For a Pennsylvania intake team, a Cigna card brings three layers. There is Evernorth’s national ABA coverage policy (EN0499), Pennsylvania’s autism mandate (Act 62 of 2008), and the plan’s size and funding type, which decide whether the mandate binds. This guide takes them in that order.
Cigna manages ABA through Evernorth Behavioral Health under national coverage policy EN0499 (Intensive Behavioral Interventions, effective 5/15/2026). The front door is easy: under the autism resource guide, assessment codes 97151, 97152 and 0362T need no prior authorization when the provider is independently licensed or a BCBA and the policy covers ABA. The hard part is the treatment request. It needs a standardized assessment given within 60 days before treatment starts, baseline data from the same window, and a treatment plan attached to Cigna’s ABA prior authorization form. That policy is the same everywhere. In Pennsylvania, what changes is the legal floor under it and whether that floor applies to the family’s plan.[1][2]
Pennsylvania’s autism mandate is Act 62 of 2008 (Insurance Company Law § 635.2, 40 P.S. § 764h). For covered individuals “under twenty-one (21) years of age” it requires coverage of the diagnostic assessment of autism spectrum disorder and of its treatment, and treatment includes rehabilitative care such as applied behavior analysis identified in a treatment plan. Coverage is subject to the plan’s copays, deductibles and coinsurance like any other medical service. A plan does not have to cover a service solely because it appears in an IEP, but coverage “shall not be contingent upon a coordination of services with an individualized education program”.[3][4][5][6]
Reach is the part intake gets wrong. Act 62 applies to health insurance policies offered, issued or renewed on or after July 1, 2009 “to groups of fifty-one (51) or more employees”, and to CHIP contracts. It does not reach individual policies, small-group policies (50 or fewer employees), self-funded employer plans governed by ERISA, or excepted coverage such as accident-only, fixed-indemnity and limited-benefit policies. So the first two questions on every benefits check are the group size and whether the plan is fully insured or self-funded.[3][4][5][6]
The statute sets an annual maximum benefit, adjusted each year for inflation: $51,908 for policies issued or renewed in 2026 and $53,310 for 2027, with no limit on the number of visits. The cap matters less than it looks. The Insurance Department treats autism as a mental health condition under the federal parity law (MHPAEA, adopted into Pennsylvania law by Act 14 of 2010). It told insurers to handle autism claims in a parity-compliant way no later than January 1, 2024, and says the annual adjustment “is not expected to have any impact on the coverage of autism services in this Commonwealth.”[3][4][5][6]
The “diagnostic assessment” is performed by a licensed physician, licensed physician assistant, licensed psychologist or certified registered nurse practitioner.[3]
“The results of a diagnostic assessment of autism spectrum disorder shall be valid for a period of twelve (12) months”, unless a licensed physician or licensed psychologist decides an earlier assessment is needed.[3]
The treatment plan is developed by a licensed physician or licensed psychologist after a comprehensive evaluation or reevaluation. Treatment is prescribed, ordered or provided by a licensed physician, physician assistant, psychologist, clinical social worker or CRNP.[3]
The insurer may review a treatment plan once every six months, subject to utilization review including concurrent review. A different interval can be agreed with the physician or psychologist who wrote the plan.[3]
The insurer must contract with, and accept as a participating provider, any autism service provider in its service area that is enrolled in Medical Assistance and accepts its terms.[3]
A denial gets an expedited internal review, then an expedited independent external review by the Insurance Department.[3]
We ran a full-text check of the current EN0499. Its only state references are New York, given as an example of a state mandate, and Virginia, whose fully insured business is not subject to the policy. Pennsylvania is not mentioned, so Pennsylvania Cigna members follow standard EN0499 criteria unless their plan documents differ. The no-assessment-PA path holds. Evernorth bases ABA authorizations on EN0499 “unless contractual requirements or federal or state law requires the use of other specifically identified clinical criteria”, and on an Act 62 plan the statutory rules above apply as well.[1][2]
One Pennsylvania-relevant line in the resource guide: Evernorth credentials providers “certified by a national governing agency or a state licensing board”, and its list names “licensed behavior specialist”, which is Pennsylvania’s license. Note, though, that EN0499 names BCBAs, licensed behavior analysts, or independently licensed mental health professionals with documented ABA training for the assessment and case supervision. Before relying on a behavior specialist in those roles, confirm with Evernorth Provider Relations.[1][2]
Many Pennsylvania children with commercial coverage also carry Medical Assistance as a second payer. PH-95 (“Medicaid for Children with Special Needs”) covers children under 18 with SSA-standard disabilities, and “Parental income must be verified but will be excluded in this category”. Medical Assistance pays last. Other private or governmental health insurance must be used before billing the MA Program, and DHS tells providers to bill the child’s private insurance before submitting an MA claim for ASD diagnostic assessment or treatment. On the Medicaid side, ABA is delivered as Intensive Behavioral Health Services (IBHS) and managed by the behavioral health MCO assigned to the family’s county, with its own order and authorization rules. Get the commercial plan’s authorization first: a claim the primary plan denied for a missed authorization is a weak one to send to MA.[13][11][12][15][14]
Pennsylvania has no behavior-analyst licensure law: the BACB’s U.S. licensure table carries no Pennsylvania entry. Act 62 had the State Board of Medicine license “behavior specialists” instead. The license requires a master’s degree in a listed field (behavioral analysis included), one year of functional-behavior-assessment experience with individuals under 21, 1,000 hours of clinical experience and 90 hours of coursework. There is no exam, and the fee is $75. The Board’s rules say they are not meant to require a second license of someone whose existing license already covers autism assessment and treatment.[8][9][10]
On rates, Cigna publishes no Pennsylvania commercial ABA fee schedule. Commercial rates are negotiated and sit in your participating-provider agreement.[8][9][10]
The questions that decide whether a family can start with Cigna / Evernorth in Pennsylvania, and what they have to bring. Each maps onto something intake should ask on the first call.
EN0499 puts no expiry on the ASD diagnosis, but requires the date it was most recently made. The data carry the clocks. The standardized instrument must be given within 60 days before treatment starts, and baseline data collected in the same window. Continued treatment needs current data within 60 days of the request and a standardized instrument no more than one year old. Any break in treatment longer than 60 calendar days means a fresh standardized assessment. On Act 62 plans, the diagnostic assessment is valid for 12 months unless a licensed physician or licensed psychologist decides an earlier one is needed.[1][3]
Under DSM-5-TR criteria, by a healthcare professional licensed to practice independently whose licensure board considers diagnostics within their scope of practice. The name, credentials and licensure type of the diagnosing clinician must be provided. On Act 62 plans, the statutory diagnostic assessment is performed by a licensed physician, licensed physician assistant, licensed psychologist or certified registered nurse practitioner.[1][3]
EN0499 names no single diagnostic instrument. The ABA assessment must use a reliable, valid, standardized instrument that measures the DSM-5-TR ASD domains (social communication and interaction; restricted, repetitive behaviors). It must be completed in full and as designed, by someone trained to give it, in the most current edition (Vineland-3, not Vineland-II), and it must show the administration date, respondent and scores.[1]
No referral, order or prescription is required under EN0499. Assessment codes 97151, 97152 and 0362T need no prior authorization for an independently licensed provider or BCBA. Treatment is authorized on the ABA Prior Authorization Form with the assessment and treatment plan attached. Act 62 plans add an ordering layer: the treatment plan is developed by a licensed physician or licensed psychologist, and treatment is prescribed, ordered or provided by a licensed physician, physician assistant, psychologist, clinical social worker or CRNP.[2][1][3]
“All ABA CPT codes are covered telehealth services” per the Evernorth autism resource guide. EN0499 allows in-person, telehealth or hybrid delivery, chosen on individual characteristics, the treatment plan, caregiver participation, environment, efficacy and safety evidence, and technology. The line-of-sight and close-proximity requirement does not apply to telehealth. A telehealth service must still meet the direct-treatment definition.[2][1]
EN0499 sets no age cap on ABA. Its glossary, following CASP 2024, says access to focused intervention “should not be restricted by age, cognitive level, diagnosis, or co-occurring conditions.” Age terms come from the member’s benefit plan document, which supersedes the coverage policy. In Pennsylvania, Act 62 covers individuals under 21 on fully insured policies issued to groups of 51 or more employees (and CHIP). Individual, small-group and self-funded ERISA plans sit outside it, so for them the plan document alone sets any age term.[1][3]
Ask the plan: Live benefits check or the Evernorth Autism Care Coordinator team (877.279.7603). Establish group size and fully insured vs. self-funded ERISA first.
Depends on how the plan is funded. Fully insured Pennsylvania plans follow Act 146 of 2022 (Insurance Company Law § 2155, effective January 1, 2024). An urgent request for care not yet started is decided “as soon as possible, but not more than 72 hours” after receipt. An ongoing urgent course asked to continue at least 24 hours before it would be cut back or ended is decided within 24 hours. Every other prior authorization request is decided “within 15 days”; the insurer can extend that only if it promptly flagged missing information, and the provider then has at least 45 days to supply it. Act 146 also makes insurers post their prior-authorization list and offer a peer-to-peer on denial. Self-funded ERISA plans follow 29 CFR 2560.503-1 instead: pre-service decisions within 15 days, one 15-day extension, and 72 hours for urgent care. Evernorth’s own guidance: request authorization up to 30 days before, or two weeks after, the service start date. Later requests may go to retrospective review, which can take up to 30 days. A continuation request needs current data collected within 60 days.[7][16][1]
Ask the plan: At benefits verification, ask whether the plan is fully insured (Pennsylvania-regulated) or self-funded (ERISA), then confirm the authorization turnaround and any continuation lead time with Cigna/Evernorth (Autism Care Coordinator team, 877.279.7603).
Which of two parents’ plans pays first is set by the plans’ own coordination terms. We found no Pennsylvania regulation fixing the order for a child on both parents’ plans, so ask each plan which one is primary. If the child also has Medical Assistance (including PH-95), Cigna pays first. MA is payer of last resort (42 CFR 433.139): other private or governmental insurance “shall be utilized before billing the MA Program” (55 Pa. Code § 1101.64), and IBHS is not paid when payment is available through a third party (55 Pa. Code § 1155.31(e)). DHS tells providers to bill private insurance before submitting an MA claim for ASD assessment or treatment. Get Cigna’s authorization even when MA is secondary. If the child also has TRICARE, TRICARE pays after this plan (10 U.S.C. 1079(i)(1)). CHAMPVA is the last payer after other health insurance (38 CFR 17.270).[11][15][12][17][18][19]
Ask the plan: Ask Cigna 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, including Medical Assistance/PH-95.
Coverage decides whether Cigna / Evernorth in Pennsylvania 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 documented ABA training. Direct supervision (the BCBA face-to-face with the individual and the RBT or BCaBA, at the same time as treatment) plus indirect supervision runs at the standard of one to two hours per ten hours of direct treatment. When direct treatment is 10 hours a week or less, at least one to two hours a week of direct supervision is provided. The supervisor’s name and credentials must be documented.[1]
Only one provider can bill for a unit of time. The exception is 97153, 97154 and 97155 during direct supervision, when the BCBA/QHP directs the technician and both are face-to-face with the patient at once. ABA is not covered when delivered at the same time as another treatment modality, such as ABA and speech therapy.[2][1]
Cigna publishes no per-day unit ceiling. All ABA codes bill in 15-minute units, only 97151–97158, 0362T and 0373T. Planned intensity must reflect severity, goals and response to treatment, and supervision runs one to two hours per ten hours of direct treatment. On Act 62 plans the statute bars visit limits, and the Insurance Department expects its CPI-adjusted dollar maximum ($51,908 for 2026 policies) to have no impact under parity.[2][1][3][4]
A separate written record for each service, by CPT code, showing: start and end date and time, location, focus, a detailed description of the intervention, individuals present, the specific service delivered, and the name, credential (if applicable) and signature of the ABA provider who rendered it.[1]
Goals are defined and measured across every setting where treatment happens (home, clinic, school, community), and data are reported separately by location. Services that are mainly educational or vocational are not covered. In academic, vocational or telehealth settings, the plan must document that the service meets the direct-treatment definition and does not replace the setting’s own responsibilities (e.g. a classroom aide). On Act 62 plans, coverage cannot hinge on coordination with an IEP.[1][3]
Evernorth does not credential non-licensed or non-certified staff; their services are billed under the supervising provider. On a CMS-1500 only a BCBA or other licensed provider goes in box 33; electronic payer ID 62308. Per the code table, 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. Evernorth’s credentialing list includes “licensed behavior specialist”, Pennsylvania’s license.[2]
Yes, for autism spectrum disorder under Evernorth policy EN0499. On fully insured policies for groups of 51 or more employees, Pennsylvania’s Act 62 adds a legal floor for members under 21. Self-funded, individual and small-group plans follow their own plan terms.
No. Assessment codes 97151, 97152 and 0362T need no prior authorization for an independently licensed provider or BCBA when the policy covers ABA, and EN0499 has no Pennsylvania carve-out. Authorization is needed at the treatment step. Confirm benefits before the assessment.
Evernorth’s credentialing list names “licensed behavior specialist” among accepted licenses. EN0499 still names BCBAs, licensed behavior analysts or independently licensed clinicians with ABA training for assessment and supervision, so confirm the role with Evernorth Provider Relations.
Commercial ABA rates are not published. They are negotiated in your participating-provider agreement.
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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