of Columbia ABA claims?

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.

### Does Cigna (DC) require a referring provider on ABA claims?

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."

### Does Cigna cover ABA therapy in Washington, DC?

Yes, under EN0499 for ASD. Fully insured DC plans must also cover habilitative services for autism for children under 21 under D.C. Code § 31-3272. Self-funded and federal employee plans follow their own terms.

### Does the Cigna ABA assessment need prior authorization in DC?

No, for 97151, 97152 and 0362T with an autism diagnosis when the provider is independently licensed or a BCBA. PA starts at treatment.

### What is Cigna’s timely filing limit for DC claims?

Evernorth’s default is 90 days, but it defers to a longer state limit, and D.C. Code § 31-3132 requires at least 180 days for District-regulated plans. Self-funded plans may hold you to 90.

### What does Cigna pay for ABA in DC?

Cigna publishes no ABA rates. Your fee schedule is Exhibit A of your Evernorth Provider Agreement; call Provider Services at 800.926.2273.

## Primary sources

1. [Evernorth EN0499 — Intensive Behavioral Interventions (eff. 5/15/2026)](https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/en_mm_0499_coveragepositioncriteria_intensive_behavioral_interventions.pdf)
2. [Cigna / Evernorth autism resource guide (March 2025, PCOMM-2025-225)](https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/autism-resource-guide.pdf)
3. [Evernorth Behavioral Health Administrative Guidelines (PCOMM-2026-191, September 2026)](https://static.evernorth.com/assets/evernorth/provider/pdf/resourceLibrary/behavioral/ebh-provider-admin-guide.pdf)
4. [D.C. Code § 31-3271 — Definitions (habilitative services; "congenital or genetic birth defect" includes autism)](https://code.dccouncil.gov/us/dc/council/code/sections/31-3271)
5. [D.C. Code § 31-3272 — Coverage of habilitative services for children under 21 (D.C. Law 16-198)](https://code.dccouncil.gov/us/dc/council/code/sections/31-3272)
6. [DC Health Benefit Exchange Authority — Executive Board Resolution on EHB standards (Mar. 22, 2013): habilitative category includes ABA for ASD](https://hbx.dc.gov/sites/default/files/dc/sites/Health%20Benefit%20Exchange%20Authority/publication/attachments/Resolution-EHBandPlanOfferingStandardsmk_0.pdf)
7. [D.C. Code § 31-3132 — Prompt payment (30-day clean claim; 180-day minimum filing window)](https://code.dccouncil.gov/us/dc/council/code/sections/31-3132)
8. [D.C. Code § 31-3133 — Retroactive denial of reimbursement](https://code.dccouncil.gov/us/dc/council/code/sections/31-3133)
9. [D.C. Code § 31-3862 — Telehealth: private reimbursement](https://code.dccouncil.gov/us/dc/council/code/sections/31-3862)
10. [D.C. Code § 31-3875.03 — Prior authorization decision timeframes (Prior Authorization Reform Amendment Act of 2023)](https://code.dccouncil.gov/us/dc/council/code/sections/31-3875.03)
11. [D.C. Code § 31-3875.07 — Continuity of care (honor a prior plan’s approval for 60 days)](https://code.dccouncil.gov/us/dc/council/code/sections/31-3875.07)
12. [D.C. Code § 3-1202.11 — Board of Psychology (regulates the practice of behavior analysis; D.C. Law 25-191)](https://code.dccouncil.gov/us/dc/council/code/sections/3-1202.11)
13. [D.C. Code § 3-1207.71 — Behavior analyst licensure: eligibility and education](https://code.dccouncil.gov/us/dc/council/code/sections/3-1207.71)
14. [BACB — U.S. Licensure of Behavior Analysts (District of Columbia: 2024, DC Board of Psychology)](https://www.bacb.com/u-s-licensure-of-behavior-analysts/)
15. [29 CFR 2560.503-1 — ERISA claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
16. [DHCF — Medicaid Managed Care Plans (MCPs): AmeriHealth Caritas DC, MedStar Family Choice DC, HSCSN (CASSIP)](https://dhcf.dc.gov/page/medicaid-managed-care-plans-mcps)
17. [CareFirst — Medical Policy Update, January 2026 (3.01.015 Autism Spectrum Disorder, eff. 3/1/2026; DC § 31-3272 pointer)](https://provider.carefirst.com/carefirst-resources/provider/pdf/medical-policy-update-january-2026.pdf)
18. [DC Health — Psychology Licensing (Board of Psychology page)](https://dchealth.dc.gov/service/psychology-licensing)
19. [CareFirst Provider Manual, Chapter 3: Provider Network Requirements / Administrative Functions (credentialing; payment policy index)](https://provider.carefirst.com/carefirst-resources/provider/pdf/provider-manual-chapter-3-administrative-functions.pdf)
20. [DHCF — Telemedicine Provider Guidance (January 2023, Transmittal 23-11)](https://dhcf.dc.gov/sites/default/files/dc/sites/dhcf/page_content/attachments/Telemedicine%20Provider%20Guidance_January%202023%20-%20Transmittal%2023-11.pdf)
21. [D.C. Code § 31-3875.04 — Length of prior authorization](https://code.dccouncil.gov/us/dc/council/code/sections/31-3875.04)
22. [D.C. Code § 31-3875.05 — Prior authorization appeals](https://code.dccouncil.gov/us/dc/council/code/sections/31-3875.05)
23. [42 CFR 433.139 — Medicaid third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
24. [10 U.S.C. 1079(i)(1) — TRICARE pays after other coverage except Medicaid](https://www.govinfo.gov/content/pkg/USCODE-2023-title10/html/USCODE-2023-title10-subtitleA-partII-chap55-sec1079.htm)
25. [38 CFR 17.270 — CHAMPVA is the last payer](https://www.ecfr.gov/current/title-38/section-17.270)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.