---
title: "Cigna / Evernorth ABA coverage in Idaho: the intake guide."
url: "https://carelu.com/payers/cigna-idaho"
markdown_url: "https://carelu.com/payers/cigna-idaho.md"
state: ID (Idaho)
payer: Cigna / Evernorth in Idaho
kind: Commercial insurance
description: "How Cigna / Evernorth covers ABA for Idaho families: EN0499 criteria, no prior authorization on assessment codes, all ABA codes eligible by telehealth, Idaho’s Bulletin 18-02 in place of an autism statute, and what intake should verify."
last_reviewed: October 2026
---

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

_Payer Guide · Cigna · Idaho · Last updated October 2026 · 13 primary sources_

> Evernorth EN0499 + the autism resource guide (no assessment PA) on top of Idaho’s Bulletin 18-02.

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.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Not required for assessment codes 97151, 97152, 0362T with an autism diagnosis, when the provider is independently licensed or a BCBA and the policy covers ABA (autism resource guide) [2]
- **Prior auth for treatment**: Required — completed assessment and treatment plan attached to the ABA Prior Authorization Form [2][1]
- **Autism diagnosis required?**: Yes — ASD (F84.0–F84.9 except F84.2 Rett syndrome) under DSM-5-TR by an independently licensed clinician with diagnostics in scope [1]

## At a glance

- **Covers ABA?:** Yes, for ASD per EN0499
- **State mandate:** No autism statute — Idaho DOI Bulletin No. 18-02 (2018) requires ASD treatment on state-regulated plans that cover rehabilitative or habilitative services (plan years from 1/1/2019)
- **Mandate age:** None — the bulletin sets no age limit
- **Mandate caps:** None separate — no separate dollar or visit limits; cost-sharing in parity with other mental health and med/surg benefits
- **Exempt from mandate:** Self-funded employer (ERISA) plans Idaho does not regulate; plans with no rehabilitative/habilitative benefit fall outside the bulletin’s trigger
- **Licensure:** None — Idaho has no behavior-analyst licensure law; BACB certification governs

## The national policy, applied in Idaho

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]

## The Idaho coverage floor: Bulletin 18-02, not a statute

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]

## Licensure & rates in Idaho

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]

## Is Cigna's ABA network open to new providers?

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]

## Claims: filing deadline and disputes

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]

## How fast must Cigna pay a clean claim in Idaho?

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]

## Does Cigna need a referring provider on the ABA claim?

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]

## What must a Cigna ABA reauthorization request contain, and are graphs required?

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]

## Intake gates

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

- **Diagnosis recency**: 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]
- **Who may diagnose**: 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]
- **Diagnostic tools required**: 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]
- **Referral required?**: 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]
- **Telehealth**: "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]
- **Age limit** _(plan-dependent)_: 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.
- **Prior-auth decision time** _(plan-dependent)_: 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).
- **Other insurance (who pays first)** _(plan-dependent)_: 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][14][15][16]
  - Ask the plan: Ask Cigna at benefits verification for the coordination-of-benefits order on file, and record every other coverage the child has.

## Delivery and billing rules

Coverage decides whether Cigna / Evernorth in Idaho 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**: 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]
- **Concurrent billing (97153 + 97155)**: "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]
- **Daily limits / MUEs**: 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]
- **Session-note signature**: 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]
- **Place of service**: 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]
- **Bill as provider**: "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]

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

- **Plan funding type:** Fully insured (Bulletin 18-02 applies) or self-funded ERISA (outside it).
- **Diagnosis report:** DSM-5-TR ASD with the diagnosing clinician’s name, credentials, licensure type and the date the diagnosis was most recently made. Provisional or "rule out" diagnoses do not count.
- **Standardized assessment within 60 days of the treatment start:** EN0499 requires the instrument and baseline data within 60 days before treatment starts.
- **Member ID + card photo:** Confirm the plan covers ABA, since the assessment PA waiver depends on it.
- **Prescription:** Bulletin 18-02 frames coverage around care prescribed or ordered by a licensed physician or psychologist.

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

## Common questions

### Does Cigna require graphs for ABA reassessments?

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.

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

CPT 97151–97158, 0362T and 0373T only; HCPCS H-codes such as H0031/H0032 are not billable for ABA (Evernorth autism resource guide).

### Does Cigna cover ABA therapy in Idaho?

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.

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

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.

### Can Cigna ABA be delivered by telehealth?

Yes. Evernorth’s autism resource guide says all ABA CPT codes are covered telehealth services.

### Is Cigna accepting new ABA providers?

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.

### Does Cigna credential RBTs?

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.

### What is Cigna’s timely filing limit in Idaho?

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.

### How fast must Cigna pay a clean ABA claim in Idaho?

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.

### Does Cigna require a referring provider (box 17) on ABA claims?

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.

## Primary sources

1. [Evernorth Coverage Policy EN0499 — Intensive Behavioral Interventions (eff. 5/15/2026): Criteria for Continued Treatment with ABA](https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/en_mm_0499_coveragepositioncriteria_intensive_behavioral_interventions.pdf)
2. [Cigna/Evernorth Autism Resource Guide (PCOMM-2025-225, March 2025): billing codes](https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/autism-resource-guide.pdf)
3. [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)
4. [Cigna / Evernorth autism resource guide (March 2025)](https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/autism-resource-guide.pdf)
5. [Idaho Department of Insurance — Bulletin No. 18-02, Clarification Regarding Coverage of Treatments for Autism Spectrum Disorder (April 2, 2018)](https://doi.idaho.gov/bulletin/18-02-clarification-regarding-coverage-of-treatments-for-autism-spectrum-disorder/)
6. [BACB — U.S. Licensure of Behavior Analysts (Idaho not listed; map updated June 2026)](https://www.bacb.com/u-s-licensure-of-behavior-analysts/)
7. [Idaho Code § 41-3930 — Managed care utilization management program requirements](https://legislature.idaho.gov/statutesrules/idstat/Title41/T41CH39/SECT41-3930/)
8. [29 CFR 2560.503-1 — ERISA claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
9. [IDAPA 18.04.14 — Coordination of Benefits (Idaho Department of Insurance)](https://proddfmmainsa.blob.core.windows.net/dfm-admin-website/rules/current/18/180414.pdf)
10. [Idaho Code § 41-5602 — Prompt payment of claims](https://legislature.idaho.gov/statutesrules/idstat/Title41/T41CH56/SECT41-5602/)
11. [Idaho Code § 41-5603 — Interest payments](https://legislature.idaho.gov/statutesrules/idstat/Title41/T41CH56/SECT41-5603/)
12. [Idaho Code § 41-5605 — Exceptions](https://legislature.idaho.gov/statutesrules/idstat/Title41/T41CH56/SECT41-5605/)
13. [Evernorth Behavioral Health Administrative Guidelines (rev. Sept. 2026)](https://static.evernorth.com/assets/evernorth/provider/pdf/resourceLibrary/behavioral/ebh-provider-admin-guide.pdf)
14. [Idaho Medicaid Provider Handbook — General Information and Requirements for Providers (December 23, 2025)](https://www.idmedicaid.com/General%20Information/General%20Information%20and%20Requirements%20for%20Providers.pdf)
15. [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)
16. [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.