A Cigna card in Idaho means Evernorth’s national ABA policy, EN0499, and its autism resource guide, sitting on Idaho’s bulletin-based coverage floor. We checked the current EN0499 (effective May 15, 2026) and found no Idaho carve-out, so the national rules apply unless the member’s plan documents differ.
The Evernorth autism resource guide removes prior authorization at the front door: "Prior authorization is no longer required for assessment CPT codes 97151, 97152, or 0362T with a diagnosis of autism," as long as the provider is independently licensed or a BCBA and the member’s policy covers ABA. Treatment requires the completed assessment and treatment plan attached to the ABA Prior Authorization Form. EN0499 then sets 60-day recency clocks on the assessment instrument and baseline data. It requires case supervision at "one to two hours per ten hours of direct treatment," and it allows in-person, telehealth or hybrid delivery. The resource guide confirms that "All ABA CPT codes are covered telehealth services." The Autism Care Coordinator team is at 877.279.7603.[2][1]
Idaho is one of the few states with no autism insurance statute, and intake should say so plainly. What Idaho has instead is Department of Insurance Bulletin No. 18-02 (April 2, 2018). Reading the federal Mental Health Parity and Addiction Equity Act, ACA § 1557 and the state’s Essential Health Benefits together, the Department declared that it "will consider an exclusion of treatments for autism spectrum disorder as discriminatory and prohibited when a plan includes coverage of rehabilitative or habilitative services, such as coverage of occupational therapy or speech therapy." It applies to the individual, small-group and large-group insured markets, and to self-funded plans subject to Idaho Code title 41, chapters 40 or 41, for plan years starting on or after January 1, 2019. Covered treatment must be "consistent with other mental health services (including applicable deductibles, copayments, or coinsurance), not subject to any separate dollar limits or visit limits, and in parity with medical and surgical benefits." The bulletin defines treatment as "evidence-based care and related equipment prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a licensed physician or a licensed psychologist who determines the care to be medically necessary, including but not limited to behavioral health treatment" — it does not name ABA by name, and it sets no age limit. Carriers may still review medical necessity and "periodically review the medical necessity of continuing" treatment. Two practical limits: a bulletin is weaker than a statute, and a self-funded employer plan the Department does not regulate (most ERISA plans) sits outside it entirely — plan funding type is the first fact to establish.[3]
Idaho has no behavior-analyst licensure law and is not on the BACB’s list of licensing states, so in Idaho a BCBA qualifies under EN0499’s "Board Certified Behavior Analyst" category without a state license. Cigna publishes no commercial ABA rates, and they are negotiated in your agreement.[4][1]
The questions that decide whether a family can start with Cigna / Evernorth in Idaho, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the diagnosis, but EN0499 requires the diagnosing clinician’s name, credentials and licensure type and the date of the most recent diagnosis. Provisional, "rule out" or "at risk of" diagnoses do not qualify. The assessment instrument must be administered within 60 days before treatment starts, baseline data collected within 60 days before the start, and current data for continued treatment within 60 days.[1]
A healthcare professional "who is licensed to practice independently and whose licensure board considers diagnostics" within scope. The ABA assessment is done by a BCBA, a Licensed Behavior Analyst, or an independently licensed mental health clinician with documented ABA training.[1]
No single named instrument. EN0499 requires a reliable, valid, standardized instrument covering the DSM-5-TR ASD domains, completed in full and as designed, in its current edition, with standardized scores reported.[1]
EN0499 requires no referral or prescription, and assessment codes need no PA when the provider is independently licensed or a BCBA and the plan covers ABA. For Idaho state-regulated plans, Bulletin 18-02 frames covered treatment as care "prescribed or ordered" by a licensed physician or licensed psychologist, so get a written prescription.[2][1][3]
"All ABA CPT codes are covered telehealth services." EN0499 allows in-person, telehealth or hybrid delivery, and the line-of-sight requirement does not apply to telehealth.[2][1]
EN0499 sets no age cap. Its glossary says access to focused intervention "should not be restricted by age, cognitive level, diagnosis, or co-occurring conditions." Bulletin 18-02 sets no age limit for state-regulated plans, and self-funded plans may carry their own terms.[1][3]
Ask the plan: Benefits verification, or the Autism Care Coordinator team at 877.279.7603 — establish fully insured vs. self-funded first.
Turns on how the plan is funded. Idaho’s Managed Care Reform Act requires a managed care organization to answer a nonemergency prior-authorization request "within two (2) business days after complete member medical information is provided," "unless exceptional circumstances warrant a longer period" (Idaho Code § 41-3930). Self-funded ERISA plans follow 29 CFR 2560.503-1: 15 days, one 15-day extension, and 72 hours for urgent claims. EN0499 publishes no submission lead time, but continuation requests need current data collected within 60 days.[5][6][1]
Ask the plan: At benefits verification ask whether the plan is fully insured or self-funded, then confirm Evernorth’s turnaround with the Autism Care Coordinator team (877.279.7603).
For a child on two parents’ plans, Idaho’s rule (IDAPA 18.04.14.022) makes "the plan of the parent whose birthday falls earlier in the calendar year" primary, with separate rules for divorced or separated parents. Self-funded plans follow their own documents. If the child also has Idaho Medicaid, this plan pays first because Medicaid is the payer of last resort, and Medicaid pays CHIS on H-codes. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)), and CHAMPVA is the last payer (38 CFR 17.270).[7][8][9][10]
Ask the plan: Ask Cigna at benefits verification for the coordination-of-benefits order on file, and record every other coverage the child has.
Coverage decides whether Cigna / Evernorth in Idaho pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Case supervision is performed by a BCBA, a Licensed Behavior Analyst, or an independently licensed mental health professional with documented ABA training. Direct and indirect case supervision run at "the generally accepted standard of care of one to two hours per ten hours of direct treatment," and when direct treatment is 10 hours a week or less, at least one to two hours a week of direct case supervision is provided. The supervisor’s name and credentials must be documented.[1]
"Only one provider can bill for a unit of time, with the exception of CPT codes 97153, 97154, and 97155" during direct supervision, when the BCBA or QHP and technician are both face-to-face with the patient. Separately, ABA is not reimbursable when delivered to the same individual "at the same time as any other treatment modality," such as speech or occupational therapy.[2][1]
No per-day unit ceiling is published. Intensity must reflect severity, goals and response across settings, supervision runs at one to two hours per ten hours of direct treatment, and all ABA is billed in 15-minute units on 97151–97158, 0362T and 0373T. Bulletin 18-02 bars separate dollar or visit limits on state-regulated plans.[1][2][3]
Each service needs a separate written record with start and end date and time, location, focus, a detailed description of the intervention, the individuals present, the service type, and the "Name, credential (if applicable), and signature of ABA provider who rendered the service."[1]
Goals must be measured across all settings where treatment occurs (home, clinic, school, community), with data reported by location. Services that are primarily educational or vocational are not covered. In academic, vocational or telehealth settings the plan must document that the service still meets the direct-treatment definition.[1]
"Evernorth does not credential nonlicensed/noncertified staff." Their services must be billed under the supervising provider. On a CMS-1500 the rendering provider prints their name in box 31, and only a BCBA or other licensed provider is listed in box 33. Electronic claims use Evernorth payer ID 62308.[2]
Yes, under EN0499 for ASD, with no Idaho carve-out in the current policy. On state-regulated plans Idaho’s Bulletin 18-02 also bars autism-treatment exclusions where rehab or habilitative services are covered.
No. Assessment codes 97151, 97152 and 0362T need no PA with an autism diagnosis when the provider is independently licensed or a BCBA and the plan covers ABA. PA applies at the treatment step.
Yes. Evernorth’s autism resource guide says all ABA CPT codes are covered telehealth services.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 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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