For an intake team in Illinois, a Cigna card means three layers: Evernorth’s national ABA policy EN0499 with the Cigna autism resource guide, Illinois’s autism mandate, and the plan’s funding type. Many Cigna members are on self-funded employer plans, and Evernorth’s own Illinois addendum says it does not apply to them, so check funding first. Cigna runs no Illinois Medicaid plan.
Cigna, through Evernorth Behavioral Health, covers ABA under EN0499 (effective May 15, 2026). The autism resource guide says 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 Board Certified Behavior Analyst® (BCBA®) and the patient’s policy covers ABA services.” Treatment needs the completed assessment and plan. “All ABA CPT codes are covered telehealth services,” electronic claims use payer ID 62308, and “Evernorth does not credential nonlicensed/noncertified staff,” so their services are billed under the supervising provider. EN0499 and the guide carry no Illinois-specific criteria.[2][3][4]
Evernorth’s Administrative Guidelines (September 2026) include an Illinois Regulatory Addendum for providers treating in Illinois. It applies only to fully insured business (“do not apply with regard to Covered Services rendered to Participants covered under self-funded plans”), asks that outpatient behavioral health participants be seen for initial appointments “within ten business days” and follow-ups within 20 days, and bars Evernorth from recouping a payment “twelve (12) months or more after the original payment was made” except in listed cases.[2][3][4]
Reauthorization: EN0499 does not ask for graphs; it asks for numbers with dates. Requests must include “Quantitative baseline data” for every target behavior and skill, collected within 60 days before treatment started, and, once treatment began more than 60 days before the request, “interim, and current data … collected and provided within no more than 60 days prior to the date the authorization request is received, with dates reported from when the data were collected,” reported separately for each setting (home, clinic, school, community), in the same unit of measurement as the goal’s mastery criteria. Claim filing: Evernorth’s Administrative Guidelines (September 2026) say “We will only consider claims submitted within 90 days of the date of service or as otherwise defined in your Provider Agreement,” with exceptions: a longer state-law limit applies, COB claims run 90 days from the primary payer’s EOB/EOP date, Medicaid-secondary three years, and a claim returned for more information gets a new 90 days from the request. For fully insured Illinois policies the Insurance Code sets the payment clock: “All claims and indemnities payable under the terms of a policy of accident and health insurance shall be paid within 30 days following receipt by the insurer of due proof of loss,” with 9% annual interest after the 30th day, and the insurer must tell the insured or assignee within 30 days if documentation is missing (215 ILCS 5/357.9). Self-funded ERISA plans are outside it. No weekly submission cutoff or check-run day is published.[2][4][1]
Illinois’s autism mandate is Section 356z.14 of the Illinois Insurance Code (215 ILCS 5/356z.14). Group and individual policies and managed care plans issued or renewed after December 12, 2008 “must provide individuals under 21 years of age coverage for the diagnosis of autism spectrum disorders and for the treatment of autism spectrum disorders.” Coverage “shall be subject to a maximum benefit of $36,000 per year but shall not be subject to any limits on the number of visits to a service provider,” and “The Director of Insurance shall, on an annual basis, adjust the maximum benefit for inflation” using the medical care CPI; we did not find the Department’s current adjusted figure, so get it from the plan. Cost sharing may apply only as it does to other medical services, and benefits “may not be subject to dollar limits, deductibles, copayments, or coinsurance provisions that are less favorable to the insured” than for physical illness. Treatment explicitly includes “applied behavior analysis,” prescribed, provided or ordered by a physician “or (B) a certified, registered, or licensed health care professional with expertise in treating effects of autism spectrum disorders when the care is determined to be medically necessary and ordered by a physician licensed to practice medicine in all its branches.” The diagnosis must be prescribed, performed or ordered by a physician licensed in all branches or “a licensed clinical psychologist with expertise in diagnosing autism spectrum disorders”; P.A. 104-561 adds a licensed speech-language pathologist with that expertise for children under 3, effective January 1, 2028. The insurer may ask for records showing medical necessity and progress, and a treatment plan (diagnosis, treatment by type, frequency, duration, goals, update schedule), but subsection (f) adds: “Nothing in this subsection supersedes the prohibition on prior authorization for mental health treatment under subsection (w) of Section 370c.” Medical-necessity decisions must be made the same way as for other illnesses, and an appeal challenge is reasonable only if the review includes a physician with current ASD treatment expertise. Subsection (e-5) bars denial “solely because of the location wherein the clinically appropriate services are provided.” The Department of Insurance has enforced that last point: Company Bulletin 2024-17 (December 4, 2024) reminds every company writing accident and health insurance and managed care plans that Public Act 102-0322, in effect since January 1, 2022, bars an insurer from denying “otherwise covered services … solely because of the location wherein the clinically appropriate services are provided,” and that for autism services “such as applied behavior analysis” sites “include non-school, non-home, or non-provider locations,” private or public. It adds that “An issuer cannot apply medical necessity criteria that contradict a statutory requirement,” that criteria for mental health conditions “including autism spectrum disorder, must be consistent with generally accepted standards of care, including with respect to setting or site of care” (215 ILCS 5/370c(h)-(i), (k)), and that members denied for medical necessity keep appeal rights under the Managed Care Reform and Patient Rights Act and the Health Carrier External Review Act. Separately, 370c(w), added by Public Act 104-0028 from January 1, 2026, says “No policy shall require prior authorization for outpatient or partial hospitalization services for treatment of mental, emotional, or nervous disorders or conditions” by licensed, certified or legally authorized providers; concurrent and retrospective review remain allowed, and a commercial insurer may require notice within “2 business days after the initiation of the covered person’s treatment,” with no concurrent review of services before that deadline. 370c(w) does not name ABA, and carriers still list ABA codes for authorization, so whether a fully insured plan may prior-authorize ABA in 2026 is a question to put to the plan and, if needed, the Department of Insurance. Like every state mandate, it reaches fully insured plans; self-funded employer plans answer to ERISA, and Evernorth’s Illinois addendum, for example, says it does “not apply with regard to Covered Services rendered to Participants covered under self-funded plans.”[5][6][7][8][9][4]
Illinois licenses behavior analysts. IDFPR lists two professions under the Behavior Analyst Licensing Act (225 ILCS 6), the Licensed Behavior Analyst and the Licensed Assistant Behavior Analyst, and says the Department “commenced licensing behavior analysts and assistant behavior analysts on January 15, 2025.” It gave applicants a grace period: IDFPR “will not begin enforcement actions for unlicensed practices provided by Behavior Analysts and Assistant Behavior Analysts until Monday, April 21, 2025,” so that date has passed and a BCBA practicing in Illinois now needs the Illinois license. A second deadline is still ahead. IDFPR quotes Section 150 of the Act: beginning 24 months after licensing began, no business may offer behavior analysis services “unless every member, partner, shareholder, director, officer, holder of any other ownership interest, agent, and employee who renders applied behavior analysis services holds a currently valid license,” and it reads that as: “By or before January 15, 2027 anyone who is not licensed as a behavior analyst or assistant behavior analyst … and who currently owns a business providing applied behavior analysis services must divest from the business.” The statute is blunter than IDFPR’s notice: Section 150 covers “every member, partner, shareholder, director, officer, holder of any other ownership interest, agent, and employee who renders applied behavior analysis services,” “Notwithstanding” the Section 20 exclusion for people implementing a plan under a licensed behavior analyst’s supervision, so ask IDFPR how it applies to RBT employees after January 15, 2027. The BACB’s licensure table lists Illinois (law enacted 2022) with IDFPR as the board. Out-of-state BCBAs and telehealth: no. Section 20 of the Act says an individual “shall not engage in the practice of applied behavior analysis unless licensed under this Act or covered by an exemption,” and its exemption list (family caregivers, staff implementing a plan under a licensed behavior analyst, listed licensed professions such as clinical psychologists, LCSWs, LCPCs, SLPs and OTs acting within their training, students and fellows, school-endorsed staff, QIDPs, DHS-designated providers, and people practicing on Medicaid when the Act took effect while working toward licensure) contains nothing for a behavior analyst licensed in another state. The Telehealth Act closes the remote route: “A health care professional treating a patient located in this State through telehealth services must be licensed or authorized to practice in Illinois” (225 ILCS 150/10). So a BCBA licensed elsewhere needs the Illinois license to treat or supervise a client located in Illinois, in person or by telehealth. For commercial credentialing this means the carrier will expect the Illinois license number as well as BACB certification.[10][11][20][12][13]
Cigna publishes no ABA rate table. Evernorth’s Administrative Guidelines say the Provider Agreement terms “include the reimbursement rates applicable to covered services” and tell ABA providers: “For your fee schedule and a listing of autism spectrum disorder–related services eligible for reimbursement, refer to Exhibit A in your Provider Agreement.” Virtual services carry modifier 95, which Evernorth says “will not change the reimbursement.” Fee questions go to Provider Services at 800.926.2273. For a public benchmark, Illinois Medicaid’s ABS fee schedule pays 97153 at $13.00 per 15 minutes; commercial contracts are negotiated separately.[4][15]
The questions that decide whether a family can start with Cigna / Evernorth in Illinois, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the diagnosis, but a provisional or rule-out diagnosis does not count, and the data clocks run at 60 days: assessment instrument within 60 days before treatment starts, baseline data within 60 days, and current data within 60 days of a continued-treatment request.[2]
A healthcare professional “licensed to practice independently and whose licensure board considers diagnostics” within scope, using DSM-5-TR criteria. For fully insured Illinois plans, 356z.14 defines the diagnosis as tests or evaluations “prescribed, performed, or ordered by (A) a physician licensed to practice medicine in all its branches or (B) a licensed clinical psychologist with expertise in diagnosing autism spectrum disorders” (a licensed speech-language pathologist with that expertise for children under 3 is added from January 1, 2028 by P.A. 104-561).[5][2]
No single instrument is mandated, but it must be standardized, valid, completed in full and the current edition (“must be the Vineland-3 vs. Vineland-II”).[2]
EN0499 requires no referral. Assessments 97151, 97152 and 0362T need no PA with an autism diagnosis when the provider is independently licensed or a BCBA; treatment needs authorization. For fully insured Illinois plans, 215 ILCS 5/356z.14 covers ABA as treatment “ordered by a physician licensed to practice medicine in all its branches” when delivered by a certified, registered or licensed professional, so keep a physician order on file; the Department of Insurance has also told carriers they may not deny covered ABA “solely because of the location” of care (Company Bulletin 2024-17). Self-funded ERISA plans sit outside state insurance law.[3][2][9]
“All ABA CPT codes are covered telehealth services” (autism resource guide), and EN0499 allows “traditional in-person service delivery, telehealth, or a hybrid.” Evernorth bills virtual services with modifier 95 at the same rate.[3][2][4]
EN0499 sets no age cap; access to intervention “should not be restricted by age.” For fully insured Illinois plans, 215 ILCS 5/356z.14 mandates autism coverage for “individuals under 21 years of age,” subject to a $36,000-a-year maximum that the Director of Insurance adjusts annually for medical inflation, with no visit limits; the plan may cover older members, and the current adjusted dollar figure should be confirmed with the plan. Self-funded ERISA plans are outside the statute.[2][5]
Ask the plan: Live benefits verification: establish fully insured vs. self-funded ERISA first, then the plan’s age terms.
Depends on how the plan is funded. Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1: pre-service decisions “not later than 15 days after receipt of the claim,” one 15-day extension, urgent care within 72 hours. For fully insured Illinois plans, 215 ILCS 5/370c(w) (Public Act 104-0028, from January 1, 2026) bars prior authorization of outpatient mental health treatment and lets the insurer set a notification deadline of up to 2 business days after treatment starts, with no concurrent review of services before that deadline; Illinois’s general prior-authorization decision deadlines were not read this run. Cigna/Evernorth publishes no Illinois-specific ABA turnaround or reauthorization lead time in the documents read.[14][8][7]
Ask the plan: At benefits verification ask whether the plan is fully insured (Illinois-regulated) or self-funded (ERISA), and what turnaround and reauthorization lead time Evernorth expects.
Illinois’s group coordination-of-benefits rule could not be retrieved this run, so the order between two parents’ plans is not stated here; ask the plan. What is certain is the order against public coverage: if the child also has Illinois Medicaid, Cigna/Evernorth pays first. HFS is “by federal and State Law, the payer of last resort,” and claims must be adjudicated by all liable third parties before HFS considers them (42 CFR 433.139). TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[16][17][18][19]
Ask the plan: Ask Cigna/Evernorth at benefits verification for the member’s coordination-of-benefits order, and record every other coverage the child has.
Coverage decides whether Cigna / Evernorth in Illinois 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.
EN0499: case supervision by a BCBA, Licensed Behavior Analyst, or independently licensed mental health clinician with ABA training, at “one to two hours per ten hours of direct treatment”; when direct treatment is 10 hours a week or less, at least one to two hours a week. In Illinois the supervising behavior analyst also needs the IDFPR license.[2][10]
“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).”[3]
No per-day cap is published. All ABA codes bill in 15-minute units and only with 97151–97158, 0362T and 0373T; intensity must reflect severity, goals and response to treatment.[3][2]
Each service needs its own record including the “Name, credential (if applicable), and signature of ABA provider who rendered the service,” with date and time, location, the intervention and who was present.[2]
EN0499 excludes services “primarily educational or vocational in nature” and asks for goals and data by setting. For fully insured Illinois plans, the Department of Insurance has told carriers they may not deny covered ABA “solely because of the location” of care (Company Bulletin 2024-17).[2][9]
Evernorth does not credential nonlicensed or noncertified staff; their services are billed under the supervising provider. On a CMS-1500, print your name in box 31 and “List only a BCBA or other licensed provider in box 33”; electronic claims use payer ID 62308.[3]
Evernorth considers claims submitted within 90 days of the date of service unless your agreement or a longer state-law limit says otherwise; COB claims have 90 days from the primary payer’s EOB.
EN0499 does not mention graphs. It requires dated quantitative baseline, interim and current data, the current data collected within 60 days before the request, broken out by setting.
Yes, under national policy EN0499 for ASD, with Illinois’s autism mandate layered on for fully insured plans. Self-funded employer plans follow their own documents.
No, for 97151, 97152 and 0362T with an autism diagnosis when the provider is independently licensed or a BCBA. PA starts at treatment.
Yes. Cigna’s autism resource guide covers all ABA CPT codes by telehealth, billed with modifier 95. The clinician still needs an Illinois license for a client in Illinois.
Cigna publishes no ABA rates. Evernorth puts your fee schedule in Exhibit A of your Provider Agreement; call 800.926.2273. Illinois Medicaid’s 97153 rate ($13.00 per 15 minutes) is the public benchmark.
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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