For a Michigan intake team, a Cigna card means Evernorth’s national ABA policy (EN0499), Cigna’s autism resource guide for the operational rules, Michigan’s autism mandate (MCL 500.3406s), and the plan’s funding type. Cigna is easy at the front door (no prior authorization on assessments) and exacting on treatment-plan data.
EN0499 (effective May 15, 2026) covers ABA for a confirmed ASD diagnosis (F84.0–F84.9, excluding F84.2 Rett syndrome) made by an independently licensed clinician, with the diagnosing clinician’s name, credentials and the date of the most recent diagnosis. The ABA assessment must use a current, standardized instrument covering the DSM-5-TR domains, and baseline data must be collected within 60 days before treatment. Case supervision runs one to two hours per ten hours of direct treatment. Cigna’s autism resource guide adds the operational rules: no prior authorization for 97151, 97152 or 0362T when the provider is independently licensed or a BCBA; only one provider bills a unit of time except the 97153/97154 plus 97155 pairing; unlicensed staff are billed under the supervising provider; and all ABA codes may be delivered by telehealth.[1][2]
Reauthorization: EN0499 asks for dated numbers, not graphs. Requests need “Quantitative baseline data” for every target behavior and skill, collected within 60 days before treatment started, and, when treatment began more than 60 days earlier, “interim, and current data … collected and provided within no more than 60 days prior to the date the authorization request is received,” reported separately for each setting and in the same unit as each goal’s mastery criteria.[1][2]
Michigan’s autism mandate has two parallel statutes: MCL 500.3406s for insurers (added by 2012 PA 100, amended by 2016 PA 276, applying to policies delivered, issued or renewed beginning 180 days after its April 18, 2012 enactment) and MCL 550.1416e for health care corporation group and nongroup certificates. Both require coverage "for the diagnosis of autism spectrum disorders and treatment of autism spectrum disorders," including behavioral health treatment such as applied behavior analysis, and bar the carrier from limiting the number of visits, from denying coverage because treatment "is educational or habilitative in nature," and from applying dollar limits, copays, deductibles or coinsurance that do not apply to physical illness generally.[3][4]
Unlike newer mandates, Michigan’s still carries age and dollar ceilings the carrier may choose to apply: coverage for treatment may be limited "through 18 years of age" and to a maximum annual benefit of $50,000 through age 6, $40,000 from 7 through 12, and $30,000 from 13 through 18. Treatment must be "prescribed or ordered" by a licensed physician or licensed psychologist who finds it medically necessary, behavioral health treatment must be "provided or supervised by a board certified behavior analyst or a licensed psychologist," and the diagnosis means assessments "including the autism diagnostic observation schedule, performed by a licensed physician or a licensed psychologist." While a member is in treatment the carrier may require a treatment plan and treatment review, request the ADOS results, request that the ADOS be repeated no more than once every three years, and request an annual development evaluation. Utilization review, medical-necessity review, network requirements and coordination of benefits still apply. Exempt: self-funded ERISA employer plans (outside state insurance law), exchange qualified health plans to the extent the coverage exceeds essential health benefits, and, under 500.3406s, short-term policies of six months or less.[3][4]
Michigan licenses behavior analysts through LARA’s Board of Behavior Analysts under Part 182A of the Public Health Code (Michigan’s licensure law dates from 2016). A license requires current BACB certification in good standing sent directly from the BACB, a criminal background check, human-trafficking and implicit-bias training, and renews every four years; assistant behavior analysts have their own LARA license and supervision verification. Technicians are not licensed by the state. Cigna does not publish commercial ABA rates for Michigan; they are contract terms.[5][6][7]
Michigan’s prompt-pay statute, MCL 500.2006(8), governs insured health plans (it excludes administrative-services-only arrangements): "A clean claim must be paid within 45 days after receipt of the claim by the health plan," with 12% simple annual interest after that; the plan must flag defects within 30 days, and the provider gets 45 days to fix them. A provider "must bill a health plan within 1 year after the date of service" for the claim to be a clean claim.[17][16]
Evernorth "will only consider claims submitted within 90 days of the date of service or as otherwise defined in your Provider Agreement," and a longer state-law limit applies where one exists. Appeals are initiated in writing within 180 calendar days of the initial payment or denial decision, and most are resolved within 60 calendar days. Evernorth’s Michigan Regulatory Addendum is longer for state-regulated plans: "Claims for Covered Services must be submitted within one (1) year of the date of service."[17][16]
Network exceptions, the Cigna term for a single case agreement. Evernorth “requires prior authorization for the applied behavior analysis (ABA) level of care, including network exception requests.” Assessment codes normally need no authorization, but “authorization is required for 97151, 97152, or 0362T when requesting a network exception.” The request goes on the ABA prior authorization form (07/26) to ABA@Evernorth.com (preferred) or fax 860.687.9230. Product type matters: Evernorth’s guidelines say “HMO plans offer in-network coverage only” while “POS plans offer in- and out-of-network coverage,” and Cigna Connect covers out-of-network providers only for emergencies and “special circumstances.” On the HMO, SureFit and Cigna Connect products the guidelines describe, “Referrals are not required for behavioral health services.” Michigan adds a network wrinkle: under the Priority Health alliance (effective January 1, 2021), Lower Peninsula providers “must be contracted through Priority Health to be considered in network for patients with a Priority Health ID card,” and “must be contracted through Evernorth to be considered in network for patients with Cigna Healthcare coverage.” Evernorth publishes no out-of-network ABA rate; the member’s plan sets it.[14][15][16][1]
Appeals packet. Evernorth wants every appeal “in writing within 180 calendar days of the date of the initial payment or denial decision,” or within 180 days of the last payment adjustment. Each appeal must be submitted by a person, not by automation software. Rate and fee-schedule disputes “may be quickly resolved through submitting an adjustment request via the reconsideration feature on Provider.Evernorth.com.” Contract-rate appeals can be faxed to 877.804.1679 or mailed to Cigna Healthcare, PO Box 188062, Chattanooga, TN 37422, unless your agreement says otherwise. For medical-necessity denials, send the clinical information; Evernorth “strongly encourage[s] the submission of clinical information prior to the peer-to-peer review or appeal process.” An out-of-network provider may also need “a valid Appointments of Representative form signed by the patient” for a standard appeal to count, so confirm on the number on the ID card.[14][15][16][1]
Whose authorization is it? The prior authorization form identifies the “Servicing clinic” by name, Taxpayer Identification Number (TIN) and servicing address, then the supervising provider and their credential, and asks whether the same provider will supervise the whole treatment. An approval “will be written on a per month basis with CPT code 97155” and can be interchanged with 97153–97158 and 0373T. EN0499 adds that ABA from “multiple ABA provider organizations/agencies/companies during the same authorization period” is not medically necessary unless the agencies document a coordination plan, consistent strategies and a combined intensity that fits. So a switching family’s new agency needs its own authorization.[14][15][16][1]
What the assessment must contain. Standard 97151, 97152 and 0362T need no prior authorization when a BCBA or independently licensed provider bills with an ASD diagnosis. The report still has to meet EN0499 when treatment is requested. It must use a standardized instrument in its current edition (“must be the Vineland-3 vs. Vineland-II”), completed in full, with the date, the respondent and the form type. It must include “Standardized scores and score tables, and/or scoring grids/figures.” Administration must fall “within 60 days prior to the start of treatment,” with dated quantitative baseline data from the same window. It must also name the diagnosing clinician, their credentials and the date of the diagnosis.[14][15][16][1]
Who may bill which code. Evernorth’s ABA billing-code table: 97151, 0362T, 97155, 97156, 97157, 97158 and 0373T are both provided and billed by a “BCBA-D, BCBA, or licensed mental health provider.” 97152, 97153 and 97154 may be provided by a “BCaBA, Technician” but are billed by the BCBA-D, BCBA or licensed provider. Evernorth’s code table, PA form and administrative guidelines define no HM/HN/HO/HP credential modifiers.[14][15][16][1]
What changes on Jan. 1, 2027. CMS records that at its September 2025 meeting the AMA CPT Editorial Panel "deleted CPT codes 0362T" and "0373T," "revised eight existing CPT codes" (97151 through 97158) and "created six new CPT codes" for adaptive behavior services; the AMA released the CPT 2027 code set on Sept. 9, 2026, with changes in effect on January 1. The ABA Coding Coalition’s 2027 guidance gives the final numbers: 97148 and add-on +97149 (behavior identification supporting assessment of harmful behavior, delivered by two technicians, additional technicians on the add-on), 97159 and add-on +97160 (adaptive behavior treatment of harmful behavior, same two-technician structure), 97173 (adaptive behavior treatment with analysis by a physician or other QHP, face-to-face with one patient) and 97180 (non-face-to-face services personally performed by the QHP, such as data review and modifying protocols). "Protocol modification" becomes "analysis" in the descriptors, and "since there is no grace period, 0362T and 0373T are invalid for dates of service on or after January 1, 2027." No state "approves" the codes themselves: they are Category I CPT codes that HIPAA requires on electronic claims, but, as the Coalition notes, HIPAA "does not, however, govern whether a payer covers a code / service, what a payer pays for a code / service, or what a payer requires to authorize" it, so each payer has to load them, price them and say how authorizations that list 0362T or 0373T carry over.[18][19][20][1]
Cigna had published no 2027 adaptive-behavior code guidance as of Nov. 1, 2026: Evernorth coverage policy EN0499 (Intensive Behavioral Interventions, effective May 15, 2026) still lists the current code set, including 0373T. Ask Cigna how it will load and price the new codes and whether authorizations that list 0362T or 0373T carry over.[18][19][20][1]
The questions that decide whether a family can start with Cigna / Evernorth in Michigan, and what they have to bring. Each maps onto something intake should ask on the first call.
EN0499 requires "The date on which the diagnosis was most recently made" and the diagnosing clinician’s name, credentials and licensure, but sets no maximum age for the diagnosis. The standardized assessment and baseline data must be within 60 days before treatment starts. On fully insured Michigan plans the mandate lets the carrier request a repeat ADOS no more than once every three years.[1][3]
A confirmed ASD diagnosis (F84.0–F84.9, except F84.2 Rett syndrome) based on DSM-5-TR "by a healthcare professional who is licensed to practice independently and whose licensure board considers diagnostics to be within their scope of practice." For fully insured Michigan plans the mandate names a licensed physician or licensed psychologist.[1][3]
EN0499 names no diagnostic instrument; it requires the ABA assessment to use a reliable, valid, standardized instrument covering the DSM-5-TR ASD domains, completed in full, current version (e.g., Vineland-3, not Vineland-II), administered by a trained person, dated and naming the respondent, within 60 days before treatment starts.[1]
Cigna’s national ABA policy requires no referral; ABA assessments (97151, 97152, 0362T) need no prior authorization when the provider is independently licensed or a BCBA and the policy covers ABA, and treatment is requested on the ABA Prior Authorization Form after the assessment. For a fully insured Michigan policy the mandate adds an order requirement: covered treatment is care "prescribed or ordered for an individual diagnosed with 1 of the autism spectrum disorders by a licensed physician or a licensed psychologist who determines the care to be medically necessary," and the treatment plan is developed "when the treatment of an autism spectrum disorder is first prescribed or ordered." Self-funded ERISA plans sit outside the statute.[2][3]
"All ABA CPT codes are covered telehealth services," per Cigna’s autism resource guide, with EN0499 governing the documentation for services delivered via telehealth. Claim coding comes from Evernorth’s administrative guidelines (September 2026): when billing telehealth, use “Modifier 95 in Field 24-D to specify telehealth” and “02 for Place of Service in Field 24-B.”[16][2][1]
EN0499 sets no age cap. Michigan’s mandate lets a fully insured carrier limit autism treatment coverage to members "through 18 years of age" and cap it at $50,000 a year through age 6, $40,000 for ages 7–12 and $30,000 for ages 13–18; whether a given plan uses those limits is in its certificate. Self-funded ERISA plans set their own terms.[1][3][4]
Ask the plan: Cigna Coverage Confirmation Grid or the Autism Care Coordinator team (877-279-7603): fully insured vs. self-funded, and any certificate age or dollar limits.
Turns on how the plan is funded. Fully insured Michigan insurance and HMO plans follow MCL 500.2212e: after May 31, 2024 a non-urgent prior authorization request "is considered granted" if the insurer does not grant it, deny it, or ask for more information "within 7 calendar days after the date and time of submission," and again within 7 calendar days after additional information is submitted; a request the provider certifies as urgent is considered granted if not acted on within 72 hours. An approved authorization "is valid for not less than 60 calendar days or for a duration that is clinically appropriate, whichever is later." The statute’s "health benefit plan" covers individual and group insurance, HMO contracts, and self-funded plans of the state or local governments, not private self-funded employer plans, which follow ERISA: pre-service decisions "not later than 15 days after receipt of the claim," one 15-day extension, urgent claims within 72 hours.[8][9]
Ask the plan: At benefits verification ask whether the plan is fully insured (Michigan-regulated) or self-funded (ERISA), then confirm the Cigna/Evernorth turnaround and reauthorization lead time (the Evernorth Autism Care Coordinator team, 877-279-7603).
Which plan pays first is set by Michigan’s Coordination of Benefits Act for state-regulated plans: for a dependent child whose parents are married or living together, "The plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (same birthday: the plan covering the parent longer); for divorced or separated parents a court order assigning health coverage controls, then the order in MCL 550.253. The autism mandate adds that a member with two policies covering autism gets benefits "subject to the limits of this section when coordinating benefits." If the child also has Michigan Medicaid, Cigna pays first: Medicaid is payer of last resort and "is not liable for payment of services denied because coverage rules of the primary health insurance were not followed," so get Cigna’s authorization even when Medicaid (the PIHP) will pay secondary. TRICARE pays after other coverage except Medicaid (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[10][3][11][12][13]
Ask the plan: Ask Cigna at benefits verification for the member’s coordination-of-benefits order (the Evernorth Autism Care Coordinator team, 877-279-7603); self-funded plans set their own COB terms in the plan document. Record every other coverage the child has.
Coverage decides whether Cigna / Evernorth in Michigan 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 mental health professional trained in ABA, with direct and indirect case supervision "consistent with the general accepted standard of care of 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 of direct case supervision. The supervisor’s name and credentials must be documented.[1]
Allowed only for the named pairs: "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)."[2]
Setting-neutral with conditions: where services are delivered in environments such as an academic setting, a vocational placement or via telehealth, the documentation must show the service is direct ABA treatment in line with the treatment plan and that ABA is "not utilized to replace or replicate activities that are the responsibility of the setting" (for example a classroom aide, 1:1 teacher or tutor). Treatment plans list the settings (home, clinic, school, community).[1]
"Evernorth does not credential nonlicensed/noncertified staff. Services for these staff members must be billed under the supervising provider." ABA must be billed with 97151–97158, 0362T and 0373T only; the resource guide lists who may provide and bill each code (BCBA-D, BCBA or licensed mental health provider for the analyst codes).[2]
Cigna publishes no per-day unit ceiling. Hours are authorized on EN0499 medical-necessity criteria from the submitted treatment plan (baseline data within 60 days of the treatment start, measurable goals, stakeholder training); multiple ABA agencies in one authorization period are not medically necessary unless coordinated and non-duplicative.[1]
Ask the plan: The Evernorth authorization determination, or the Autism Care Coordinator team, 877-279-7603.
Not addressed in EN0499 or the autism resource guide beyond requiring the name and credentials of the supervisor and stakeholder trainer to be documented.[1][2]
Ask the plan: The Cigna/Evernorth provider agreement and administrative guidelines, or Provider Services, 800-926-2273.
EN0499 does not mention graphs. It requires dated quantitative baseline, interim and current data, with current data collected within 60 days before the request, broken out by setting.
No, for 97151, 97152 and 0362T when the provider is independently licensed or a BCBA and the member’s policy covers ABA. Treatment requires prior authorization.
Cigna’s autism resource guide says all ABA CPT codes are covered telehealth services, with EN0499 documentation rules.
Only to fully insured plans. Many Cigna employer plans are self-funded and exempt; verify funding type first.
Within 45 days of receipt for a clean claim on an insured plan (MCL 500.2006(8)), with 12% interest after that. Self-funded plans are not covered.
One year from the date of service for state-regulated plans under Evernorth’s Michigan Regulatory Addendum; 90 days is Evernorth’s general limit.
EN0499 (effective 5/15/2026) requires a confirmed DSM-5-TR ASD diagnosis from an independently licensed clinician whose scope includes diagnosis. The record must give "the name, credentials, and type of licensure" of the diagnosing clinician and "the date on which the diagnosis was most recently made." A provisional or rule-out diagnosis, or an IDEA educational identification, does not count. For treatment, the BCBA's assessment must use a current-edition standardized instrument, completed in full and administered "within 60 days prior to the start of treatment," with score tables. The treatment plan's goals must match the deficits it found.
Cigna/Evernorth calls it a network exception. It needs prior authorization on the Evernorth ABA PA form, including for the 97151, 97152 and 0362T assessment codes that otherwise need none. HMO plans cover in-network providers only.
The PA form names the servicing clinic by TIN and the supervising provider by credential. Approvals are written per month on 97155. A new agency requests its own authorization, and two agencies in the same period must document coordination.
Not as of Nov. 1, 2026. Evernorth policy EN0499 (effective May 15, 2026) still lists the current codes, including 0373T. CPT 2027 deletes 0362T and 0373T and adds 97148/97149, 97159/97160, 97173 and 97180 from Jan. 1, 2027, so ask Cigna how it will price them and handle existing authorizations.
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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