For an intake team in Kentucky, a Cigna card means three layers: Evernorth’s national ABA policy EN0499 with the Cigna autism resource guide, Kentucky’s autism mandate in KRS 304.17A-142, and the plan’s funding type. Evernorth’s administrative guidelines add a Kentucky regulatory addendum for provider contracts.
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 … codes 97151, 97152, or 0362T with a diagnosis of autism, as long as the provider is independently licensed or a Board Certified Behavior Analyst® and the patient’s policy covers ABA services"; treatment needs authorization with the completed assessment and plan. EN0499 names no Kentucky-specific criteria, so the national policy plus the mandate apply.[1][2]
Kentucky’s autism mandate is KRS 304.17A-142. Every health benefit plan "issued or renewed on or after January 1, 2019, shall provide coverage for the diagnosis and treatment of autism spectrum disorders," and treatment expressly includes "applied behavior analysis prescribed or ordered by a licensed health or allied health professional" and habilitative or rehabilitative care "including applied behavior analysis." The 2018 amendment removed the old age bands and dollar caps: coverage "shall not be subject to any maximum annual benefit limit, including any limits on the number of visits an individual may make to an autism services provider," and cost-sharing may be no less favorable than for other medical services. For ongoing outpatient treatment the insurer may request a utilization review "not more than once every twelve (12) months" unless the insurer and the treating physician or psychologist agree to more, may ask for records showing medical necessity and improved clinical status, and may request a treatment plan with diagnosis, type, frequency, anticipated duration, goals and update frequency; goals must be "clearly defined, directly observed, and continually measured." Plans need not pay for services in an IEP, IFSP or other publicly funded program, for services by a relative who would not otherwise charge, or for "services provided by persons who are not licensed as required by law." KRS 304.17A-144 also requires each insurer to give members an autism liaison who explains the ABA benefit, the prior-authorization process and documentation, ABA claim coding, and appeal rights. The mandate reaches fully insured plans; self-funded employer plans answer to ERISA instead.[4][5]
Kentucky licenses behavior analysts under KRS Chapter 319C through the Kentucky Applied Behavior Analysis Licensing Board (BACB lists Kentucky licensure since 2010). No one may practice or "render services designated as applied behavior analysis" in Kentucky without a license, except people delivering ABA in a public school setting, implementing ABA for an immediate family member or as a supervisee, other licensed health professionals within their own scope, and people providing Medicaid waiver services (KRS 319C.020). A licensed behavior analyst must hold and keep an active BCBA; a licensed assistant behavior analyst an active BCaBA, supervised by a certified behavior analyst (KRS 319C.080). The practice of ABA "shall not include diagnosis" (KRS 319C.010(8)), so the autism diagnosis must come from another licensed clinician. A BCBA licensed in another state can get a Kentucky license through KRS 319C.090 (valid license elsewhere, KRS 319C.080 requirements met, no pending discipline), but cannot simply treat a Kentucky child remotely: the board’s telehealth rule says "a person providing applied behavior analytic services via telehealth to a person physically located in Kentucky while services are provided shall be required to be licensed by the board" (201 KAR 43:100). For commercial telehealth, KRS 304.17A-138 likewise lets a plan require the telehealth provider to be licensed in Kentucky or under a recognized interstate compact. On rates, commercial ABA rates are negotiated and unpublished; the public benchmark is the Kentucky Medicaid fee-for-service schedule (2026: 97153 $12.18 per 15 minutes for an RBT; 97155 $21.99 for a licensed behavior analyst).[11][12][13][14][15][6][16][17]
Evernorth puts ABA rates in the contract: "For your fee schedule and a listing of autism spectrum disorder–related services eligible for reimbursement, refer to Exhibit A in your Provider Agreement," and payment is "the lesser of the billed charge or the applicable fee under Exhibit A." Its Kentucky Regulatory Addendum (which does not apply to self-funded plans) requires Evernorth to provide fee schedules on request before contracting, to give at least 90 days’ notice of fee-schedule changes and material changes, 15 days’ notice of changes to prior authorization programs, and limits retroactive denials to 24 months after payment. Fee questions go to Provider Services at 800.926.2273. Telehealth is billed with modifier 95, which "will not change the reimbursement." Kentucky’s prompt-pay law requires an insurer to pay a clean claim, or send notice denying or contesting it, "within thirty (30) calendar days from the date that the claim is received" (KRS 304.17A-702), with interest added automatically on late clean claims at 12 percent a year for the first 30 days late, 18 percent for days 31–60, and 21 percent after that (KRS 304.17A-730). Self-funded ERISA plans are outside the state statute.[3][8][9]
Evernorth’s Behavioral Health Administrative Guidelines (September 2026) set the filing limit: "We will only consider claims submitted within 90 days of the date of service or as otherwise defined in your Provider Agreement," unless "Applicable state law provides for a longer timely filing limit." 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]," Medicaid-primary claims get three years, and a timely claim returned for more information gets a new 90 days from the date of the request. The Kentucky Regulatory Addendum adds no filing deadline, but Evernorth need not correct a claim payment error if the request is filed "more than twenty-four (24) months after the date that Provider received payment for the claim." State addenda do not apply to self-funded plans. The guidelines publish no check-run or weekly cut-off schedule.[3][8][9]
Evernorth’s EN0499 sets what a continued-treatment request must show: "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," with collection dates, for every behavior and skill targeted; data showing "ongoing and sustained progress toward mastering the treatment goals"; measurable improvement on "a reliable, valid, and standardized assessment instrument completed no more than one year prior to the start date of the continued treatment request"; an account of barriers and plan changes where progress is not shown; and dated stakeholder (caregiver) training data. EN0499 does not require the data to be graphed.[1]
The questions that decide whether a family can start with Cigna / Evernorth in Kentucky, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the diagnosis, but the request needs "the date on which the diagnosis was most recently made," the standardized instrument within 60 days before treatment, and baseline data within 60 days; provisional or rule-out diagnoses are not confirmed (EN0499).[1]
A professional licensed to practice independently "whose licensure board considers diagnostics to be within their scope of practice," with name, credentials and licensure type provided (EN0499). Kentucky excludes diagnosis from ABA practice (KRS 319C.010(8)).[1][11]
No single instrument is mandated; it must be reliable, valid and standardized and the current edition ("must be the Vineland-3 vs. Vineland-II"), with date, respondent and form type reported (EN0499).[1]
EN0499 requires no referral; assessments need no PA with an autism diagnosis, and treatment needs authorization. Evernorth publishes no ABA order form or validity period. On the claim, Evernorth’s administrative guidelines (September 2026) define a complete CMS-1500 claim without a referring provider (they require the rendering provider’s name, NPI and license type and the billing provider’s name, address and NPI); any "Referring Provider" reported on an 837 claim "must include the name and NPI." For a fully insured Kentucky plan, KRS 304.17A-142 defines covered ABA as ABA "prescribed or ordered by a licensed health or allied health professional," so keep a signed order or prescription on file; the insurer may also request a treatment plan for continuing services. Self-funded ERISA plans sit outside the statute.[2][1][4][3]
"All ABA CPT codes are covered telehealth services" (autism resource guide), and EN0499 allows in-person, telehealth or hybrid delivery chosen on clinical factors; bill modifier 95 with POS 02. Fully insured Kentucky plans must also cover telehealth equivalently to in person and may require a Kentucky-licensed provider (KRS 304.17A-138).[2][1][3][6]
EN0499 sets no age cap; access to focused intervention "should not be restricted by age." For fully insured Kentucky plans issued or renewed on or after January 1, 2019, KRS 304.17A-142 carries no age limit and bars any maximum annual benefit or visit limit on autism treatment. Self-funded ERISA plans are outside the statute, so plan funding type decides whether that binds.[1][4]
Ask the plan: Live benefits verification: establish fully insured vs. self-funded ERISA first.
Depends on how the plan is funded. Fully insured Kentucky plans fall under KRS 304.17A-607: a utilization review decision on urgent care is due "no later than twenty-four (24) hours after obtaining all necessary information," and on non-urgent care "within five (5) days of obtaining all necessary information" (limited to face-to-face evaluation results, any required second opinion, and information the Department of Insurance designates). A missed deadline "shall be deemed to be a prior authorization for the health care services." For ongoing autism treatment, KRS 304.17A-142 limits utilization review to once every 12 months unless the insurer and the treating physician or psychologist agree otherwise. Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1: pre-service decisions "not later than 15 days after receipt of the claim," with one 15-day extension. Cigna/Evernorth publishes no Kentucky-specific ABA turnaround.[7][4][18]
Ask the plan: At benefits verification ask whether the plan is fully insured (Kentucky-regulated) or self-funded (ERISA).
For a child on two group plans, Kentucky follows the birthday rule: when the parents are married, are not separated, or share joint custody without a decree assigning coverage, the plan of the parent "whose birthday is earlier in the year" is primary; same birthday, the plan that has covered a parent longer; a court decree naming the responsible parent controls (806 KAR 18:030). If the plans cannot agree within 30 calendar days of having everything needed, they pay in equal shares and settle afterwards. That rule binds state-regulated group plans; a self-funded plan sets its own order. If the child also has Kentucky Medicaid, the commercial plan pays first: Medicaid MCOs "cost avoid" claims when other coverage is known (42 CFR 433.139).[10][19]
Ask the plan: Ask Cigna/Evernorth at benefits verification for the coordination-of-benefits order.
Coverage decides whether Cigna / Evernorth in Kentucky 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.
Direct and indirect case supervision at "one to two hours per ten hours of direct treatment"; at 10 hours a week or less, at least one to two hours a week of direct case supervision (EN0499). Kentucky’s board rule (201 KAR 43:050) governs supervision of licensed assistants and temporary licensees.[1][20]
"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)." EN0499 also says ABA "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)."[2][1]
No per-day cap is published; ABA codes bill in 15-minute units using 97151–97158, 0362T and 0373T only. Kentucky’s mandate bars visit limits in fully insured plans.[2][4]
Each service record includes the "Name, credential (if applicable), and signature of ABA provider who rendered the service," with service type and details (EN0499).[1]
Services "primarily educational or vocational in nature, or related to academic or work performance are not covered"; services in academic or vocational settings or by telehealth must still meet the direct-treatment definition (EN0499).[1]
No. Evernorth’s EN0499 requires dated data collected within 60 days before both the requested start date and the request’s receipt, sustained progress, and a standardized assessment from the past year, but it does not require graphs.
90 days from the date of service unless your provider agreement or a longer state limit applies; secondary claims get 90 days from the primary payer’s EOB/EOP date, and a claim returned for more information gets a new 90 days. No check-run schedule is published.
Yes, under EN0499 for ASD, with Kentucky’s KRS 304.17A-142 mandate layered on for fully insured plans.
No, for 97151, 97152 and 0362T with an autism diagnosis when the provider is independently licensed or a BCBA. PA starts at treatment.
Only with a Kentucky license: the Kentucky ABA board requires a license for telehealth to a client located in Kentucky (201 KAR 43:100), and fully insured plans may require a Kentucky-licensed telehealth provider (KRS 304.17A-138).
Cigna publishes no ABA rates; your fee schedule is Exhibit A of your Evernorth Provider Agreement. The Kentucky Medicaid FFS rate for 97153 ($12.18 per 15 minutes) is the only 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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