For an intake team in Montana, a Cigna card means three layers: Evernorth’s national ABA policy EN0499 with the Cigna autism resource guide, Montana’s autism mandate in MCA 33-22-515, and the plan’s funding type. Many Cigna members are on self-funded employer plans, which the Montana mandate does not reach, so check funding first.
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 and 0362T with an autism diagnosis, "as long as the provider is independently licensed or a Board Certified Behavior Analyst" and the policy covers ABA; treatment needs the completed assessment and treatment plan on the ABA Prior Authorization Form. Evernorth’s Administrative Guidelines carry a Montana Regulatory Addendum to its provider agreements, which "do not apply" to self-funded plans; the ABA criteria themselves contain nothing Montana-specific.[1][2][3]
Montana’s autism mandate is MCA 33-22-515, enacted in 2009. It reaches "each group disability policy, certificate of insurance, or membership contract" delivered, issued, renewed, extended or modified in Montana, and requires "coverage for diagnosis and treatment of autism spectrum disorders for a covered child 18 years of age or younger." Health service corporations (MCA 33-30-102 applies chapter 22 to them) and HMOs (MCA 33-31-111 lists 33-22-515 among the provisions that bind them) are covered too. The covered diagnoses are written in older DSM terms: autistic disorder, Asperger’s disorder, or pervasive developmental disorder not otherwise specified, "as defined by the most recent edition" of the DSM. Habilitative and rehabilitative care "includes medically necessary interactive therapies derived from evidence-based research, including applied behavior analysis," and it must be "prescribed, provided, or ordered by a licensed physician or licensed psychologist." ABA under the statute "must be provided by an individual who is licensed by the behavior analyst certification board or is certified by the department of public health and human services as a family support specialist with an autism endorsement." The statute lets a plan cap the benefit: coverage "may be limited to a maximum benefit of" $50,000 a year for a child 8 or younger and $20,000 a year from 9 through 18. Ordinary deductibles, coinsurance and copays may apply, but special cost sharing for autism care may not. When treatment is ongoing, the insurer "may request that the treating physician provide a treatment plan" (diagnosis, treatment by type and frequency, anticipated duration and outcomes, and why it is medically necessary) and may ask for an update "every 6 months." The section also binds the state and university employee plans, local-government employee plans and non-ERISA self-funded MEWAs. Two gaps matter at intake: the text speaks only of group coverage, and ERISA self-funded employer plans sit outside state insurance law altogether.[4][5][6]
Montana licenses behavior analysts. Since 2017 (Ch. 425, L. 2017), MCA Title 37, chapter 17, part 4 has the Board of Psychologists license behavior analysts and assistant behavior analysts; the BACB’s licensure table lists Montana (2017, MT Board of Psychologists). "An individual may not represent to the public that the individual is an assistant behavior analyst or a behavior analyst without a license," and a license requires current BACB certification at the matching level (BCBA or BCaBA), a fingerprint background check and the Board’s coursework rules (MCA 37-17-403). A behavior technician supervised by a licensed behavior analyst does not need a license, and neither do school district staff, licensed psychologists and those acting under their authority, licensed clinical professional counselors, licensed social workers and family support specialists with an autism endorsement (MCA 37-17-404). A BCaBA or technician must be supervised by a licensed behavior analyst or by a licensed psychologist board-certified by ABPP in behavioral and cognitive psychology (MCA 37-17-405). For telehealth, MCA 37-2-305 lets "a person licensed under this title" treat by telehealth when it is appropriate and meets the standard of care; it creates no registration for providers licensed only in another state. So a BCBA licensed elsewhere should plan on a Montana license before treating a child located in Montana, including by video. Commercial ABA rates are negotiated and unpublished; the public benchmark is the Montana Medicaid ABA fee schedule (July 1, 2025: 97153 $11.36 and 97155 $20.46 per 15-minute unit).[21][12][13][14][15][16][22][20]
Montana’s prompt-pay statute, MCA 33-18-232, says an insurer "shall pay or deny a claim within 30 days after receipt of a proof of loss" unless it makes a reasonable request for more information, and then within 60 days. A late insurer owes the claim "plus 10% annual interest" from the date it was due (interest under $5 is not payable). The statute governs insurers; a self-funded ERISA plan follows its own plan document and federal claims rules. Timely filing limits are set by each carrier’s contract, not by Montana statute.[8][3][20][2][1]
Evernorth "will only consider claims submitted within 90 days of the date of service or as otherwise defined in your Provider Agreement," unless state law allows longer; for coordination of benefits the 90 days run from the primary payer’s EOB, and Medicaid claims get three years. Contract-related appeals "must be submitted within 180 days of the initial denial." Evernorth’s guidelines put the fee schedule 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." Virtual services carry modifier 95, which "will not change the reimbursement." For a public benchmark, Montana Medicaid pays 97153 at $11.36 per 15 minutes (July 2025).[8][3][20][2][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.[8][3][20][2][1]
The questions that decide whether a family can start with Cigna / Evernorth in Montana, 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 it was most recently made, and provisional or rule-out diagnoses don’t count. The clocks run on data: a standardized instrument and baseline data within 60 days before treatment, and current data within 60 days of a continued-treatment request.[1]
A professional "licensed to practice independently and whose licensure board considers diagnostics" within scope, applying DSM-5-TR criteria; the request must give the diagnostician’s name, credentials and type of licensure.[1]
No single instrument is mandated; assessments must be standardized and the current edition (the policy’s example: Vineland-3, not Vineland-II).[1]
EN0499 requires no referral. Assessments 97151, 97152 and 0362T need no PA with an autism diagnosis when the provider is independently licensed or a BCBA; treatment needs the assessment and plan on the ABA PA form. For a fully insured Montana group plan, MCA 33-22-515 covers ABA "prescribed, provided, or ordered by a licensed physician or licensed psychologist," and lets the insurer ask the treating physician for a treatment plan, updated every 6 months. Self-funded ERISA plans sit outside the statute.[2][1][4]
"All ABA CPT codes are covered telehealth services" (autism resource guide), and EN0499 allows in-person, telehealth or hybrid delivery. Bill modifier 95; Evernorth says providers "must meet all state requirements to provide virtual behavioral services, including any licenses." For state-regulated plans, MCA 33-22-138 requires telehealth coverage equivalent to in-person care with no site restriction, and its provider list includes behavior analysts licensed under Title 37, chapter 17. 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][3][7]
EN0499 sets no age cap; it says access to intervention "should not be restricted by age." Age terms come from the benefit plan and any controlling mandate. For fully insured Montana group plans, MCA 33-22-515 requires coverage "for a covered child 18 years of age or younger" and lets the plan cap the autism benefit at $50,000 a year through age 8 and $20,000 a year from 9 through 18. Self-funded ERISA plans and individual policies are outside the statute’s text, so funding type and plan type decide whether that binds.[1][4]
Ask the plan: Live benefits verification, or the Evernorth Autism Care Coordinator team at 877.279.7603: establish fully insured group vs. self-funded first.
Depends on how the plan is funded. Fully insured Montana plans fall under MCA 33-32-211: for a prospective (prior-authorization) review the insurer must decide and notify "not later than 7 business days after the date the health insurance issuer receives the request" or after it receives all necessary information, with one extension of up to 7 business days for matters beyond its control; a request that fails the filing procedure must be flagged within 3 days. Urgent care requests are decided within 48 hours (MCA 33-32-212). A reduction or termination of an approved course of treatment before it ends is an adverse determination that must be noticed in advance, and the service continues pending the internal review. Once approved, a certification "is valid for at least 6 months," and 12 months for treatment of a chronic condition (MCA 33-32-107). 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," with one 15-day extension. Evernorth encourages ABA authorization requests "up to 30 days in advance of or two weeks after the start date of service."[10][11][9][17][2]
Ask the plan: At benefits verification ask whether the plan is fully insured (Montana-regulated) or self-funded (ERISA), and what reauthorization lead time Evernorth expects.
If the child also has Montana Medicaid, the commercial plan pays first: Montana Healthcare Programs requires providers to "bill other insurance carriers before billing Montana Healthcare Programs" in most cases, and Medicaid is the payer of last resort under 42 CFR 433.139. If the other insurer has not responded in 90 days, Medicaid can be billed with proof the claim was sent. When a child is on two commercial plans, the order of benefits comes from Montana’s coordination-of-benefits rules for state-regulated plans and from the plan document for self-funded plans; we could not open the Montana rule text this run (rules.mt.gov returned a captcha), so get the order from the carrier.[18][19]
Ask the plan: Ask Cigna/Evernorth at benefits verification for the member’s coordination-of-benefits order, and record every other coverage the child has.
Coverage decides whether Cigna / Evernorth in Montana 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.
EN0499: case supervision by a BCBA, a Licensed Behavior Analyst, or an independently licensed mental health clinician with ABA training, at one to two hours per ten hours of direct treatment, and at least one to two hours a week when direct treatment is 10 hours a week or less. Montana law adds that BCaBAs and technicians must be supervised by a licensed behavior analyst or ABPP-certified behavioral psychologist (MCA 37-17-405). EN0499 publishes no cap on the number of technicians one supervisor may oversee.[1][14]
"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]
No per-day cap is published. All ABA codes bill in 15-minute units and only as 97151–97158, 0362T and 0373T; intensity must reflect severity, goals and response to treatment. A Montana group plan may also apply the mandate’s annual dollar caps.[2][1][4]
Each service record needs the date and time, location, a description of the service, who was present, and the "Name, credential (if applicable), and signature of ABA provider who rendered the service."[1]
Data must be reported separately by setting (home, clinic, school, community). Services "primarily educational or vocational in nature" are not covered, nor are services that are the responsibility of the setting (such as a classroom aide).[1]
"Evernorth does not credential nonlicensed/noncertified staff. Services for these staff members must be billed under the supervising provider." On a CMS-1500 the rendering provider prints their name in box 31 and only a BCBA or other licensed provider goes in box 33; electronic claims use payer ID 62308.[2]
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.
Yes, under national policy EN0499 for ASD. Fully insured Montana group plans must also meet MCA 33-22-515 for children 18 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. PA starts at treatment.
Evernorth considers claims submitted within 90 days of the date of service unless your agreement or state law allows longer.
Evernorth requires providers to meet all state licensing requirements for virtual services, and Montana licenses behavior analysts, so get a Montana license first.
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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