---
title: "Cigna / Evernorth ABA coverage in Georgia: the intake guide."
url: "https://carelu.com/payers/cigna-georgia"
markdown_url: "https://carelu.com/payers/cigna-georgia.md"
state: GA (Georgia)
payer: Cigna / Evernorth in Georgia
kind: Commercial insurance
description: "How Cigna / Evernorth covers ABA for Georgia families — the national clinical policy, prior authorization, the O.C.G.A. § 33-24-59.10 (Ava’s Law) mandate (ages, caps, exemptions), Georgia behavior-analyst licensure, and what intake should verify."
last_reviewed: October 2026
vob_data_updated: 2026-10-15
---

# Cigna / Evernorth ABA coverage in Georgia: the intake guide.

_Payer Guide · Cigna · Georgia · Last updated October 2026 · 8 primary sources_

> EN0499 + autism resource guide + the O.C.G.A. § 33-24-59.10 (Ava’s Law) mandate layer.

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.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Not required for assessment codes 97151, 97152, 0362T (per Cigna's autism resource guide — EN0499 itself states no prior-authorization rule) [1]
- **Prior auth for treatment**: Required — assessment + treatment plan with the ABA PA form (see Cigna's autism resource guide; EN0499 sets the clinical criteria, not the PA rule) [1]
- **Autism diagnosis required?**: Yes — ASD only; Rett syndrome (F84.2) excluded under EN0499 [1]

## At a glance

- **Covers ABA?:** Yes — for ASD, per the national Cigna policy
- **State mandate:** O.C.G.A. § 33-24-59.10 (Ava’s Law)
- **Mandate age:** Age 20 and under (mandate); parity may extend in practice
- **Mandate caps:** $35,000/yr nominal ABA cap; no visit limits allowed
- **Exempt from mandate:** ≤10-employee groups; self-funded ERISA plans
- **Licensure:** Licensed Behavior Analyst (GA Behavior Analyst Licensing Board)
- **Fee schedule:** Not public — rates are a contract question for your Evernorth provider relations representative

## The national policy, applied in Georgia

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]

## The Georgia mandate: what it guarantees (and doesn't)

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]

## No Georgia-specific Cigna policy exists

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]

## Licensure & rates in Georgia

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]

## How do I join Cigna’s (Evernorth’s) ABA network, and what does it pay?

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]

## Can an out-of-state BCBA treat a Georgia member, including by telehealth?

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]

## Does a doctor’s referral meet Cigna’s diagnosis requirement in Georgia?

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]

## Cigna (Evernorth) ABA claims in Georgia: filing deadline, corrections, codes and appeals

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]

## What an ABA reauthorization request must contain (and whether graphs are required)

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]

## Intake gates

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

- **Diagnosis recency**: 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]
- **Who may diagnose**: 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]
- **Diagnostic tools required**: 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]
- **Telehealth**: 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]
- **Age limit** _(plan-dependent)_: 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.
- **Referral required?** _(plan-dependent)_: 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.
- **Prior-auth decision time** _(plan-dependent)_: 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.
- **Other insurance (who pays first)** _(plan-dependent)_: 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.

## Delivery and billing rules

Coverage decides whether Cigna / Evernorth in Georgia 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**: 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]
- **Concurrent billing (97153 + 97155)**: 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]
- **Bill as provider**: 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]
- **Daily limits / MUEs** _(ask the plan)_: 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.
- **Place of service** _(ask the plan)_: 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.

## What intake should collect for Cigna / Evernorth in Georgia

- **Plan funding type:** Fully insured (mandate applies) vs. self-funded ERISA (exempt) — it decides which rulebook governs. Ask for the employer and check the card.
- **Member ID + card photo:** Enough to run a live benefits verification — the only reliable answer on limits and cost-sharing.
- **Diagnosis report:** DSM-5 ASD diagnosis, diagnosing provider and credentials, evaluation date.
- **Age:** Where the mandate carries age terms, flag edge cases for the parity analysis rather than turning families away.

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

## Verification of benefits (VOB) data

How Cigna / Evernorth in Georgia ABA benefits route and read on an eligibility check. Data last updated 2026-10-15.

### EDI routing

- **Payer ID (pVerify):** 00004
- **Payer ID (Availity):** 62308
- **Payer ID (Change Healthcare / Optum):** 62308
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** Evernorth Behavioral Health
- **BH administrator payer ID:** 62308
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### How the 271 reports ABA benefits

- **ABA benefit bucket (service type code):** MH
- **Deductible applies to ABA:** yes — Base deductible for MH-flavored codes is returned per the companion guide's own worked example, but REMAINING deductible/benefit amounts are explicitly withheld for Mental Health, Pharmacy, and Vision plans (§7.2.2-7.2.3) — a real 271 for an ABA member may show the base figure but not how much has been used.
- **Cost-share type:** plan-dependent — Both copay (EB*C) and coinsurance (EB*A) segments are structurally supported per plan; which applies to a given member is plan-document-specific.
- **271 response quality for ABA:** high

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Not required (per EN0499) | — | — | — | — |
| 97152 | Yes | Not required (per EN0499) | — | — | — | — |
| 97153 | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — |
| 97154 | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — |
| 97155 | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — |
| 97156 | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — |
| 97157 | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — |
| 97158 | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — |
| 0362T | Yes | Not required (per EN0499) | — | — | — | — |
| 0373T | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** Verify via: Cigna/Evernorth provider services — EN0499 is a medical-necessity policy only; no coding/reimbursement mechanics are published in it.

### Contacts

- **Benefits by phone:** Yes
- **Provider services phone:** 877-279-7603
- **Hours:** Monday–Friday, 8:30 a.m.–5:00 p.m. CT (Autism Care Coordinator team — benefits/eligibility/authorization for ABA specifically; the general Provider Services line, 800-926-2273, is staffed Monday–Friday 7 a.m.–7 p.m. CT for broader billing/benefits/eligibility questions)
- **Portal:** [Evernorth Provider website](https://provider.evernorth.com)

Questions to ask on a verification call:

- Is the ABA cost share a copay or coinsurance, and is it charged per visit or per day?
- Does the member's out-of-pocket maximum apply to ABA cost share?
- What's the daily unit cap and cap period for 97153 and 97155, and the rest of the ABA code set — EN0499 doesn't publish coding/reimbursement mechanics?
- What POS codes and telehealth modifiers (GT/95) do you accept for ABA billing?
- What licensure-tier modifiers do you require on ABA claims?
- Does eligibility checking return real-time or batch-only 271 responses?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months)
- https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/autism-resource-guide.pdf (accessed 2026-07-23)
- https://www.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23)
- https://www.cigna.com/static/www-cigna-com/docs/5010-270-271-companion-guide.pdf (accessed 2026-07-23)
- https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/en_mm_0499_coveragepositioncriteria_intensive_behavioral_interventions.pdf (accessed 2026-07-23)

## Common questions

### What telehealth modifier and place of service does Cigna want on ABA claims?

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.

### Does Cigna require graphs for ABA reassessments?

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.

### What is Cigna's timely filing limit for ABA claims in Georgia?

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.

### Does Cigna accept H0031 or H0032 for ABA?

No. Cigna's autism resource guide says all ABA services must be billed with CPT 97151–97158, 0362T and 0373T only.

### How long do I have to appeal a Cigna ABA claim decision?

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.

### Does Cigna cover ABA therapy in Georgia?

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.

### What does the Georgia autism mandate require?

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.

### What is Cigna’s fee schedule for ABA in Georgia?

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.

### How do I join Cigna’s ABA network in Georgia?

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.

### Can an out-of-state BCBA treat Cigna members in Georgia, including by telehealth?

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.

### Does a doctor’s referral count as the diagnosis for Cigna ABA in Georgia, or is a new evaluation needed?

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.

### How fast must Cigna pay an ABA claim in Georgia?

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).

## Primary sources

1. [Evernorth EN0499 — Intensive Behavioral Interventions](https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/en_mm_0499_coveragepositioncriteria_intensive_behavioral_interventions.pdf)
2. [Cigna autism resource guide (Mar 2025)](https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/autism-resource-guide.pdf)
3. [Georgia Code § 33-24-59.10 (Ava's Law)](https://codes.findlaw.com/ga/title-33-insurance/ga-code-sect-33-24-59-10/)
4. [Autism Speaks — Georgia state-regulated coverage](https://www.autismspeaks.org/georgia-state-regulated-insurance-coverage)
5. [Georgia Association for Behavior Analysis — licensure (HB 412)](https://www.georgia-aba.org/licensure)
6. [Georgia HB 412 (2022) — O.C.G.A. Title 43, Ch. 7A behavior analyst licensure (effective July 1, 2023)](https://gov.georgia.gov/document/2022-signed-legislation/hb-412/download)
7. [Evernorth Behavioral Health — Administrative Guidelines (September 2026)](https://static.evernorth.com/assets/evernorth/provider/pdf/resourceLibrary/behavioral/ebh-provider-admin-guide.pdf)
8. [O.C.G.A. § 33-24-59.14 — claim payment deadlines and interest (FindLaw)](https://codes.findlaw.com/ga/title-33-insurance/ga-code-sect-33-24-59-14/)
9. [Georgia SB 80 (2021) — O.C.G.A. 33-46-26, -27, -29, -30 (Ensuring Transparency in Prior Authorization Act)](https://gov.georgia.gov/document/2021-signed-legislation/sb-80/download)
10. [O.C.G.A. 33-46-26 — prior authorization notice within 7 calendar days (FindLaw)](https://codes.findlaw.com/ga/title-33-insurance/ga-code-sect-33-46-26/)
11. [29 CFR 2560.503-1 — ERISA claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
12. [Ga. Comp. R. & Regs. 120-2-48-.05 — Group Coordination of Benefits, order of benefits](https://www.law.cornell.edu/regulations/georgia/Ga-Comp-R-Regs-R-120-2-48-.05)
13. [GA DCH — Part I Policies and Procedures for Medicaid/PeachCare for Kids (version date July 1, 2026), 104.3 and 303 (GAMMIS copy retrieved via web.archive.org)](https://www.mmis.georgia.gov/portal/Portals/0/StaticContent/Public/ALL/HANDBOOKS/Part%201%20Policies%20and%20Procedures%20for%20Medicaid%20PeachCare%20for%20Kids%20Q3%20July%202026%2020260706155614.pdf)
14. [10 U.S.C. 1079(i)(1) — TRICARE pays after other coverage, Medicaid excepted](https://www.govinfo.gov/content/pkg/USCODE-2023-title10/html/USCODE-2023-title10-subtitleA-partII-chap55-sec1079.htm)
15. [CHAMPVA Guidebook (updated Jan. 1, 2025) — Other Health Insurance](https://www.va.gov/COMMUNITYCARE/docs/pubfiles/programguides/CHAMPVA-Guide.pdf)

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.