For an intake team in Missouri, a Cigna card means three layers at once: the carrier's national clinical policy, Missouri's autism insurance mandate (RSMo § 376.1224), and the plan's funding type deciding which of the two actually binds. This guide stacks them in order.
Cigna (through Evernorth Behavioral Health) covers ABA for autism under national policy EN0499 with one of the friendliest front doors in the industry: no prior authorization on assessment codes 97151, 97152, and 0362T. The rigor arrives at the treatment step, which requires the completed assessment plus a treatment plan with Cigna's ABA PA form. And unlike some states, Missouri gets the national policy straight: we searched the current EN0499 (effective 5/15/2026) end to end and Missouri appears nowhere — no carve-out, no state-specific criteria — so EN0499 applies to Missouri members except where state law requires otherwise. The legal floor underneath it is the mandate below, which governs fully-insured plans, while self-funded employer plans answer to ERISA and federal parity instead. Plan funding type is therefore the first fact to establish on every benefits check. The full national policy breakdown lives in our Cigna / Evernorth guide; this page covers what changes in Missouri.[1][2]
Missouri's mandate — enacted by 2010's HB 1311, with the current version applying to plans delivered, issued, continued, or renewed on or after January 1, 2020 (which added developmental and physical disability coverage) — reaches unusually far: beyond ordinary individual and group policies, it covers the state consolidated health care plan, self-insured governmental plans, MEWAs, and self-insured school district health plans established after 1/1/2020. ABA must be ordered by the treating licensed physician or psychologist in a treatment plan, supervised by a board-certified behavior analyst licensed under Chapter 337, and insurers may review the ABA treatment plan no more than once every 6 months unless the provider agrees otherwise. The headline number: ABA carries a $40,000-per-calendar-year cap for individuals through age 18 — statutory base value. Three things soften it: the cap may be exceeded with prior plan approval when additional ABA is medically necessary; it is CPI-indexed (carriers must adjust at least triennially, with the current adjusted figure published annually in the Missouri Register — don't quote $40K as the live number without checking); and other autism treatments (OT/PT/speech, psychiatric, pharmacy) sit outside the cap entirely. Self-funded private ERISA plans remain federally preempted.[3]
Missouri requires behavior-analyst licensure: RSMo 337.315 prohibits practicing applied behavior analysis without an LBA (or Licensed Assistant Behavior Analyst) license or an enumerated exception — supervised trainees, licensed psychologists within scope, IDEA school personnel, and students among them. The Behavior Analyst Advisory Board within the State Committee of Psychologists (Division of Professional Registration, RSMo 337.300–337.345) reviews applications, and the mandate itself requires BCBA-supervised, Chapter 337-licensed delivery — so licensure is a coverage requirement, not just a credentialing one. On rates: Cigna does not publish commercial ABA fee schedules for Missouri (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement. Benchmark against MO HealthNet's published fee schedule ($20.13/unit on 97153 at the analyst tier) when modeling.[4]
Evernorth Behavioral Health, which runs Cigna's ABA network, says it "is committed to expanding our network of autism providers." It requires providers to be certified by a national governing body or a state licensing board (BCBA, BCBA-D, BCaBA, licensed behavior analyst or other behavioral health licensure). Individual providers complete the Evernorth Behavioral Provider Information Form; autism clinics and large group practices complete the Evernorth Screening Application for Autism Clinics. An application can take up to 90 days, and once a clinic contract is signed each certified or licensed provider must also be credentialed, which "can take an additional 60 to 90 days." Providers must be fully credentialed to render in-network services. "Evernorth does not credential nonlicensed/noncertified staff": technician services are billed under the supervising provider.[2]
Yes — this is the closest any commercial payer in the state comes to a DSM-5 structure. EN0499 (effective 5/15/2026) requires "Clearly defined and measurable goals designed to target specific behaviors and skills across all settings," each naming the target behavior, the measurement method and the mastery standard, and requires that "Treatment goals are directly related to the individual's diagnosis of ASD and the symptoms of ASD defined by the DSM-5-TR (e.g., social communication and social interaction; restricted, repetitive patterns of behavior, interest, or activities)." Goals must come from the full ABA assessment, be developmentally appropriate, and carry dated quantitative baseline data and mastery criteria. The policy ties each goal to the DSM-5-TR symptom domains; it does not prescribe a template that groups them under headings.[1][3]
Missouri's mandate requires only that the plan, when requested, include "a diagnosis, proposed treatment by type, frequency and duration of treatment, and goals" (RSMo § 376.1224.4(2)).[1][3]
EN0499 requires a "Stakeholder Training" component in the treatment plan but sets no hour minimum or cap. Stakeholder (parent/caregiver, relative, teacher) training "will be conducted by a BCBA®, LBA, or a mental health professional who is licensed to practice independently" and must have "clearly defined, measurable stakeholder goals with mastery criteria," baseline data, a plan to collect progress data, separately documented data for each stakeholder group, and the trainer's name and credentials. Planned group stakeholder training needs its own measurable goals. For continued care, Cigna wants baseline, interim and current data showing stakeholders "continue to actively participate in the treatment" and are progressing toward their goals. The hours approved are set case by case on the authorization.[1]
Missouri law sets the floor for health carriers, which the statute defines to include self-insured plans "to the extent allowed by federal law". A carrier must "Permit participating health care providers to file a claim for reimbursement for a health care service provided in this state for a period of up to six months from the date of service, unless the contract between the health carrier and health care provider specifies a different standard," and must give nonparticipating providers up to one year (RSMo 376.384). So the filing window in your Cigna agreement controls, and without one it is six months.[6][7]
On payment, the carrier acknowledges an electronic claim within 48 hours and, within 30 processing days, tells you whether it is clean or what additional information it needs. Once it has the information it has ten processing days to pay or deny (or make a final request), then five more. A claim still unpaid on the 45th processing day earns "one percent interest per month and a penalty in an amount equal to one percent of the claim per day" (RSMo 376.383). Processing days stop counting while the carrier waits for your answer, and the 2003 electronic-filing rule means a paper claim falls outside these protections.[6][7]
Cigna’s timely filing policy, for claims submitted directly to Cigna: it will consider "Participating provider claims submitted three (3) months [90 days] after the date of service" and out-of-network claims submitted six months (180 days) after the date of service. The limit is longer where applicable law requires it or your provider agreement allows more time. In Missouri the statute’s defaults are six months for participating providers absent a different contract standard and one year for nonparticipating providers, so check which term your agreement sets.[8][6]
Cigna (Evernorth) publishes no referring-provider requirement for ABA. Its autism resource guide gives the ABA paper-claim instructions field by field and names only box 31 (your name), the claims mailing address and box 33 ("List only a BCBA or other licensed provider in box 33"); box 17 is not mentioned. The Evernorth administrative guidelines state for SureFit, Connect and HMO/POS plans alike that "Referrals are not required for behavioral health services."[2][5]
Leave box 17 blank unless a referral actually exists for the service. Bill technician time under the supervising provider: "Evernorth does not credential nonlicensed/noncertified staff. Services for these staff members must be billed under the supervising provider."[2][5]
CPT codes only. Evernorth’s autism resource guide states that “All ABA services must be billed with CPT codes 97151–97158, 0362T, and 0373T ONLY,” that “All of the ABA CPT codes are in 15-minute increments,” and that “Only one provider can bill for a unit of time,” except 97153, 97154 and 97155 billed during direct supervision. HCPCS H-codes such as H0031, H0032, H2014 or H2019 are not accepted for ABA on Cigna plans. EN0499’s coding section lists the same ten CPT codes as medically necessary when the policy’s criteria are met.[2][1]
EN0499’s “Criteria for Continued Treatment with ABA” require dated numbers rather than graphs. The request needs an updated treatment plan and “Quantitative baseline, interim and current data … with dates reported from when the data were collected for all behaviors and skills” across every setting where treatment occurs. Current data must be “collected within no more than 60 days prior to the start date of the continued treatment request, as well as … within no more than 60 days prior to the date the authorization request is received.” It also needs a reliable, valid, standardized assessment “completed no more than one year prior to the start date,” dated data on stakeholder (caregiver) training goals, and, where progress has stalled, the barriers and the protocol changes made. A new standardized assessment and fresh data are required after any break in treatment longer than 60 days. The policy defines interim data as covering at least the previous six months and allows it to be “reported as patient data points and/or as a relevant average.” The policy does not require graphs.[1]
The questions that decide whether a family can start with Cigna / Evernorth in Missouri, and what they have to bring. Each maps onto something intake should ask on the first call.
Cigna's recency rule attaches to the standardized assessment rather than to the diagnosis, and it is tight: initiation requires a standardized, validated instrument in its current edition administered within 60 days before treatment start. Continued treatment needs current data no more than 60 days old, a repeat standardized assessment within a year, and a re-assessment after any break longer than 60 days. Missouri's mandate sets no diagnosis-recency rule; its six-month clock governs plan review, not the age of the evaluation.[1][3]
A standardized, validated instrument in its current edition — the policy gives Vineland-3 as the example rather than a closed list — administered within 60 days before treatment start, with the deficits it measures mapped to DSM-5-TR ASD domains and into the treatment plan's goals. Continued treatment requires a repeat standardized assessment within a year. Missouri's mandate names no instrument.[1]
No Cigna referral, but the state mandate wants an order. The Evernorth administrative guidelines state for SureFit, Connect and HMO/POS plans alike that "Referrals are not required for behavioral health services." EN0499 gates ABA on a confirmed ASD diagnosis, a standardized assessment and a compliant treatment plan, not on a physician order. Assessment codes 97151, 97152 and 0362T need no prior authorization when the provider is independently licensed or a BCBA. Missouri's mandate requires ABA to be "ordered by the insured's treating licensed physician or licensed psychologist, pursuant to the powers granted under such licensed physician's or licensed psychologist's license, in accordance with a treatment plan" (RSMo § 376.1224). Keep that order and the treatment plan on file for any plan the statute reaches. It does not reach private self-funded ERISA plans, but it does reach self-insured governmental plans. Cigna publishes no order form and sets no validity period for one. The gate is the Applied Behavior Analysis Prior Authorization Form, filed with the assessment and treatment plan. The same statute requires the ABA to be supervised by a board-certified behavior analyst licensed under chapter 337, limits the carrier to reviewing the treatment plan once every six months unless the provider agrees otherwise, and puts the cost of any review or treatment plan on the plan.[5][1][2][3]
The most permissive position in this directory: Cigna's March 2025 autism resource guide states that all ABA CPT codes are covered telehealth services, with the delivery model — in person, telehealth or hybrid — chosen on the individual's needs. Missouri adds nothing for a commercial plan; its telemedicine regulation governs MO HealthNet. That includes the 97151 assessment and 97155 protocol modification. EN0499 describes direct case supervision as occurring "concurrently with the delivery of direct treatment," with the BCBA "face-to-face with the individual and either the Registered Behavior Technician® [RBT®] or the Board Certified Assistant Behavior Analyst® [BCaBA®]," at one to two hours per ten hours of direct treatment; it publishes no separate in-person minimum for supervision delivered by telehealth. On the claim, Evernorth’s Behavioral Health Administrative Guidelines (September 2026) say: “If billing telehealth services, please use the following guidance: Modifier 95 in Field 24-D to specify telehealth. 02 for Place of Service in Field 24-B.” Modifier 95 “will not change the reimbursement.” To deliver virtual sessions the provider first attests to Evernorth’s telehealth specialty requirements on the Attested Specialty Form, which adds “telehealth” to the provider profile. The guidelines and EN0499 say nothing about flagging telehealth on the ABA authorization itself.[5][2]
Evernorth follows the NAIC order "subject to applicable law and the terms of the benefit plan": "The plan of the parent whose birthday falls earlier in the calendar year is primary … Only the month and day of birth are relevant" (same birthday: the longer-running plan); a court decree controls for divorced or separated parents, and with no decree the order is custodial parent, custodial parent's spouse, noncustodial parent, noncustodial parent's spouse. Missouri's COB rule (20 CSR 400-2.030) governs fully insured group plans: when parents are not separated or divorced, "The benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later in that year" (same birthday: the plan that covered the parent longer); for divorced or separated parents a court decree naming the responsible parent controls. When Cigna is secondary, bill the primary first, then send the claim "along with a copy of the primary payer's EOP" (not needed if HIPAA-compliant COB data goes electronically to payer ID 62308). If the child also has Medicaid, this plan pays first: Medicaid is payer of last resort (42 CFR 433.139) — bill here, then send the EOB or denial to Medicaid, and get Medicaid's own prior auth too if the state requires it. TRICARE is secondary to this plan ("TRICARE shall be last pay," 32 CFR 199.8), and "CHAMPVA is the last payer to OHI" (38 CFR 17.276(d)).[5][11][12][13][14]
The mandate sets no overall age limit on autism coverage — what it ages out is the dollar cap. RSMo § 376.1224 subjects ABA to “a maximum benefit of forty thousand dollars per calendar year for individuals through eighteen years of age,” a statutory base that is CPI-indexed (the Department of Commerce and Insurance publishes the adjusted figure annually). Coverage required under the section other than ABA “shall not be subject to the age and dollar limitations described in this subsection,” so OT, PT, speech, psychiatric and pharmacy care for autism carry no age cut-off and no dollar cap. Self-funded private ERISA plans are preempted from all of it; note Missouri's unusual reach into the state consolidated health care plan, self-insured governmental plans, MEWAs and self-insured school-district plans established on or after 1/1/2020.[3]
Ask the plan: Benefits verification on the specific plan, via the payer portal or the number on the member’s card — ask whether RSMo § 376.1224 reaches this plan (it reaches fully-insured plans, the state consolidated health care plan, self-insured governmental plans, MEWAs and self-insured school-district plans established on or after 1/1/2020, but not private self-funded ERISA plans), and what the plan applies as this year’s dollar cap. The Missouri Department of Commerce and Insurance publishes the CPI-adjusted figure annually — quote that year’s number, never the $40,000 statutory base.
EN0499 as quoted in this guide sets the credential bar for who performs the ABA assessment and supervises the case — an independently licensed provider or a BCBA — rather than naming who may make the ASD diagnosis; the diagnosis must be DSM-5-TR autism spectrum, with Rett syndrome (F84.2) excluded. On a plan the Missouri mandate reaches, the ABA must additionally be ordered by the treating licensed physician or psychologist, which is the narrower and more operationally important list.[1][2][3]
Ask the plan: Evernorth Behavioral Health provider services (the behavioral health number on the member's card) — ask which diagnosing credentials EN0499 accepts before relying on a diagnosis from a non-doctoral clinician.
Cigna (Evernorth Behavioral Health) makes "coverage determinations in accordance with the time frames required under applicable law," and warns: "You must supply all information requested within the time frames specified … Failure to provide information within the time frames requested may result in nonpayment." ABA requests go to the Autism Utilization Management team. Lead time is published: "For ABA, we encourage providers to request authorizations up to 30 days in advance of or two weeks after the start date of service. A delay in request may result in a retrospective review and could delay the determination for up to 30 days" — so file each reauthorization up to 30 days before the current one ends. Missouri fully insured plans are bound by RSMo 376.1363: a carrier "shall make the determination within thirty-six hours, which shall include one working day, of obtaining all necessary information," with an approval phoned or sent electronically to the provider within 24 hours; concurrent review (continuing an approved course) is decided "within one working day of obtaining all necessary information." The clock starts when the file is complete, not when the form lands. Self-funded ERISA plans are outside state law and follow 29 CFR 2560.503-1: a pre-service decision "not later than 15 days after receipt of the claim" (one 15-day extension), 72 hours for urgent care, and an urgent extension request decided within 24 hours if made at least 24 hours before the approval expires.[5][2][9][10]
Ask the plan: Evernorth Behavioral Health / Cigna Autism Care Coordinator team, 877.279.7603: confirm whether the plan is fully insured or self-funded, which sets the legal decision clock.
Coverage decides whether Cigna / Evernorth in Missouri 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.
Assessment and case supervision must come from a BCBA, a licensed behavior analyst, or an independently licensed clinician with documented ABA training, with direct supervision at the standard 1–2 hours per 10 hours of direct treatment; Evernorth does not credential non-licensed staff. Missouri makes the licence a coverage condition: § 376.1224 requires ABA to be supervised by a board-certified behavior analyst licensed under chapter 337. EN0499 sets no caseload cap: it does not limit how many technicians or cases one BCBA may supervise, only the supervision hours per case.[1][3][4]
Restrictive, and the restriction is about other therapies as much as about ABA codes. EN0499 does not cover ABA delivered at the same time as another therapy (speech, OT) to the same child, and only one provider may bill a unit of time, with the standard supervision exceptions. Agency-to-agency transitions with overlapping authorization periods require documented coordination between agencies.[1]
No per-day or per-week unit cap is published. Evernorth’s autism resource guide says “All of the ABA CPT codes are in 15-minute increments” and “All ABA services must be billed with CPT codes 97151–97158, 0362T, and 0373T ONLY,” and adds that “Only one provider can bill for a unit of time,” except 97153, 97154 and 97155 during direct supervision. Neither the guide, EN0499 nor Evernorth’s Behavioral Health Administrative Guidelines (September 2026) sets a unit maximum or names an MUE table for ABA. The authorization, sized to the treatment plan under EN0499, is what bounds the day; ask Evernorth at authorization if a schedule needs more than eight hours of 97153 in a day.[2][1][5]
Every session note needs the date, start and end times, location, focus, a detailed description of the intervention, the persons present, the service type, and the rendering provider's name, credential and signature. No countersignature requirement and no signing deadline are published.[1]
Evernorth does not credential non-licensed staff, so RBT-delivered services bill under the supervising provider, and the treatment plan must name a credentialed supervisor. Missouri's mandate points the same way from the statutory side: reimbursement runs to the autism service provider or the entity the supervising board-certified behavior analyst works for, and expressly covers line-therapist services under that supervision.[1][3]
Not published as a payable-settings list. Two sourced facts bear on setting nonetheless: the treatment plan must carry dated baseline data per setting, so settings are declared and measured rather than assumed; and every session note must record the location. Whether a given setting is payable is a plan-benefit question.[1]
Ask the plan: Benefits verification on the specific plan — ask which places of service are payable for ABA, and whether school-based delivery is excluded before you write school goals.
Yes — under the carrier's national EN0499 policy for ASD (which applies in Missouri without any state carve-out), layered on Missouri's mandate (RSMo § 376.1224) for fully-insured plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.
Coverage of ASD diagnosis and treatment including ABA, with a $40,000-per-year ABA cap through age 18 — a CPI-indexed statutory base that can be exceeded with plan approval when medically necessary. Treatment-plan reviews are limited to once every 6 months, and ABA must be supervised by a Chapter 337-licensed behavior analyst.
Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against the MO HealthNet fee schedule, and treat rate-setting as part of contracting.
Evernorth, which runs Cigna's behavioral network, says it is "committed to expanding our network of autism providers." Individual providers submit the Evernorth Behavioral Provider Information Form and clinics the Screening Application for Autism Clinics; allow up to 90 days for the application plus 60 to 90 days of credentialing per provider.
No. "Evernorth does not credential nonlicensed/noncertified staff. Services for these staff members must be billed under the supervising provider." EN0499 expects the direct work from an RBT or BCaBA under BCBA case supervision.
EN0499 requires every treatment goal to be "directly related to" the ASD diagnosis and the DSM-5-TR symptoms (social communication/interaction; restricted, repetitive behavior), with measurable targets, baseline data and mastery criteria.
No hour figure is published. EN0499 requires measurable stakeholder (parent/caregiver) training goals with mastery criteria and progress data, delivered by a BCBA or licensed clinician; the hours are set on the authorization.
Cigna’s policy says 90 days for participating providers and 180 days out of network, longer where law or your agreement allows; Missouri law gives nonparticipating providers up to one year (RSMo 376.384).
No. Cigna's ABA billing instructions cover boxes 31 and 33 only, and Evernorth states that referrals are not required for behavioral health services.
No. Evernorth’s autism resource guide requires all ABA services to be billed with CPT 97151–97158, 0362T and 0373T only, in 15-minute units.
No graph is required. EN0499 requires dated quantitative baseline, interim and current data for every behavior and skill (current data no older than 60 days at the request and the start date), a standardized assessment within the past year, and caregiver-goal data. Data may be reported as data points or averages.
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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