---
title: "Cigna / Evernorth ABA coverage in New Jersey: the intake guide."
url: "https://carelu.com/payers/cigna-new-jersey"
markdown_url: "https://carelu.com/payers/cigna-new-jersey.md"
state: NJ (New Jersey)
payer: Cigna / Evernorth in New Jersey
kind: Commercial insurance
description: "How Cigna / Evernorth covers ABA for New Jersey families — the national EN0499 policy with no assessment PA, the P.L. 2009, c.115 mandate (ages, the parity-voided $36k cap, exemptions), New Jersey behavior-analyst licensure, and what intake should verify."
last_reviewed: October 2026
vob_data_updated: 2026-10-15
---

# Cigna / Evernorth ABA coverage in New Jersey: the intake guide.

_Payer Guide · Cigna · New Jersey · Last updated October 2026 · 11 primary sources_

> EN0499 + autism resource guide + the P.L. 2009, c.115 mandate layer.

For an intake team in New Jersey, a Cigna card means three layers at once: the carrier's national clinical policy, New Jersey's autism insurance mandate (P.L. 2009, c.115), and the plan's funding type deciding which of the two actually binds. This guide stacks them in order.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Not required for assessment codes 97151, 97152, 0362T (per Cigna's autism resource guide — EN0499 itself states no prior-authorization rule) [2][1]
- **Prior auth for treatment**: Required — assessment + treatment plan with the ABA PA form (see Cigna's autism resource guide; EN0499 sets the clinical criteria, not the PA rule) [2][1]
- **Autism diagnosis required?**: Yes — ASD only; Rett syndrome (F84.2) excluded under EN0499 [1]

## At a glance

- **Covers ABA?:** Yes — for ASD, per the national Cigna policy
- **State mandate:** P.L. 2009, c.115 (N.J.S.A. 17:48-6ii and parallel sections)
- **Mandate age:** Under 21 in statute; IHC/SEH markets extended to adults 21+ (Jan 2015)
- **Mandate caps:** $36,000/yr in statute — voided for MHPAEA group plans (DOBI Bulletin 10-02)
- **Exempt from mandate:** Self-funded ERISA plans (may exclude ABA entirely)
- **Licensure:** NJ Licensed Applied Behavior Analyst (Consumer Affairs board)
- **Fee schedule:** Not public — your ABA fee schedule is Exhibit A of your Evernorth Provider Agreement; fee questions to Evernorth Provider Services, 800.926.2273

## The national policy, applied in New Jersey

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 Virginia — the one state whose fully-insured business the current EN0499 (effective 5/15/2026) carves out of the policy — New Jersey has no carve-out: EN0499 applies, with the state mandate below as the legal floor for fully-insured plans and ERISA plus federal parity governing self-funded ones. 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 New Jersey. [1][2]

## The New Jersey mandate: strong, and stronger than it reads

P.L. 2009, c.115 (effective February 9, 2010, codified across N.J.S.A. 17:48-6ii and parallel sections for insurers, HMOs, individual and small-employer plans, plus the SHBP and SEHBP) requires state-regulated plans to cover autism screening and diagnosis, medically necessary PT/OT/ST for autism or other developmental disabilities, and medically necessary ABA-based behavioral interventions for autism in individuals under 21 — coverage owed even when services aren't restorative. The statute's headline limitation, a $36,000/year ABA cap, is largely dead: DOBI Bulletin 10-02 held the cap cannot be applied to group health plans subject to MHPAEA, because New Jersey classifies autism as a biologically-based mental illness and dollar limits conflict with federal parity — leaving it live mainly in nongroup policies. The IHC and SEH program boards went further in amendments effective January 2015, extending ABA to adults 21+ and removing therapy visit limits in the individual and small-employer markets. Practical current state: state-regulated plans cover medically necessary ABA without dollar caps. Self-funded ERISA plans remain exempt and may exclude ABA entirely. [3][4]

## What does Cigna need to continue ABA in New Jersey — are graphs required?

Evernorth’s EN0499 (effective May 15, 2026), which applies in New Jersey, lists the “Criteria for Continued Treatment with ABA.” The updated treatment plan must address current deficits and “any progress made across all targeted areas.” The request needs “Quantitative baseline, interim and current data,” “with dates reported from when the data were collected for all behaviors and skills,” and the current data must be “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.” Improvement must show on “a reliable, valid, and standardized assessment instrument completed no more than one year prior to the start date of the continued treatment request.” Where progress is missing, the plan must name the barriers and show protocol changes. Caregiver (stakeholder) training needs its own baseline, interim and current data, and a break in treatment of more than 60 days requires a new standardized assessment and fresh data. A request for more hours needs a clinical rationale and data showing how the added intensity would improve outcomes. EN0499 does not mention graphs: it requires dated numbers, which a graph can present but cannot replace. [1]

## No New Jersey-specific Cigna policy exists

We checked: Cigna / Evernorth publishes no New Jersey-specific ABA policy, form, or supplement, and runs no NJ Medicaid plan — the national EN0499 policy plus the state mandate is the whole picture. That's worth knowing in itself: it means benefits verification (plan funding type, mandate applicability, benefit limits) is where New Jersey-specific answers come from, not a carrier document. One EN0499 detail with a New Jersey wrinkle: the policy excludes Rett syndrome from its ASD definition — and DOBI's implementing bulletin similarly notes carriers may exclude clear Rett and CDD diagnoses from the mandate's autism definition, but must still consider them under the mandate's developmental-disability therapy prongs. [1][3]

## Licensure & rates in New Jersey

New Jersey licenses behavior analysts through the State Board of Applied Behavior Analyst Examiners at the Division of Consumer Affairs: the Licensed Applied Behavior Analyst (LBA — master's or doctorate, current BCBA/BCBA-D, and the NJ jurisprudence exam) and the assistant-level LaBA, under N.J.S.A. 45:8B-91 et seq. and N.J.A.C. 13:42B. The board's position is that supervision in all its forms constitutes practicing behavior analysis and requires a license; RBTs are unlicensed and work under a licensee. On rates: Cigna does not publish commercial ABA fee schedules for New Jersey (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement. Benchmark against NJ FamilyCare's published FFS schedule ($15.00/unit for 97153, $21.25 for 97155, $25.00 for 97151/97156) and treat rate-setting as a contracting conversation, not a lookup. [5]

## What is Cigna’s fee schedule for ABA?

Cigna publishes no ABA rate table. Evernorth, which runs Cigna’s behavioral health network, puts the rates in the contract: its Administrative Guidelines (September 2026) say the Provider Agreement and the guidelines set the terms, which “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-schedule and contract questions go to Provider Services at 800.926.2273. Virtual services are billed with modifier 95, which Evernorth says “will not change the reimbursement.” Non-credentialed technicians are paid only through the supervising provider’s claim. For a public benchmark, see the NJ FamilyCare fee-for-service rates in the New Jersey Medicaid guide. [7]

## Does Cigna allow retroactive authorization for ABA in New Jersey?

Within two weeks, yes. Cigna asks providers to request ABA authorization "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." Assessment codes 97151, 97152 and 0362T need no prior authorization when the provider is independently licensed or a BCBA and the plan covers ABA. EN0499 applies the same criteria to late requests: "When authorization requests involve coverage of services conducted retrospectively, ALL the criteria from initiation of treatment section (and continued treatment section as applicable) are met, coinciding with the dates of service." For requests outside that, Evernorth's administrative guidelines require "an explanation of the extraordinary circumstances responsible for the delay or failure to obtain prior authorization" (for example, wrong insurance information) with the medical records; "The denial decision will be upheld if the provider or facility only submits a medical record and not the explanation." On a fully insured New Jersey plan, the Ensuring Transparency in Prior Authorization Act adds two protections: a payer may not deny a claim for lack of prior authorization if you asked before the service and the payer did not answer within the legal deadline, and when a covered person moves to another payer that payer "shall accept the authorization" issued by the old one, based on its own plan's benefits. Self-funded employer plans are outside the Act. [2][1][7][8]

## How fast does Cigna have to pay an ABA claim in New Jersey?

On a fully insured New Jersey plan, state law sets the clock. The Health Claims Authorization, Processing and Payment Act requires the insurer, HMO or health service corporation to “remit payment for every insured claim submitted by a covered person or health care provider, no later than the 30th calendar day following receipt of the claim” when it is filed electronically, and “no later than the 40th calendar day following receipt if the claim is submitted by other than electronic means,” as long as the provider and member were eligible on the date of service, the service is covered, the claim carries everything the payer asked for in advance, and there is no reason to suspect fraud. If the payer holds back for missing documentation, coding errors or a disputed amount, it must tell you within the same 30 or 40 days; for an electronic claim missing data it must ask “within seven days of that determination,” and it must acknowledge an electronic claim within two working days. “An overdue payment shall bear simple interest at the rate of 12% per annum.” You may appeal a claims determination internally “on or before the 90th calendar day” after receiving it; the payer must decide within 30 days, and an unresolved dispute can go to arbitration. [9][10][7][11]

Self-funded employer plans are outside these rules: DOBI lists “self-insurance” and the State Health Benefits Program among the plans its prompt-pay rules do not cover, so ask the employer plan’s administrator for its payment terms. Evernorth writes the same rule into its contracts: its New Jersey Regulatory Addendum (Administrative Guidelines, September 2026) says fee-for-service amounts “shall be paid within thirty (30) calendar days following receipt of a claim” filed electronically and within 40 days on paper, with overdue payments bearing 12% simple interest, and that the addendum does “not apply with regard to Covered Services rendered to Participants covered under self-funded plans.” Filing limit: 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 gives longer; where you bill under the member’s assignment of benefits, the New Jersey addendum says to file “within one hundred eighty (180) days of the last course of treatment,” under N.J.S.A. 45:1-10.1. [9][10][7][11]

Filing deadline and the “weekly cutoff” question. New Jersey sets the outer limit in licensing law rather than insurance law. A licensed behavior analyst is a Title 45 professional, and N.J.S.A. 45:1-10.1 says that where “the patient has assigned his benefits to the professional, the professional shall file the claim within 180 days of the last date of service for a course of treatment”; after that “the third party payer shall reserve the right to deny payment of the claim” and the professional “shall be prohibited from seeking any payment directly from the patient.” A claim the professional files on the patient’s behalf without an assignment is due “within 60 days of the last date of service for a course of treatment.” Neither the statute nor the prompt-pay rules set a weekly submission cutoff: the 30- and 40-day payment clocks start on the day the payer receives a clean claim. Evernorth’s 90-day filing limit above is shorter than the statute, so file within 90 days unless your agreement says otherwise. [9][10][7][11]

## Does Cigna (New Jersey) require a referring provider on ABA claims?

Not required. Evernorth’s Behavioral Health Administrative Guidelines (September 2026), which govern Cigna behavioral claims including ABA, say for 837 claims: “The ‘Billing Provider’ Taxpayer Identification Number (TIN) and NPI are required. Any additional provider identification on the claim, such as the ‘Rendering Provider’ or ‘Referring Provider,’ must include the name and NPI when submitted.” So box 17/17b is optional, but if you fill it in, give the referring clinician’s name and NPI together. [7]

## Intake gates

The questions that decide whether a family can start with Cigna / Evernorth in New Jersey, and what they have to bring.

- **Diagnosis recency**: Evernorth dates the diagnosis without expiring it, and expires the assessment instead. The diagnosis package must carry "The name, credentials, and type of licensure of the individual who made the diagnosis" and "The date on which the diagnosis was most recently made" — but no maximum age for that date. Where recency does bite is the continued-treatment request: improvement must be demonstrated "with the use of a reliable, valid, and standardized assessment instrument completed no more than one year prior to the start date of the continued treatment request," against data collected within the previous six months of treatment. [1]
- **Who may diagnose**: An independent-practice test, with two explicit disqualifiers. The diagnosis must be made "based on the criteria in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (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." What does not count: "educational identification or meeting educational eligibility for services related to autism through the [Individuals] with Disabilities Education Act may not meet criteria as a formal diagnosis of ASD," and a diagnosis termed "provisional," "proposed," "potential," "at risk of" or "rule out" is not confirmed. F84.2 (Rett syndrome) is excluded from the covered code range. One New Jersey wrinkle on the code range: DOBI's implementing bulletin notes carriers may exclude clear Rett and childhood disintegrative disorder diagnoses from the mandate's autism definition, but must still consider them under the mandate's developmental-disability therapy prongs — so a Rett exclusion in the carrier policy is not the end of the coverage conversation on a state-regulated plan. [1][3]
- **Diagnostic tools required**: No named instrument, but a strict standard for whichever one is used. The comprehensive ABA assessment must include "Administration of a reliable, valid, and standardized assessment instrument that measures the individual's functioning in the domains included in the diagnostic criteria for ASD in the DSM-5-TR" — social communication and social interaction, and restricted, repetitive patterns of behavior. The instrument must be completed in its entirety and as designed, be reliable and valid for the population tested, be administered and interpreted by someone trained to do so, be the most current version ("must be the Vineland-3 vs. Vineland-II"), assess current abilities, and record the date of administration, the respondent and the form type. Where someone other than the requesting provider administered it, the request must show documented collaboration with that professional and that the results correspond with the requesting provider's own direct observation. [1]
- **Referral required?**: No referral or physician order from Cigna. EN0499 requires none, and no prior authorization is needed on assessment codes 97151, 97152 and 0362T when there is an autism diagnosis on file and the provider is independently licensed or a BCBA. Treatment is the gated step: the completed assessment plus a treatment plan on Cigna’s ABA prior authorization form. New Jersey adds a document rather than a referral on fully insured plans: P.L. 2009, c.115 covers ABA for children under 21 “as prescribed through a treatment plan,” and that plan must include “a diagnosis; proposed treatment by type, frequency, and duration; the anticipated outcomes stated as goals; the frequency by which the treatment plan will be updated; and the treating physician’s signature.” The carrier “may only request an updated treatment plan once every six months from the treating physician,” unless both agree more frequent review is needed. No state form exists; the plan is the provider’s own document. Self-funded ERISA plans are outside the state mandate, so for them the carrier’s own rule above is the whole answer. [1][2][12][3]
- **Telehealth**: The most permissive telehealth position of the three national carriers, stated in one line: "All ABA CPT codes are covered telehealth services." EN0499 backs it structurally — "ABA treatment may be rendered via traditional in-person service delivery, telehealth, or a hybrid of in-person and telehealth service modalities," with the modality chosen on individual characteristics, the treatment plan, caregiver participation, environment, evidence of efficacy and safety, and technological requirements. Two qualifications worth carrying into scheduling: telehealth delivery is one of the settings the policy expects treatment goals to address, and the requirement to have the treatment plan signed does not apply to telehealth services. No POS code list is published. Nothing in the New Jersey mandate or DOBI Bulletin 10-02 addresses telehealth delivery of ABA, so there is no state floor to fall back on here — unlike Nebraska, whose statute names telehealth expressly. For a New Jersey fully insured plan, N.J.S.A. 26:2S-29 (as amended by P.L.2021, c.310) requires a carrier to cover telehealth "on the same basis as" in person for otherwise covered services, bars restrictions on the originating or distant site except to keep the in-person standard of care, and lets the carrier limit coverage to in-network providers; self-funded employer plans are outside it. [6][2][1]
- **Age limit** _(plan-dependent)_: EN0499 sets no age limit. The policy's medical-necessity criteria turn on diagnosis, assessment and treatment-plan content rather than on age, and its own definitions note only that assessment instruments must have established reliability and validity "for use with members of the population tested (e.g., age, language preference, etc.)." The binding age question is the legal layer underneath: New Jersey's mandate (P.L. 2009, c.115) reaches individuals under 21 on state-regulated plans, with the IHC and SEH program boards extending ABA to adults 21+ in the individual and small-employer markets from January 2015; a self-funded ERISA plan answers to its own plan document. So a 21-plus New Jersey inquiry is a market-analysis question, not an automatic turn-away. [1][3]
  - Ask the plan: The member's benefit document and Evernorth Provider Services at 800.926.2273 — funding type decides whether the state mandate or the plan document sets the age boundary.
- **Prior-auth decision time** _(plan-dependent)_: Depends on how the plan is funded. Fully insured New Jersey plans follow the Ensuring Transparency in Prior Authorization Act (in force January 1, 2025): for outpatient services such as ABA, a denial must be communicated "no later than 12 days if the request is submitted in paper, or nine days if submitted through an electronic portal provided by the payer," and urgent-care determinations no later than 72 hours after receipt; if the payer asks for more information and the provider does not respond within 72 hours, the request is deemed withdrawn. Useful for reauthorizations: a prior authorization for a chronic or long-term condition "shall remain in effect for 180 days" unless a shorter period is needed with notice to the provider. Self-funded (ERISA) plans follow the federal claims rule instead: pre-service decisions within 15 days of receipt (one 15-day extension), urgent within 72 hours. Cigna's ABA policy (EN0499) sets no decision clock; continued-treatment requests need current data "collected within no more than 60 days prior to the start date of the continued treatment request." [8][13][14][1]
  - Ask the plan: Benefits verification: fully insured NJ policy (ETPAA 9/12-day clock, 180-day authorizations) vs. self-funded ERISA plan (15 days / 72 hours), plus the carrier's behavioral health reviewer turnaround.
- **Other insurance (who pays first)** _(plan-dependent)_: For a child on two parents' plans, New Jersey's group coordination-of-benefits rule (fully insured group contracts) puts the plan of "the parent whose birthday falls earlier in a year" first — month and day only; same birthday → the plan that covered the parent longer. Divorced or separated parents: the custodial parent's plan pays first, then the custodial parent's spouse's plan, then the non-custodial parent's plan, unless a court decree makes one parent responsible for the child's health care. Self-funded plans set their own order in the plan document. Cigna's ABA documents publish no coordination-of-benefits rule of their own. If the child also has TRICARE, this plan pays first — TRICARE is the secondary payer to other health insurance under its double-coverage rule (Medicaid is the only coverage it pays ahead of). CHAMPVA likewise pays last: "In double coverage situations, CHAMPVA would be the last payer." If the child also has Medicaid, this plan is primary and Medicaid pays last. [15][16][17][18]
  - Ask the plan: Benefits verification with both plans: funding type, which is primary for the child, and whether the secondary plan requires its own authorization.

## Delivery and billing rules

Coverage decides whether Cigna / Evernorth in New Jersey pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.

- **Supervision**: Evernorth DOES publish a supervision standard, in EN0499 — direct case supervision (the BCBA face-to-face with the individual alongside the RBT or BCaBA) plus indirect case supervision “is consistent with the general accepted standard of care of one to two hours per ten hours of direct treatment”, and “when direct treatment is 10 hours per week or less, a minimum of one to two hours per week of direct case supervision is provided.” It is stated as a standard of care rather than a hard caseload cap, and supervisory services must match the CPT code descriptions. [1]
- **Concurrent billing (97153 + 97155)**: Yes — and Evernorth writes it as an explicit carve-out from its general rule: “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).” Both must be with the patient; analyst time away from the patient is not inside the exception. Overlap with other therapies is a separate exclusion in EN0499: “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]
- **Bill as provider**: Under the supervising provider, because the technician cannot be credentialed: “Evernorth does not credential nonlicensed/noncertified staff. Services for these staff members must be billed under the supervising provider.” Practically, the BCBA’s credential is what the claim rides on for technician-delivered 97153. [2]
- **Daily limits / MUEs** _(ask the plan)_: Not published. The resource guide sets the code set (97151–97158, 0362T, 0373T only, all in 15-minute increments) but no per-day unit ceiling and no statement of which MUE table Evernorth applies. [2]
  - Ask the plan: Evernorth Provider Services at 800.926.2273.
- **Session-note signature** _(ask the plan)_: Not published in the autism resource guide — no rule on who signs a session note or when.
  - Ask the plan: The Evernorth Behavioral Health provider administrative guide and your participation agreement.
- **Place of service** _(ask the plan)_: Only the telehealth half is published: “all ABA CPT codes are covered telehealth services,” subject to the Intensive Behavioral Interventions coverage policy (EN0499). The guide states no school, community or group-home rule. [2]
  - Ask the plan: Evernorth Provider Services at 800.926.2273 for school and community settings, plus the member’s benefit document.

## What intake should collect for Cigna / Evernorth in New Jersey

- **Plan funding type:** Fully insured (mandate applies, no dollar cap in practice) vs. self-funded ERISA (exempt) — it decides which rulebook governs. Ask for the employer and check the card.
- **Member ID + card photo:** Enough to run a live benefits verification — the only reliable answer on limits and cost-sharing.
- **Diagnosis report:** DSM-5 ASD diagnosis, diagnosing provider and credentials, evaluation date — noting EN0499's Rett exclusion.
- **Age:** Under 21 for the statutory ABA prong — but IHC/SEH-market plans extend ABA to adults, so flag 21+ cases for market analysis rather than turning them away.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How Cigna / Evernorth in New Jersey ABA benefits route and read on an eligibility check. Data last updated 2026-10-15.

### EDI routing

- **Payer ID (pVerify):** 00004 — pVerify 00004 = "Cigna" (Medical, Eligibility=Yes); "Cigna Behavioral" 00510 also listed.
- **Payer ID (Availity):** 62308 — Evernorth payer ID 62308 per the Cigna Autism Resource Guide (same ID as Cigna medical); inferred pending a current Availity export.
- **Payer ID (Change Healthcare / Optum):** 62308 — Change Healthcare/Optum lists 62308 = "CIGNA - PPO" (supports 270/271). NOTE: EN0499 is Evernorth's ABA COVERAGE-POLICY number, not a payer ID — "EN0499 applies to NJ" means the policy governs (no carve-out); routing stays on 62308.
- **Supports 270/271 eligibility:** Yes
- **Behavioral health administrator:** Evernorth Behavioral Health (same-payer-ID pass-through)
- **BH administrator payer ID:** 62308
- **ABA rides on:** medical benefit
- **Two-hop verification required:** No

### How the 271 reports ABA benefits

- **ABA benefit bucket (service type code):** MH
- **Deductible applies to ABA:** yes — Base deductible for MH-flavored codes is returned per the companion guide's own worked example, but REMAINING deductible/benefit amounts are explicitly withheld for Mental Health, Pharmacy, and Vision plans (§7.2.2-7.2.3) — a real 271 for an ABA member may show the base figure but not how much has been used.
- **Cost-share type:** plan-dependent — Both copay (EB*C) and coinsurance (EB*A) segments are structurally supported per plan; which applies to a given member is plan-document-specific.
- **271 response quality for ABA:** high

### Code-level coverage

| Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers |
| --- | --- | --- | --- | --- | --- | --- |
| 97151 | Yes | Not required (per EN0499) | — | — | — | — |
| 97152 | Yes | Not required (per EN0499) | — | — | — | — |
| 97153 | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — |
| 97154 | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — |
| 97155 | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — |
| 97156 | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — |
| 97157 | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — |
| 97158 | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — |
| 0362T | Yes | Not required (per EN0499) | — | — | — | — |
| 0373T | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — |

Code notes:

- **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** Verify via: Cigna/Evernorth provider services and a live benefits check (funding type first) — EN0499 is a medical-necessity policy with no unit caps, POS codes, or modifiers. Unlike Virginia, EN0499 applies to NJ fully-insured business (no carve-out); the P.L. 2009, c.115 mandate is the legal floor for fully-insured plans. Commercial ABA rates are contract-specific (out of Layer 4 scope).

### Contacts

- **Benefits by phone:** Yes
- **Provider services phone:** 1-800-926-2273
- **Phone menu path:** Select prompt #5 for providers, then choose among claims / eligibility / authorization / online services / personal updates.
- **Portal:** [Evernorth Provider Portal](https://provider.evernorth.com/app/login)

Questions to ask on a verification call:

- What is the member's plan funding type — fully-insured (P.L. 2009, c.115 mandate applies) or self-funded (ERISA)?
- Are there unit or hour caps on the treatment codes (97153-97158, 0373T) for this member's plan?
- Which places of service are approved, and is telehealth allowed for this member?
- Is eligibility checking real-time or batch through your clearinghouse?

### VOB data sources

- https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/autism-resource-guide.pdf (accessed 2026-07-23)
- https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/en_mm_0499_coveragepositioncriteria_intensive_behavioral_interventions.pdf (accessed 2026-07-23)
- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23)
- https://www.optum.com/content/dam/o4-dam/resources/pdfs/guides/professional-claims-payer-list.pdf (accessed 2026-07-23)
- https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months)
- https://www.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23)
- https://www.cigna.com/static/www-cigna-com/docs/5010-270-271-companion-guide.pdf (accessed 2026-07-23)
- https://static.evernorth.com/assets/evernorth/provider/resourceLibrary/behavioralResources/doingBusinessWithUs/cbhProviderServiceCenter.html (accessed 2026-07-23)
- https://provider.evernorth.com/app/login (accessed 2026-07-23)

## Common questions

### Does Cigna require graphs for ABA reassessments in New Jersey?

Not in its policy. Evernorth’s EN0499 asks for quantitative baseline, interim and current data with the dates collected, current data from within 60 days of the request, and a standardized assessment from within the past year, plus parent-training data. It never mentions graphs, so the numbers with dates are what matter; a graph can show them but does not replace them.

### What is the timely filing limit for Cigna ABA claims in New Jersey, and is there a weekly cutoff?

Evernorth considers claims filed within 90 days of the date of service unless your agreement or state law gives longer. New Jersey law allows 180 days from the last date of service when benefits are assigned. There is no weekly cutoff: on fully insured plans a clean claim must be paid within 30 days of receipt electronic, or 40 days on paper.

### Does Cigna (New Jersey) require a referring provider on ABA claims?

No. Evernorth’s September 2026 administrative guidelines require only the billing provider’s TIN and NPI; a referring provider is optional, but if you report one it "must include the name and NPI."

### Does Cigna cover ABA therapy in New Jersey?

Yes — under the carrier's national EN0499 policy for ASD (no PA on assessment codes 97151/97152/0362T), layered on New Jersey's mandate (P.L. 2009, c.115) for fully-insured plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.

### Does EN0499 apply to New Jersey fully-insured plans?

Yes — unlike Virginia, New Jersey has no carve-out in the current EN0499. NJ fully-insured plans sit under the policy's generic state-mandate language, with P.L. 2009, c.115 controlling as the state mandate.

### Does the $36,000 ABA cap in New Jersey's mandate still apply?

Mostly not — DOBI Bulletin 10-02 held the cap cannot be applied to group plans subject to federal parity (MHPAEA). In practice, state-regulated plans cover medically necessary ABA without dollar caps; the cap survives mainly in nongroup policies.

### What does Cigna pay for ABA in New Jersey?

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. NJ FamilyCare's fee-for-service schedule (see the New Jersey Medicaid guide) is the public benchmark.

### Does Cigna allow retro authorization for ABA?

Cigna accepts ABA authorization requests up to two weeks after services start (a later request may go to retrospective review, up to 30 days). Assessment codes need no authorization. Beyond that you need to document extenuating circumstances, such as wrong insurance information.

### What is Cigna’s timely filing limit for ABA in New Jersey?

Evernorth considers claims filed within 90 days of the date of service unless your provider agreement or a longer state-law limit says otherwise. Its New Jersey addendum notes the 180-day limit of N.J.S.A. 45:1-10.1 when you file under an assignment of benefits.

### How fast does Cigna pay ABA claims in New Jersey?

For fully insured NJ plans, within 30 days for electronic clean claims and 40 days for paper, with 12% yearly interest if late, per state law and Evernorth’s New Jersey addendum. Self-funded plans are excluded.

## Primary sources

1. [Evernorth EN0499 — Intensive Behavioral Interventions](https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/en_mm_0499_coveragepositioncriteria_intensive_behavioral_interventions.pdf)
2. [Cigna autism resource guide](https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/autism-resource-guide.pdf)
3. [NJ DOBI Bulletin 10-02 — Implementation of P.L. 2009, c.115](https://www.nj.gov/dobi/bulletins/blt10_02.pdf)
4. [Autism NJ — Amendments to Insurance Mandate Expand Coverage](https://autismnj.org/news/amendments-to-insurance-mandate-expand-coverage/)
5. [NJ Board of Applied Behavior Analyst Examiners — FAQ](https://www.njconsumeraffairs.gov/abae/Pages/FAQ.aspx)
6. [P.L.2021, c.310 — amends N.J.S.A. 30:4D-6k (Medicaid/NJ FamilyCare telehealth coverage) and 26:2S-29 (carrier telehealth coverage)](https://nj.gov/treasury/pensions/documents/laws/ch310-2021.pdf)
7. [Evernorth Behavioral Health Administrative Guidelines (PCOMM-2026-191, September 2026)](https://static.evernorth.com/assets/evernorth/provider/pdf/resourceLibrary/behavioral/ebh-provider-admin-guide.pdf)
8. [P.L. 2023, c.296 — Ensuring Transparency in Prior Authorization Act (N.J.S.A. 17B:30-55.1 et seq.)](https://www.nj.gov/treasury/pensions/documents/laws/ch296-2023.pdf)
9. [P.L.2005, c.352 — Health Claims Authorization, Processing and Payment Act (N.J.S.A. 17B:30-48 et seq.; prompt pay in 17B:26-9.1, 17B:27-44.2, 17:48E-10.1, 26:2J-8.1)](https://pub.njleg.state.nj.us/Bills/2004/PL05/352_.PDF)
10. [NJ DOBI — Prompt Pay Regulations FAQ (N.J.A.C. 11:22-1)](https://www.nj.gov/dobi/division_insurance/promptfaqs.htm)
11. [N.J.S.A. 45:1-10.1 — Title 45 professionals file third-party claims within 60 days (patient-filed) or 180 days (assigned benefits) of the last date of service (FindLaw)](https://codes.findlaw.com/nj/title-45-professions-and-occupations/nj-st-sect-45-1-10-1.html)
12. [P.L. 2009, c.115 — New Jersey autism and developmental disability coverage (enrolled law)](https://pub.njleg.state.nj.us/Bills/2008/PL09/115_.PDF)
13. [NJ DOBI Bulletin 24-17 — Ensuring Transparency in Prior Authorization Act](https://nj.gov/dobi/bulletins/blt24_17.pdf)
14. [29 CFR 2560.503-1 — ERISA claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
15. [N.J.A.C. 11:4-28.6 — Rules for coordination of benefits (LII)](https://www.law.cornell.edu/regulations/new-jersey/N-J-A-C-11-4-28-6)
16. [32 CFR 199.8 — TRICARE double coverage (eCFR)](https://www.ecfr.gov/current/title-32/section-199.8)
17. [38 CFR 17.270 — CHAMPVA definitions, double coverage (eCFR)](https://www.ecfr.gov/current/title-38/section-17.270)
18. [N.J.A.C. 10:49-7.3 — Third-party liability (TPL) benefits (LII)](https://www.law.cornell.edu/regulations/new-jersey/N-J-A-C-10-49-7-3)

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.

Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.