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.[5]
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.[6][1]
Evernorth Behavioral Health, which runs Cigna's ABA network, says it "is committed to expanding our network of autism providers." It requires providers to be certified by a national governing body or a state licensing board (BCBA, BCBA-D, BCaBA, licensed behavior analyst or other behavioral health licensure). Individual providers complete the Evernorth Behavioral Provider Information Form; autism clinics and large group practices complete the Evernorth Screening Application for Autism Clinics. An application can take up to 90 days, and once a clinic contract is signed each certified or licensed provider must also be credentialed, which "can take an additional 60 to 90 days." Providers must be fully credentialed to render in-network services. "Evernorth does not credential nonlicensed/noncertified staff": technician services are billed under the supervising provider.[2]
Cigna’s behavioral benefits, ABA included, are administered by Evernorth Behavioral Health, whose administrative guidelines (revised September 2026) “will only consider claims submitted within 90 days of the date of service or as otherwise defined in your Provider Agreement” — a longer state-law limit overrides it, the clock resets to the date Cigna asks for more information, and Medicaid-secondary claims get three years. Appeals must be started in writing within 180 calendar days of the payment or denial decision.[2][13]
More of Evernorth’s filing rules (administrative guidelines, September 2026): 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]," and the primary EOP goes in with the claim unless the COB data is sent electronically; Medicaid gets three years; a claim returned for more information gets a fresh 90 days from the date of the request. Corrected or replacement claims carry frequency code 7 (replace) or 8 (void) in box 22, not a "Corrected Claim" stamp, and no separate corrected-claim deadline is published. Evernorth publishes no weekly payment cycle or submission cutoff; it offers ERA and EFT "to help reduce your payment cycle."[2][13]
Which codes: Evernorth’s autism resource guide (March 2025) says "All ABA services must be billed with CPT codes 97151–97158, 0362T, and 0373T ONLY," so state HCPCS ABA codes such as H0031, H0032, H2014 or H2019 are not billable to Cigna for ABA. The same guide says "All ABA CPT codes are covered telehealth services."[2][13]
Idaho’s prompt-pay clock depends on how fast the provider files. Under Idaho Code § 41-5602, if an electronic claim is submitted within thirty days of the date of service, the insurer “shall pay or deny the claim not later than thirty (30) days after receipt”; a paper claim submitted within forty-five days of service must be paid or denied within forty-five days. A denial or request for more information must be sent in writing within the same thirty or forty-five days and must describe everything needed, after which the insurer has thirty days from receiving it. Late claims accrue interest at the statutory contract rate (§ 41-5603). The time limits do not apply where the insurer is complying with a provider contract that sets different payment terms (§ 41-5605(3)). These statutes bind fully insured plans issued in the state; a self-funded employer plan (ERISA) is not subject to them and follows its plan documents and your contract.[10][11][12]
No. Evernorth’s administrative guidelines (September 2026) define a complete CMS-1500 claim as the patient’s ID number, name, address and date of birth; the subscriber’s name and address; release of information and assignment of benefits; diagnosis codes and pointer; date and place of service; CPT/HCPCS code and modifier; billed charge, units, TIN and total charge; the “Rendering provider’s name, NPI, and license type”; and the “Billing provider’s name, address, and NPI.” No referring or ordering provider is on that list. If you do report one on an 837, “Any additional provider identification on the claim, such as the “Rendering Provider” or “Referring Provider,” must include the name and NPI when submitted.”[13][2]
The ABA-specific paper-claim rules sit in the autism resource guide: use Form CMS-1500, “Print your name in box 31,” and “List only a BCBA or other licensed provider in box 33.” Evernorth does not credential non-licensed or non-certified staff, so their services are billed under the supervising provider.[13][2]
Evernorth’s EN0499 (effective May 15, 2026) sets what a continued-treatment request must show: an updated treatment plan covering current deficits and progress in every targeted area; "Quantitative baseline, interim and current data ... with dates reported from when the data were collected" for every behavior and skill, across all settings; current data collected "within no more than 60 days prior to the start date of the continued treatment request" and within 60 days before the request is received; data showing "ongoing and sustained progress"; and a reliable, valid, standardized assessment completed no more than one year before the continued-treatment start date. Where progress is not shown, the request must name the barriers and the protocol changes made. EN0499 asks for dated quantitative data, not for graphs as such; graphs are a common way to present it, but the policy does not require them.[1]
Who may deliver and who may bill (Evernorth's ABA code table): 97151, 97155, 97156, 97157, 97158, 0362T and 0373T are provided and billed by a BCBA-D, BCBA or licensed mental health provider; 97152, 97153 and 97154 may be provided by a BCaBA or technician but are billed by the BCBA-D, BCBA or licensed mental health provider. "All ABA services must be billed with CPT codes 97151–97158, 0362T, and 0373T ONLY." Evernorth's guide names no HM/HN/HO credential modifiers.[2][13]
Joining the network: Evernorth says it "is committed to expanding our network of autism providers." Individuals file the Evernorth Behavioral Provider Information Form; autism clinics and large groups file the Screening Application for Autism Clinics; "It may take up to 90 days for an application to be processed," and after the clinic contract each certified or licensed provider must be credentialed, "an additional 60 to 90 days." "Providers must be fully credentialed to render in-network services." A departing provider or roster change goes to Provider Services (800.926.2273) or the Clinic Location Changes form.[2][13]
Out-of-network: it depends on the product. HMO, HMO Open Access, Cigna Connect and OAP In-Network plans cover in-network care only (emergencies aside); POS and Open Access Plus plans cover out-of-network services at a reduced benefit level. Evernorth's guidelines publish no single case agreement process; a family without out-of-network benefits needs an in-network provider, and Evernorth's care managers email in-network providers near the family to find an opening.[2][13]
Payment disputes: call Provider Services first; then appeal "in writing within 180 calendar days of the date of the initial payment or denial decision" (or of the last adjustment). Fee-schedule and reimbursement disputes can go through the reconsideration feature on Provider.Evernorth.com. Medical necessity appeals should include the clinical record; untimely-filing appeals need proof of timely submission or of a COB delay. "Most appeals are resolved within 60 calendar days," with notice within 75 days unless state law differs. Some out-of-network providers must attach a patient-signed Appointment of Representative form.[2][13]
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. LCSW: yes under Evernorth's test — Idaho's board rule puts "assessment, diagnosis, and treatment of mental, emotional, and behavioral disorders" inside clinical social work (IDAPA 24.14.01.200.03), and the LCSW is an independent licence.[1][14]
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][5]
"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. That includes the 97151 assessment and 97155 protocol modification. EN0499 describes direct case supervision as occurring "concurrently with the delivery 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®]," at one to two hours per ten hours of direct treatment; it publishes no separate in-person minimum for supervision delivered by 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][5]
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.[7][8][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).[9][15][16][17]
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][5]
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]
Only on plans with out-of-network benefits. Evernorth's September 2026 guidelines say HMO, Connect and OAP In-Network plans cover in-network care only, while POS and Open Access Plus plans cover out-of-network services at a reduced benefit level. Evernorth publishes no single case agreement process for ABA; its care managers help families find an in-network provider.
Not graphs as such. EN0499 requires dated quantitative baseline, interim and current data (current data no more than 60 days old), an updated plan and a standardized assessment no more than a year old; graphs are a common way to show the data, but the policy does not require them.
CPT 97151–97158, 0362T and 0373T only; HCPCS H-codes such as H0031/H0032 are not billable for ABA (Evernorth autism resource guide).
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.
Evernorth, which runs Cigna's behavioral network, says it is "committed to expanding our network of autism providers." Individual providers submit the Evernorth Behavioral Provider Information Form and clinics the Screening Application for Autism Clinics; allow up to 90 days for the application plus 60 to 90 days of credentialing per provider.
No. "Evernorth does not credential nonlicensed/noncertified staff. Services for these staff members must be billed under the supervising provider." EN0499 expects the direct work from an RBT or BCaBA under BCBA case supervision.
Evernorth Behavioral Health, which administers Cigna’s ABA benefit, considers claims submitted within 90 days of the date of service unless your provider agreement or a longer state-law limit says otherwise.
Idaho law (Idaho Code § 41-5602) requires a fully insured plan to pay or deny an electronic claim within 30 days of receipt (45 for paper) — but only when the claim was filed within 30 days of the service (45 for paper), and a contract with different payment terms overrides it. Self-funded employer plans are not bound by the statute.
No. Evernorth’s complete-claim definition for the CMS-1500 lists the rendering and billing providers but no referring provider. If you report a referring provider on an electronic claim, include both the name and the NPI.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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