For an intake team in Louisiana, a Cigna card means three layers: Evernorth’s national ABA policy EN0499 and the Cigna autism resource guide, Louisiana’s autism mandate in R.S. 22:1050, and the plan’s funding type. Many Cigna members are on self-funded employer plans, so check funding first.
Evernorth authorizes ABA under EN0499 (effective May 15, 2026) "unless contractual requirements or federal or state law requires the use of other specifically identified clinical criteria." The autism resource guide says prior authorization "is no longer required for assessment" codes 97151, 97152 and 0362T with an autism diagnosis when the provider is independently licensed or a BCBA; treatment needs the ABA Prior Authorization Form with the assessment and treatment plan, ideally requested up to 30 days ahead (late requests become retrospective reviews that can take up to 30 days). EN0499 requires an ASD diagnosis by an independently licensed clinician with diagnostic scope, a standardized assessment administered within 60 days before treatment starts, baseline data from the same window, and case supervision of 1–2 hours per 10 hours of direct treatment. Neither document mentions Louisiana.[1][2]
Louisiana’s autism mandate is La. R.S. 22:1050. Any "health coverage plan" issued, delivered or renewed in the state on or after January 1, 2014 must "provide coverage for the diagnosis and treatment of autism spectrum disorders in individuals less than twenty-one years of age," and the definition of a health coverage plan reaches insurance policies, HMO and PPO contracts, group plans and the Office of Group Benefits programs (state employees). Treatment includes habilitative care, defined to include applied behavior analysis, plus pharmacy, psychiatric, psychological and therapy care, but only care "prescribed, provided, or ordered" by "a physician or psychologist who shall be licensed in this state and who shall supervise provision of such care." Coverage may not be limited by visit count and may carry ordinary copays and deductibles, but it "shall be subject to a maximum benefit of thirty-six thousand dollars per year," and payments for unrelated care do not count toward that cap. An ABA provider must be BACB-certified or able to document equivalent education, training and supervised experience. Plans may review treatment against medical-necessity criteria "based in part on evidence of continued improvement," with appeal rights under R.S. 22:1121 et seq. The statute does not apply to individually underwritten guaranteed-renewable policies or limited-benefit policies, and self-funded employer plans answer to ERISA rather than state insurance law. legis.la.gov notes its text is current through the 2025 First Extraordinary Session.[4]
Louisiana licenses behavior analysts (La. R.S. 37:3701 et seq.; the BACB lists Louisiana’s law as enacted in 2013). The Louisiana Behavior Analyst Board issues three credentials: the licensed behavior analyst (LBA, master’s degree plus a nationally accredited exam and a Louisiana jurisprudence exam), the state-certified assistant behavior analyst (SCABA, bachelor’s level, practicing under an LBA), and the registered line technician (RLT, 18 or older with a high school diploma, registered with the board by the supervising LBA and renewed every year). It is a misdemeanor for anyone not licensed, certified or registered "to engage in the practice of behavior analysis," and to "employ as a line technician, a line technician who is not registered." Licensed psychologists may provide ABA within their training. Out-of-state BCBAs: BACB certification alone does not authorize practice in Louisiana. The board may make rules for temporary licensure and for reciprocity from states with standards "at least as stringent," and the Telehealth Access Act (R.S. 40:1223.4) requires each licensing board to provide by rule for "Licensing or registration of out-of-state healthcare providers who seek to furnish healthcare services via telehealth to persons at originating sites in Louisiana." We could not open the board’s own rules (its website is behind a captcha), so confirm the current telehealth or temporary-licensure route with the board before a remote BCBA treats a Louisiana child. The chapter is scheduled to terminate on July 1, 2028 unless the legislature extends it. On rates: commercial ABA rates are negotiated and unpublished; the public benchmark is the Louisiana Medicaid fee schedule (97153 $12.50 and 97155 $22.50 per 15 minutes), which Medicaid MCOs must pay at least.[5][6][7][8][9][10][11][12][17][18]
Evernorth’s administrative guidelines (September 2026) 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." Electronic claims use payer ID 62308. Louisiana’s prompt-pay law covers contracted providers of fully insured plans: an electronic clean claim "shall be paid, denied, or pended not more than twenty-five days" after receipt (R.S. 22:1833), a paper clean claim filed within 45 days of service within 45 days (60 days if filed later or resubmitted) (R.S. 22:1832), and a late payment carries "a late payment adjustment equal to twelve percent per annum." An issuer may elect a single 30-day standard by notice to the commissioner, and it gets the same window to audit a paid claim that it gives you to file one. These sections do not apply to the Office of Group Benefits, and self-funded ERISA plans are outside them.[3][2][14][15][1]
Billing details from Evernorth’s own documents. Codes: "All ABA services must be billed with CPT codes 97151–97158, 0362T, and 0373T ONLY," so H-codes are not accepted for ABA. Telehealth: "All ABA CPT codes are covered telehealth services"; on the CMS-1500 use "Modifier 95 in Field 24-D to specify telehealth" and "02 for Place of Service in Field 24-B"; neither document says the authorization must flag telehealth. Filing: claims must be "submitted within 90 days of the date of service or as otherwise defined in your Provider Agreement" unless state law gives longer; for coordination of benefits the 90 days run from the primary payer’s EOB or EOP; a claim Evernorth returns for more information gets a fresh 90 days from its request; corrected claims carry frequency code 7 (replace) or 8 (void) in field 22, without a "Corrected Claim" stamp. Reauthorization (EN0499): an updated treatment plan; "Quantitative baseline, interim and current data" with the dates they were collected for every behavior and skill across all settings; current data collected within 60 days before the continued-treatment start date and within 60 days before the request is received; a standardized assessment no more than one year before the start date; and a written plan to address barriers if progress stalls. EN0499 asks for dated data, not graphs by name. Supervision runs one to two hours per ten hours of direct treatment, with no published cap on technicians per supervisor.[3][2][14][15][1]
The questions that decide whether a family can start with Cigna / Evernorth in Louisiana, 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 must give "The date on which the diagnosis was most recently made," and the standardized ABA assessment must be administered within 60 days before treatment starts.[1]
A healthcare professional "licensed to practice independently and whose licensure board considers diagnostics to be within their scope of practice."[1]
A reliable, valid, standardized instrument covering the DSM-5-TR ASD domains, completed in full, in its current edition ("must be the Vineland-3 vs. Vineland-II"), with the date, respondent and form type recorded.[1]
Evernorth requires prior authorization of treatment, not a physician referral. 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 Louisiana plan, R.S. 22:1050(G)(11) covers autism treatment "prescribed, provided, or ordered" by "a physician or psychologist who shall be licensed in this state and who shall supervise provision of such care," so keep that order on file. Self-funded ERISA plans sit outside the statute.[2][4][3]
EN0499 sets no age limit. For a fully insured Louisiana plan, R.S. 22:1050 requires autism coverage for individuals "less than twenty-one years of age," subject to "a maximum benefit of thirty-six thousand dollars per year." Self-funded ERISA plans, individually underwritten guaranteed-renewable policies and limited-benefit policies are outside the statute.[1][4]
Ask the plan: Live benefits verification: fully insured vs. self-funded, then the plan’s autism age and dollar terms.
The resource guide says "All ABA CPT codes are covered telehealth services," and EN0499 allows in-person, telehealth or hybrid delivery chosen on the child’s needs. For a fully insured Louisiana plan, R.S. 22:1821(F)(2) makes services by telehealth subject to the insurer’s "utilization review criteria and requirements" and voids policy terminology "that either discriminates against or prohibits" telehealth. The clinician still needs Louisiana authority to practice: the behavior analyst licensing law applies, and R.S. 40:1223.4 tells each board to license or register out-of-state providers serving patients located in Louisiana. Self-funded employer plans are outside the state insurance statute. On the claim, Evernorth wants "Modifier 95 in Field 24-D to specify telehealth" and "02 for Place of Service in Field 24-B"; its documents do not say the authorization must flag telehealth.[2][1][13][11][3]
Ask the plan: The number on the member’s card: confirm the plan’s telehealth benefit and the POS/modifier Evernorth wants.
Evernorth asks for ABA requests "up to 30 days in advance of or two weeks after the start date of service"; a late request may become a retrospective review taking up to 30 days. 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 Louisiana plans whose contract requires prospective review, R.S. 22:1821(D)(3) treats an answer within "two working days" of the provider’s request as not unreasonable, and says a longer delay "may be considered unreasonable depending on the circumstances"; that section governs the insurer’s liability for unreasonable delay rather than setting a hard deadline.[2][19][13]
Ask the plan: At benefits verification ask whether the plan is fully insured or self-funded, and the expected turnaround.
For a child on two plans, ask both carriers for the order of benefits; Louisiana’s commissioner sets the order by regulation (R.S. 22:1836(B)), which we did not read. What the statute does say: no plan may call itself "always excess" or "always secondary" outside those rules, a plan may not reduce benefits because the child could have enrolled in another plan, and a plan may not "pend, delay, or deny payment" to a provider "solely on the basis of the insured’s failure" to report other coverage (a contracted provider must pass along any coordination-of-benefits information it gets). If the child also has Louisiana Medicaid, the commercial plan pays first: Medicaid is payer of last resort (42 CFR 433.139), and since November 2025 the Medicaid plans hold ABA authorizations as pending until you send the primary insurer’s determination. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[16][20][23][21][22]
Ask the plan: Ask Evernorth at benefits verification for the coordination-of-benefits order and record all other coverage.
Coverage decides whether Cigna / Evernorth in Louisiana 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 by a BCBA, LBA or independently licensed clinician trained in ABA, "consistent with the general accepted standard of care of one to two hours per ten hours of direct treatment," and at least 1–2 hours a week of direct supervision when direct treatment is 10 hours a week or less; the supervisor’s name and credentials must be documented. In Louisiana, technicians must also be registered line technicians (R.S. 37:3708). EN0499 publishes no cap on the number of technicians one supervisor may oversee.[1][7]
"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]
EN0499 accepts home, clinic, school and community settings but, where services happen in a setting with its own expectations (an academic setting, a vocational placement, telehealth), the record must show direct treatment for ASD symptoms and that ABA is "not utilized to replace or replicate" the setting’s own staff (classroom aide, 1:1 teacher, tutor, respite). Data must be reported separately by setting.[1]
"Evernorth does not credential nonlicensed/noncertified staff. Services for these staff members must be billed under the supervising provider."[2]
No daily unit cap is published in EN0499 or the resource guide; intensity must reflect severity, goals and response to treatment. For fully insured Louisiana plans the mandate allows no visit limits but a $36,000 annual cap.[1][4]
Ask the plan: Evernorth Autism Care Coordinator team, 877.279.7603, or your provider agreement: ask about unit edits.
No. Evernorth says all ABA services must be billed with CPT 97151–97158, 0362T and 0373T only.
EN0499 asks for dated quantitative baseline, interim and current data (current data within 60 days) and a standardized assessment within a year; it does not name graphs.
90 days from the date of service unless your agreement or state law allows longer; for secondary claims, 90 days from the primary payer’s EOB.
No, for 97151, 97152 and 0362T with an autism diagnosis when the provider is independently licensed or a BCBA and the plan covers ABA. Treatment needs the ABA Prior Authorization Form.
For fully insured plans, R.S. 22:1050 covers autism treatment for people under 21 up to $36,000 a year, with no visit limits. Self-funded plans follow their own documents.
Yes for 97155 with 97153 or 97154, when the BCBA directs the technician and both are face-to-face with the patient. Otherwise only one provider bills a unit of time.
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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