For an intake team in Maine, a Cigna card means three layers: Evernorth’s national ABA policy EN0499 with the Cigna autism resource guide, Maine’s autism mandate in Title 24-A, and the plan’s funding type. Many Cigna members are on self-funded employer plans, which the Maine mandate does not reach, so check funding first.
Cigna, through Evernorth Behavioral Health, covers ABA under EN0499 (effective May 15, 2026). Per the autism resource guide, "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 the completed assessment and treatment plan on the ABA Prior Authorization Form. EN0499 and the resource guide contain no Maine-specific criteria, so the national criteria apply. Evernorth’s September 2026 Administrative Guidelines carry a Maine Regulatory Addendum that applies to insured (not self-funded) business and repeats Maine’s 12-month limit on retrospective denials of paid claims.[1][2][3]
Maine’s autism mandate is written three times, once for each kind of contract: 24-A M.R.S. § 2768 for individual health insurance, § 2847-T for group policies, and § 4259 for individual and group HMO contracts. The operative text is the same in all three. The plan "must provide coverage for autism spectrum disorders for an individual covered under a policy or contract who is 10 years of age or under." It must cover "any assessments, evaluations or tests by a licensed physician or licensed psychologist to diagnose whether an individual has an autism spectrum disorder," and must cover treatment "when it is determined by a licensed physician or licensed psychologist that the treatment is medically necessary," with ongoing medical necessity demonstrable "at least annually." It "may not include any limits on the number of visits," but it "may limit coverage for applied behavior analysis to $36,000 per year" (the group and HMO versions add "to the extent allowed by federal law"), and payments for unrelated care may not count toward that cap. ABA is covered as a habilitative or rehabilitative service, and "To be eligible for coverage, applied behavior analysis must be provided by a person professionally certified by a national board of behavior analysts or performed under the supervision of" such a person. The mandate does not change a school’s obligations under an IEP or IFSP. The age ceiling was 5 until P.L. 2013, c. 597 raised it to 10 for policies issued or renewed from January 1, 2015. Two practical consequences: a child turns out of the mandate at 11, after which ABA depends on the plan’s own terms; and the mandate binds fully insured plans regulated in Maine, not self-funded employer plans, which answer to ERISA and their plan documents.[4][5][6][7]
Maine does not license behavior analysts. The BACB’s U.S. licensure table, which lists every state with a behavior-analyst licensure law and its board, does not include Maine, and Title 32 of the Maine Revised Statutes (professions and occupations) has no behavior-analyst chapter (chapter 141, sometimes cited for this, is the professional land surveyors chapter). The working credential is BACB certification, which the mandate itself requires for whoever provides or supervises ABA. Maine’s credentialing statute still helps: under 24-A M.R.S. § 4303(2)(D) a carrier must decide a completed credentialing application "within 60 days," must review a new application within 30 days and return an incomplete one "with a comprehensive list of all corrections needed," and "may not require that a provider have a home address within the State." Under § 4303(2-A), once credentials are granted the carrier pays claims for services rendered "from the date a complete application for credentialing is submitted," though you may not submit those claims until the carrier tells you the credentialing outcome and effective date. Commercial ABA rates are negotiated and unpublished, and the MaineCare ABA rate (Section 28, H2021 U1 HK) sits on a fee schedule we could not retrieve this month.[13][14][10][5][17]
Cigna publishes no ABA rate table. Evernorth’s Administrative Guidelines (September 2026) 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." Fee questions go to Provider Services at 800.926.2273. Virtual services carry modifier 95, which Evernorth says "will not change the reimbursement." Non-credentialed technicians are paid only through the supervising provider’s claim.[3][2]
Maine’s prompt-pay law, 24-A M.R.S. § 2436, makes a health claim "payable within 30 days after proof of loss is received"; a claim "neither disputed nor paid within 30 days is overdue" and bears interest at 1½% a month. A provider may submit a claim to every carrier that may be liable, primary and secondary, at the same time, and each must pay or deny "within 30 calendar days after the carrier has received all information needed," whether or not the other carrier has acted. A claim the carrier rejects for not using the standard claim form cannot be billed to the family; fix and resubmit it. After payment, § 4303(10) bars a carrier from retrospectively denying a paid claim more than 12 months after payment unless it gives the reason in writing and the claim falls within narrow exceptions (up to 36 months for duplicate payment, services not delivered, adjustment with another insurer or legal action; beyond that only for fraud or Medicaid/Medicare/CHIP claims). Appeals of an adverse treatment decision must be heard by a clinical peer who was not involved in the first decision (§ 4304(7)). The timely-filing limit itself is a contract term, not a statute. Evernorth’s own filing limit: it "will only consider claims submitted within 90 days of the date of service or as otherwise defined in your Provider Agreement," with exceptions including a longer limit under state law; electronic claims use payer ID 62308.[11][10][8][3][2]
Evernorth’s guidelines also set the secondary and resubmission clocks: 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 Maine Regulatory Addendum also says Evernorth "shall allow for the submission of a claim that was previously denied by another insurer because of Participant’s transfer or termination of coverage." No check-run or weekly cut-off schedule is published.[11][10][8][3][2]
Maine issues no behavior-analyst license, so there is no Maine license to add. Evernorth’s Administrative Guidelines say "Providers must meet all state requirements to provide virtual behavioral services, including any licenses and certifications," and that providers who meet the telehealth specialty requirements "may deliver services virtually with no additional credentialing" after filing the Attested Specialty Form. Maine’s telehealth law for insured plans keys eligibility to "acting within the scope of the provider’s license" and bars telehealth-only credentialing. Check your home state’s rules on serving clients located in Maine.[3][9][13]
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 Maine, 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, rule-out or school-only identification doesn’t count. The clocks run on data: the standardized instrument within 60 days before treatment, baseline data within 60 days, and current data within 60 days of a continued-treatment request.[1]
A healthcare professional "licensed to practice independently and whose licensure board considers diagnostics" within scope, applying DSM-5-TR criteria.[1]
No single instrument is mandated, but it must be standardized, complete and the current edition (the policy’s example: "must be the Vineland-3 vs. Vineland-II").[1]
EN0499 requires no referral. Assessments 97151, 97152 and 0362T need no PA with an autism diagnosis; treatment needs the ABA PA form. For a fully insured Maine plan, the mandate covers treatment "when it is determined by a licensed physician or licensed psychologist that the treatment is medically necessary," and the plan may require that physician or psychologist to demonstrate ongoing medical necessity "at least annually." Self-funded ERISA plans sit outside the statute.[2][1][5]
"All ABA CPT codes are covered telehealth services" per the autism resource guide, and EN0499 allows in-person, telehealth or hybrid delivery; the line-of-sight requirement "does not apply to telehealth services." Evernorth bills virtual services with modifier 95. For a fully insured Maine plan, 24-A M.R.S. § 4316 says a carrier "may not deny coverage on the basis that the health care service is provided through telehealth if the health care service would be covered if it were provided through in-person consultation," that "Prior authorization is required for telehealth services only if prior authorization is required for the corresponding covered health care service," and that "An in-person consultation prior to the delivery of services through telehealth is not required." Coverage may not be limited "on the basis of geography, location or distance for travel," and the carrier may not add telehealth-only credentialing. Self-funded employer plans are outside the statute.[2][1][3][9]
EN0499 sets no age cap; it says access to focused intervention "should not be restricted by age, cognitive level, diagnosis, or co-occurring conditions." For fully insured Maine plans, 24-A M.R.S. §§ 2768, 2847-T and 4259 require autism coverage for a covered person "10 years of age or under" and allow ABA to be capped at $36,000 a year; from age 11 the plan’s own terms decide. Self-funded ERISA plans are outside the statute.[1][4][5][6]
Ask the plan: Live benefits verification, or the Evernorth Autism Care Coordinator team on 877.279.7603: establish fully insured vs. self-funded ERISA first.
Depends on how the plan is funded. Fully insured Maine plans fall under 24-A M.R.S. § 4304(2): a provider’s prior-authorization request for a nonemergency service "must be answered by a carrier within 72 hours or 2 business days, whichever is less." The same clock restarts when the carrier asks for more information (from receipt of it) or says outside consultation is needed. "If a carrier does not grant or deny a request for prior authorization within the time frames required under this subsection, the request for prior authorization by the provider is granted." Once approved, the carrier "may not retrospectively deny coverage or payment for the originally approved service" absent fraudulent or materially incorrect information, and may not deny the claim when the service is delivered within 14 days before or after the approved date. Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1 instead: pre-service decisions "not later than 15 days after receipt of the claim," one 15-day extension. Cigna/Evernorth publishes no Maine-specific ABA turnaround or reauthorization lead time. Evernorth’s resource guide warns that a late ABA request "may result in a retrospective review and could delay the determination for up to 30 days."[8][15][2]
Ask the plan: At benefits verification ask whether the plan is fully insured (Maine-regulated) or self-funded (ERISA), and what reauthorization lead time Evernorth expects.
Maine lets a provider bill every potentially liable carrier at once: under 24-A M.R.S. § 2436(1-A) each carrier, primary or secondary, must pay or deny "within 30 calendar days after the carrier has received all information needed to pay or deny the claim whether or not another carrier with which it is attempting to coordinate has acted." If two carriers cannot agree on the order of benefits within 30 days of having everything they need, Bureau of Insurance Rule ch. 790 says they "shall immediately pay the claim in equal shares" and settle up afterward, with neither paying more than it would have as primary. We did not find Maine’s order-of-benefit (birthday-rule) text this month, so ask the carriers which plan is primary. If the child also has MaineCare, Cigna/Evernorth pays first: "MaineCare is the payer of last resort," and a medical-necessity denial from the commercial plan must be appealed before MaineCare will consider the claim (MaineCare Benefits Manual Ch. I, § 1.07-3). TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[11][12][16][18][19][20]
Ask the plan: Ask Cigna/Evernorth at benefits verification for the member’s coordination-of-benefits order (and whether a self-funded plan follows its own order), and record every other coverage the child has, including MaineCare.
Coverage decides whether Cigna / Evernorth in Maine 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 by a BCBA, a Licensed Behavior Analyst, or an independently licensed mental health professional with ABA training. Direct plus indirect case supervision runs 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.[1]
"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)." Other therapies are a separate rule: EN0499 (eff. 5/15/2026) says “Provision of ABA treatment 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. All ABA codes bill in 15-minute units and only with 97151–97158, 0362T and 0373T. A fully insured Maine plan may cap ABA at $36,000 a year but may not limit visits.[2][5]
Each service record must include, among other elements, the "Name, credential (if applicable), and signature of ABA provider who rendered the service."[1]
"Services that are considered primarily educational or vocational in nature, or related to academic or work performance are not covered or reimbursable." EN0499 lists academic and vocational placements among settings with their own behavioral expectations, so ABA there must still be direct treatment. The Maine mandate leaves school IEP and IFSP obligations untouched.[1][5]
"Evernorth does not credential nonlicensed/noncertified staff. Services for these staff members must be billed under the supervising provider." On a CMS-1500, "List only a BCBA or other licensed provider in box 33"; electronic claims use payer ID 62308.[2]
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 national policy EN0499 for ASD, with Maine’s autism mandate layered on for fully insured plans (children 10 and under). 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 and the plan covers ABA. PA starts at treatment.
Maine issues no behavior-analyst license, and Evernorth accepts a BCBA as an ABA billing provider. Technicians are not credentialed and are billed under the supervising provider.
Cigna publishes no ABA rates. Evernorth says your fee schedule and the list of reimbursable autism services are in Exhibit A of your Provider Agreement; call Evernorth Provider Services (800.926.2273) with fee questions.
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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