For an intake team in New Hampshire, a Cigna card means three layers: Evernorth’s national ABA policy EN0499 with the Cigna autism resource guide, New Hampshire’s autism mandate in RSA 417-E, and the plan’s funding type, which decides whether the mandate applies. Many Cigna members are on self-funded employer plans, 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 and 0362T with an autism diagnosis, as long as the provider is independently licensed or a BCBA and the plan covers ABA. Treatment needs the completed assessment and treatment plan on the ABA Prior Authorization Form. A full-text check of EN0499 and the resource guide found no mention of New Hampshire, so the national criteria apply. Cigna runs no New Hampshire Medicaid plan.[1][2]
New Hampshire’s autism mandate sits inside its mental-illness parity statute. RSA 417-E:1 requires every insurer, nonprofit health service corporation and HMO issuing or renewing accident or health coverage in the state to cover "pervasive developmental disorder or autism" on terms "no less extensive than the coverage provided for any other type of health care for physical illness." RSA 417-E:2 then defines the treatment: "applied behavioral analysis, necessary to produce socially significant improvements in human behavior or to prevent loss of attained skill or function," plus pharmaceuticals, psychiatric, APRN, psychologist and social-work services, and speech, occupational and physical therapy. Two conditions bind ABA specifically. It "must be provided by a person professionally certified by the national Behavior Analyst Certification Board or performed under the supervision of" one. And the insurer "may require submission of a treatment plan, including the frequency and duration of treatment," signed by the primary care provider or a listed specialist (child psychiatrist, developmental-behavioral pediatrician, child neurologist, or a psychologist trained in child psychology), updated "no more frequently than on a semi-annual basis." Coverage "shall not be denied on the basis that services are habilitative in nature." The age and dollar question has changed since enactment: HB 569 as passed in 2010 let a policy "limit coverage for applied behavior analysis to $36,000 per year for children 0 to 12 years of age, and $27,000 from ages 13 to 21." That paragraph does not appear in the current RSA 417-E:2, whose source note lists amendments in 2011 and 2022, and no other age or dollar limit appears in the section. Autism Speaks’ New Hampshire summary (last updated December 2019) still describes the caps, so expect some plan documents and benefit summaries to lag. The mandate reaches fully insured plans only; self-funded employer plans answer to ERISA and federal parity.[3][4]
New Hampshire does not license behavior analysts. The BACB’s state licensure table (updated 2026) lists no New Hampshire law or board, and the practical credential is therefore BACB certification, which the mandate itself requires. That shapes credentialing in two ways. First, carriers credential BCBAs on certification rather than a state license number, even where a form asks for one (WellSense’s New Hampshire ABA form has a "BCBA license #" field). Second, the state credentialing clock in RSA 420-J:4 does help: a carrier must tell you an application is incomplete within 15 business days and must "act upon and finalize the credentialing process within 30 calendar days" of a clean and complete application for primary care physicians and mental health providers (45 days for specialists). The statute does not say which bucket a BCBA falls in, so ask. The provisional-pay rule in RSA 420-J:8-c is keyed to "a valid license from the respective state licensing board," which New Hampshire BCBAs do not hold, so do not plan on being paid before credentialing completes. On rates: commercial ABA rates are negotiated and unpublished. RSA 417-E:1, V-b requires carriers’ contracts to pay mental health and substance use treatment services, on average, at least as favorably as non-hospital primary care, measured against relative Medicare reimbursement; the statute does not say whether ABA codes are in that comparison. The public benchmark is the NH Medicaid fee-for-service schedule, which is low (97153 $17.79 and 97155 $16.43 per 15-minute unit).[7][5][3][9][10]
The questions that decide whether a family can start with Cigna / Evernorth in New Hampshire, 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 a provisional, rule-out or school-only identification doesn’t count. The clocks run on data: standardized instrument within 60 days before treatment, baseline data within 60 days, current data within 60 days of the request, a standardized instrument no more than a year old for continued treatment, and a new one after any break over 60 days.[1]
A healthcare professional licensed to practice independently whose board considers diagnosis within scope, applying DSM-5-TR criteria. The ABA assessment itself is by a BCBA, a Licensed Behavior Analyst, or an independently licensed mental health clinician with ABA training.[1]
No single instrument is mandated, but it must be reliable, valid and standardized, measure both DSM-5-TR ASD domains, be completed in full by a trained administrator, and be the current edition (the policy’s example: Vineland-3, not Vineland-II), with dates, respondent and standardized scores reported.[1]
EN0499 requires no referral or prescription. 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 New Hampshire plan, RSA 417-E:2, II lets the insurer require a treatment plan, with frequency and duration, signed by the primary care provider or a listed specialist, updated no more than every six months. Self-funded ERISA plans sit outside the statute.[2][1][3]
All ABA CPT codes are covered telehealth services per the autism resource guide, and EN0499 allows in-person, telehealth or hybrid delivery chosen on clinical factors. The line-of-sight requirement does not apply to telehealth.[2][1]
EN0499 sets no age cap; it says access to focused intervention "should not be restricted by age." Age terms come from the benefit plan and any controlling mandate. For fully insured New Hampshire plans, the current RSA 417-E:2 carries no age or dollar limit on ABA (the 2010 caps of $36,000 a year for ages 0–12 and $27,000 for 13–21 are no longer in the text). Self-funded ERISA plans are outside the statute, so plan funding type decides whether that binds.[1][3][4]
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 New Hampshire plans fall under RSA 420-J:6. For requests sent through the carrier’s electronic prior-authorization process, a non-urgent decision is due "within 7 calendar days of obtaining all information necessary to make the determination"; for paper or fax requests the limit is 14 calendar days; urgent requests are decided within 72 hours. Any request for more information must come within 7 calendar days of the request date, and information supplied in a peer-to-peer counts. A missed deadline means the request "shall be considered approved." Once approved, the carrier may not revoke or limit it "if care is provided within 60 business days" of the approval, and a peer-to-peer must be offered within 2 business days of a request. 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, urgent care within 72 hours. Cigna/Evernorth publishes no New Hampshire-specific ABA turnaround or reauthorization lead time.[5][8]
Ask the plan: At benefits verification ask whether the plan is fully insured (New Hampshire-regulated) or self-funded (ERISA), whether you are submitting electronically, and what reauthorization lead time Cigna/Evernorth expects.
For a child on two group plans, New Hampshire follows the birthday rule: when parents are married or living together, "the plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (Ins 1904.05(d)(2)); for separated parents a court decree controls, and otherwise the custodial parent’s plan pays first. That rule binds group plans regulated by the state; a self-funded plan sets its own order. When both plans require precertification, RSA 420-J:3-b says the member "shall obtain pre-certification from the primary plan," and the secondary plan "shall not refuse payment for such services solely on the basis that the services were not pre-certified by the secondary plan" (it can still apply its own criteria). If the child also has NH Medicaid, Cigna/Evernorth pays first: Medicaid is payer of last resort (42 CFR 433.139), and NH Medicaid will not pay a balance the primary denied for "incorrect billing, non-eligible provider, or lack of medical necessity." TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[6][5][11][12][13][14]
Ask the plan: Ask Cigna/Evernorth at benefits verification for the member’s coordination-of-benefits order (and whether a self-funded plan uses the birthday rule), and record every other coverage the child has.
Coverage decides whether Cigna / Evernorth in New Hampshire 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. The supervisor’s name and credentials must be documented.[1]
Only one provider may bill for a unit of time, except 97153, 97154 and 97155 during direct supervision, when the BCBA or QHP directs the technician and both are face-to-face with the patient at the same time. ABA delivered at the same time as another treatment (speech or occupational therapy, for example) is not reimbursable.[2][1]
No per-day cap is published. All ABA codes bill in 15-minute units and only with 97151–97158, 0362T and 0373T; intensity must reflect severity, goals and response to treatment.[2][1]
Each service needs its own record with start and end date and time, location, focus, a description of the intervention, who was present, the service type, and the name, credential and signature of the provider who rendered it.[1]
Goals and data are reported separately for each setting (home, clinic, school, community). Primarily educational or vocational services are not covered, and services in academic or vocational settings must still meet the direct-treatment definition.[1]
Evernorth does not credential non-licensed or non-certified staff; their services are billed under the supervising provider. On a CMS-1500 the rendering provider signs box 31 and only a BCBA or other licensed provider goes in box 33; electronic claims use payer ID 62308. 97152, 97153 and 97154 may be provided by a BCaBA or technician but billed only by a BCBA-D, BCBA or licensed mental health provider.[2]
Yes, under national policy EN0499 for ASD, with New Hampshire’s RSA 417-E mandate layered on for fully insured plans. 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.
New Hampshire issues no behavior-analyst license, and Cigna accepts a BCBA as the billing credential for ABA.
Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 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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