For an intake team in Georgia, a Cigna card means three layers at once: the carrier's national clinical policy, Georgia's autism insurance mandate (O.C.G.A. § 33-24-59.10 (Ava’s Law)), and the plan's funding type deciding which of the two actually binds. This guide stacks them in order.
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 Georgia 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 Georgia.[1][2]
Ava’s Law requires state-regulated accident and sickness plans (including the state employee health plan) to cover ASD treatment for individuals 20 years of age or under, with ABA nominally cappable at $35,000 per year — and no limits allowed on the number of visits. The statute exempts employers with 10 or fewer employees, and insurers can seek a one-year opt-out if an actuary certifies the mandate raises average premiums more than 1%. Self-funded ERISA plans are exempt by federal preemption. Federal mental-health parity (MHPAEA) generally makes the dollar and age caps hard to enforce against covered large-group plans — a payer applying the $35K cap to a large-group member is a red flag to escalate, not accept.[3][4]
We checked: Cigna / Evernorth publishes no Georgia-specific ABA policy, form, or supplement — the national policy plus the state mandate is the whole picture. That’s worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where Georgia-specific answers come from, not a carrier document.[1]
Georgia now licenses behavior analysts: HB 412 (2022) created the Georgia Behavior Analyst Licensing Board under the Secretary of State, with licensure built on BCBA certification. Confirm your supervising analysts hold the Georgia license when credentialing with any commercial plan. On rates: Cigna does not publish commercial ABA fee schedules for Georgia (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement, so treat rate expectations as a contracting conversation, not a lookup.[5]
Cigna’s behavioral health network is run by Evernorth. Its autism resource guide (March 2025): “Individual providers and autism clinics must complete an application if they would like to join our network” — individuals use the Evernorth Behavioral Provider Information Form, and autism clinics and large group practices use the Evernorth Screening Application for Autism Clinics. Processing can take up to 90 days (questions after that go to BehavioralContracting@Evernorth.com), and once a clinic contract is signed, each certified or licensed provider must be credentialed, which “can take an additional 60 to 90 days.” Evernorth “does not credential nonlicensed/noncertified staff”; their services are billed under the supervising provider. The guide does not say whether the network is accepting new ABA providers in a given area, so ask Provider Services (800-926-2273).[2]
Evernorth publishes no ABA fee schedule. The guide sends questions about “credentialing, contracts, or rates” to your provider relations representative, so your rates are in your Evernorth contract.[2]
Georgia licenses the practice: “The unlicensed practice of applied behavior analysis is prohibited in this state,” at a fine of $1,000 per violation (O.C.G.A. 43-7A-6, added by HB 412, effective July 1, 2023). A BCBA “residing and practicing in another state who temporarily provides applied behavior analysis services in this state to a resident of this state” may apply for a temporary license covering “not more than a total of 30 days within a calendar year” (43-7A-8), and the board licenses by reciprocity someone actively licensed in a state with comparable requirements that reciprocates with Georgia (43-7A-9). As enacted, Chapter 7A contains no telehealth exception.[6][7]
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 Georgia’s licensure law above and confirm with Evernorth before a remote start.[6][7]
Only if the doctor actually made and documented the diagnosis. Cigna’s policy EN0499 requires “a confirmed diagnosis of autism spectrum disorder (ASD)… 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,” together with “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.” A physician’s note that records a confirmed DSM-5-TR ASD diagnosis with those details can therefore serve; a referral “to evaluate for autism,” or one that calls the diagnosis “provisional,” “potential,” “at risk of” or “rule out,” does not, and an IEP or school eligibility alone “may not meet criteria as a formal diagnosis.” EN0499 sets no maximum age on the diagnosis.[1][8]
Payment clock: Georgia’s prompt-pay statute (O.C.G.A. 33-24-59.14) gives an insurer or administrator 15 working days for an electronic claim and 30 calendar days for a paper claim to pay it, or to send written notice of why it is denied and what is needed, with interest of 12 percent a year on late payments; any undisputed part of a claim must be paid on that clock. A self-funded employer plan may sit outside Georgia insurance law, so confirm the funding type first.[1][8]
Filing deadline: Evernorth, which runs Cigna's behavioral network, “will only consider claims submitted within 90 days of the date of service or as otherwise defined in your Provider Agreement,” unless state law allows longer. For a COB claim the 90 days run “based on the primary payer's processing date as stated on an explanation of benefits [EOB] or explanation of payment [EOP],” and a timely claim returned for more information gets a new 90 days from the date of the request. A correction goes in as a replacement or void claim (CMS-1500 field 22 with frequency code 7 or 8); do not stamp it “Corrected Claim.” Codes: “All ABA services must be billed with CPT codes 97151–97158, 0362T, and 0373T ONLY,” so H-codes such as H0031 or H0032 are not used for ABA. Georgia addendum (insured plans): when the claim was filed within 90 days of the last date of service, a written request to adjust a paid claim must be made within the earlier of 12 months after all payments and appeals are settled or 24 months after the date of service (six months instead of 12 when the claim was filed later than 90 days). Appeals: “all appeals are to be initiated in writing within 180 calendar days of the date of the initial payment or denial decision” (or of the last payment adjustment); fee-schedule and reimbursement disputes can often be settled through the reconsideration feature on Provider.Evernorth.com, and a second-level appeal is due within 60 days of the first-level decision letter. The guidelines publish no check-run day or weekly submission cutoff; the payment clock for insured plans is Georgia's prompt-pay statute: 15 working days for an electronic claim, 30 calendar days for paper, 12 percent a year interest on late payment.[7][2][8]
Cigna (Evernorth EN0499) asks for dated quantitative data rather than graphs. Continued treatment needs an updated treatment plan, “quantitative baseline, interim and current data … with dates reported from when the data were collected” for every behavior and skill targeted across settings, 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,” evidence of “ongoing and sustained progress,” and improvement shown on “a reliable, valid, and standardized assessment instrument completed no more than one year prior to the start date of the continued treatment request.” The policy does not require the data to be graphed.[1]
The questions that decide whether a family can start with Cigna / Evernorth in Georgia, and what they have to bring. Each maps onto something intake should ask on the first call.
EN0499 sets no maximum age on the diagnosis, but it requires the date to be on the record and puts the currency burden on the instruments. Required with the diagnosis: “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.” For the assessment instrument, “the instrument used represents the most current version, and does not represent obsolete editions of the assessment (e.g., must be the Vineland-3 vs. Vineland-II)” and it must assess “the individual’s specific and current abilities and skills,” with the date of administration and the respondent named. A diagnosis termed “provisional,” “proposed,” “potential,” “at risk of” or “rule out” is not a confirmed diagnosis.[1]
Scope-of-practice based, and strict about what does not count. The individual must have “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.” Two disqualifiers intake should screen for: “educational identification or meeting educational eligibility for services related to autism through the [Individuals] with Disabilities Education Act may not meet criteria as a formal diagnosis of ASD,” and a provisional or rule-out diagnosis is not confirmed. The ABA assessment itself must be performed by a BCBA, a Licensed Behavior Analyst, or an independently licensed mental health clinician with documented training in ABA — and in Georgia that analyst must also hold a Georgia Behavior Analyst Licensing Board licence under HB 412.[1]
EN0499 names no required instrument list — it sets instrument criteria instead, which is a harder bar to meet by accident. The assessment must include “administration of a reliable, valid, and standardized assessment instrument that measures the individual’s functioning in the domains included in the diagnostic criteria for ASD in the DSM-5-TR… social communication and social interaction; and restricted, repetitive patterns of behavior, interests, or activities,” and the instrument “must be completed in its entirety and as designed,” have established reliability and validity “for use with members of the population tested (e.g., age, language preference),” be administered and interpreted by someone trained to do so, be the most current version, assess current abilities, and carry the date of administration, the respondent’s name and the form type.[1]
Open, and stated at both the policy and the guide level. EN0499: “ABA treatment may be rendered via traditional in-person service delivery, telehealth, or a hybrid of in-person and telehealth service modalities,” with the modality chosen on individual characteristics, the treatment plan, caregiver participation, environment, evidence of efficacy and safety, and technological requirements — and the line-of-sight/close-proximity documentation rule expressly “does not apply to telehealth services, when applicable.” The Evernorth autism resource guide is blunter: “all ABA CPT codes are covered telehealth services,” subject to EN0499. Services delivered via telehealth must still meet the direct treatment / direct engagement definition and be documented as such. Because the guide covers all ABA CPT codes, that includes the 97151 assessment and 97152 supporting assessment and the BCBA’s 97155 direction of a technician. EN0499 sets supervision at one to two hours per ten hours 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®]”; it does not say that face-to-face must be in person. On the claim, Evernorth's Administrative Guidelines (September 2026) say that when billing telehealth services providers should use “Modifier 95 in Field 24-D to specify telehealth” and “02 for Place of Service in Field 24-B.” They name no separate POS 10 rule, and say nothing about flagging telehealth on the authorization.[7][1][2]
EN0499 publishes no age limit — coverage turns on a confirmed DSM-5-TR ASD diagnosis and medical necessity, not on age. The age term in Georgia comes from Ava’s Law, which reaches individuals 20 years of age or under on state-regulated plans, with employers of 10 or fewer employees exempt and self-funded ERISA plans preempted; federal parity generally makes that cap hard to enforce against covered large-group plans.[1][3]
Ask the plan: Plan funding type and employer size, then a live benefits verification — EN0499 itself will not answer an age question.
No referral requirement is published, and Cigna’s front door is unusually open: assessment codes 97151, 97152 and 0362T need no prior authorization under EN0499, so the assessment can start on the diagnosis alone. The rigour arrives at the treatment step, which requires the completed assessment plus a treatment plan submitted with Cigna’s ABA prior-authorization form. Whether a specific plan layers a PCP referral on top is a benefit-design question. State law adds no order requirement either: Ava's Law (O.C.G.A. § 33-24-59.10) defines covered treatment as care "prescribed, provided, or ordered" for an individual diagnosed with ASD without naming a required prescriber; what it does allow a fully insured plan to require is that a licensed physician or licensed psychologist demonstrate ongoing medical necessity for applied behavior analysis at least annually. Self-funded plans sit outside it. So: no statutory service order, but expect the plan to want an annual physician or psychologist medical-necessity statement — ask at benefits verification whether this plan requires one, and whether a PCP referral is needed on top of authorization.[1][2][3]
Ask the plan: A live benefits verification and Evernorth Provider Services at 800.926.2273 — confirm whether the plan requires a referral in addition to the treatment PA.
It depends on how the plan is funded. A fully insured Cigna plan sold in Georgia follows the Ensuring Transparency in Prior Authorization Act. A standard request gets notice "within 7 calendar days of obtaining all necessary information to make such authorization or adverse determination" (O.C.G.A. 33-46-26). Urgent requests get notice "no later than 72 hours after receiving all information needed" (33-46-27). A missed deadline means "automatic authorization" of the service (33-46-29), with a narrow de minimis exception. Both clocks start only once the plan has everything it needs, so send a complete packet. The Act also binds DCH contracts under the State Health Benefit Plan. A self-funded employer plan is governed by ERISA instead: "not later than 15 days after receipt of the claim," with one 15-day extension, and 72 hours for urgent care. No reauthorization lead time is published for Cigna ABA in Georgia.[9][10][11]
Ask the plan: Benefits verification with Cigna: ask whether the plan is fully insured (Georgia prior-authorization law), self-funded (ERISA), or the State Health Benefit Plan, and the plan's reauthorization lead time.
Between two parents' group plans, Georgia's coordination-of-benefits rule uses the birthday rule: "The benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year." "Birthday" means month and day only. If the birthdays match, the plan that has covered the parent longer pays first. For separated or divorced parents, the order is the custodial parent's plan, then the step-parent's, then the non-custodial parent's, unless a court decree assigns health costs to one parent. That rule governs fully insured group plans. A self-funded employer plan sets its own order in its plan document. The Cigna plan pays before Georgia Medicaid, which is payer of last resort and still wants its own ABS PA when secondary. It also pays before TRICARE, which pays only after other coverage. When the child also has CHAMPVA, the Cigna plan pays first: "If you have any other type of other health insurance, CHAMPVA will pay secondary."[12][13][14][15]
Ask the plan: Cigna member services / benefits verification: confirm funding type and the COB order in the plan document, and collect the other parent's plan, each parent's date of birth and any custody decree at intake.
Coverage decides whether Cigna / Evernorth in Georgia 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.
Evernorth DOES publish a supervision standard, in EN0499 — direct case supervision (the BCBA face-to-face with the individual alongside the RBT or BCaBA) plus indirect case supervision “is consistent with the general accepted standard of care of one to two hours per ten hours of direct treatment”, and “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.” It is stated as a standard of care rather than a hard caseload cap, and supervisory services must match the CPT code descriptions.[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. ABA alongside speech or occupational therapy: EN0499 (effective 5/15/2026) states that "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)." Same-day sessions at different times are not barred; overlapping clock time is.[2][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]
Not published. The resource guide sets the code set (97151–97158, 0362T, 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 published in the autism resource guide — no rule on who signs a session note or when.
Blocked on: The Evernorth Behavioral Health provider administrative guide and your participation agreement.
Only the telehealth half is published: “all ABA CPT codes are covered telehealth services,” subject to the Intensive Behavioral Interventions coverage policy (EN0499). The guide states no school, community or group-home rule.[2]
Ask the plan: Evernorth Provider Services at 800.926.2273 for school and community settings, plus the member’s benefit document.
Evernorth, which administers Cigna's behavioral benefits, tells providers to bill telehealth with modifier 95 in field 24-D and place of service 02 in field 24-B. Its autism resource guide says all ABA CPT codes are covered telehealth services, subject to the Intensive Behavioral Interventions policy.
No graph requirement is published. Cigna's policy EN0499 requires dated baseline, interim and current data for every target, current data collected within 60 days of the request and of the requested start date, and a standardized assessment no more than one year old.
Evernorth, which administers Cigna's behavioral network, considers claims filed within 90 days of the date of service unless your provider agreement or state law sets a longer period. For a secondary (COB) claim the 90 days run from the primary payer's processing date on its EOB or EOP.
No. Cigna's autism resource guide says all ABA services must be billed with CPT 97151–97158, 0362T and 0373T only.
180 calendar days from the initial payment or denial decision (or from the last payment adjustment), in writing; a second-level appeal is due within 60 days of the first-level decision. Fee-schedule disputes can often go through the reconsideration feature on Provider.Evernorth.com.
Yes — under the carrier's national policy for ASD, layered on Georgia's mandate (O.C.G.A. § 33-24-59.10 (Ava’s Law)) for fully-insured plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.
Ava’s Law requires state-regulated accident and sickness plans (including the state employee health plan) to cover ASD treatment for individuals 20 years of age or under, with ABA nominally cappable at $35,000 per year — and no limits allowed on the number of visits. See the mandate section above for ages, caps, and exemptions — and remember federal parity limits how hard the numeric caps can be enforced against group plans.
Evernorth (Cigna’s behavioral health arm) publishes no ABA fee schedule. Its autism resource guide sends questions about credentialing, contracts or rates to your provider relations representative, so the rate is in your Evernorth contract.
Apply to Evernorth: individuals use the Evernorth Behavioral Provider Information Form and autism clinics the Screening Application for Autism Clinics. Allow up to 90 days for the application and another 60 to 90 days to credential each provider after the clinic contract. Technicians are not credentialed; their services bill under the supervising provider.
Georgia prohibits unlicensed ABA practice (O.C.G.A. 43-7A-6); a temporary license of up to 30 days a year and reciprocity exist. Evernorth (Cigna) requires providers to “meet all state requirements to provide virtual behavioral services, including any licenses”; confirm with Evernorth before a remote start.
A referral counts only if it documents a confirmed DSM-5-TR ASD diagnosis made by an independently licensed clinician whose scope includes diagnosis, with that clinician’s name, credentials and licence type and the date the diagnosis was most recently made (Cigna EN0499). A referral for evaluation, or a provisional or “rule out” diagnosis, is not enough, so a full diagnostic evaluation is needed.
On a plan subject to Georgia law, within 15 working days of an electronic claim or 30 calendar days of a paper claim, or Cigna must say in writing why not, with 12% annual interest on late payments (O.C.G.A. 33-24-59.14).
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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