---
title: "Cigna / Evernorth ABA coverage in Rhode Island: the intake guide."
url: "https://carelu.com/payers/cigna-rhode-island"
markdown_url: "https://carelu.com/payers/cigna-rhode-island.md"
state: RI (Rhode Island)
payer: Cigna / Evernorth in Rhode Island
kind: Commercial insurance
description: "How Cigna / Evernorth covers ABA for Rhode Island families: policy EN0499, no PA on assessments, all ABA codes covered by telehealth, Rhode Island’s ch. 27-20.11 mandate (until age 15), state licensure, prompt pay and appeals."
last_reviewed: October 2026
---

# Cigna / Evernorth ABA coverage in Rhode Island: the intake guide.

_Payer Guide · Cigna · Rhode Island · Last updated October 2026 · 18 primary sources_

> EN0499 + autism resource guide + Rhode Island’s ch. 27-20.11 mandate (to age 15); no PA on assessment codes; all ABA codes telehealth-eligible.

For an intake team in Rhode Island, a Cigna card means three layers: Evernorth’s national ABA policy EN0499 with the Cigna autism resource guide, Rhode Island’s autism mandate in chapter 27-20.11, and the plan’s funding and size, which decide whether the mandate applies. Many Cigna members are on self-funded employer plans, so check funding first. Cigna runs no Rhode Island Medicaid plan.

## Prior authorization and diagnosis at a glance

- **Prior auth for the assessment**: Not required for 97151, 97152 and 0362T with an autism diagnosis when the provider is independently licensed or a BCBA (Cigna autism resource guide) [2]
- **Prior auth for treatment**: Required: completed assessment and treatment plan attached to the Applied Behavior Analysis Prior Authorization Form [2][1]
- **Autism diagnosis required?**: Yes: ASD (F84.0–F84.9 except F84.2 Rett) under DSM-5-TR criteria [1]

## At a glance

- **Covers ABA?:** Yes, for ASD, per national policy EN0499
- **State mandate:** R.I. Gen. Laws ch. 27-20.11 (group plans issued or renewed from 1/1/2012)
- **Mandate age:** Until the covered individual reaches age 15 (§ 27-20.11-3(b))
- **Mandate caps:** None in the current text; cost sharing no more restrictive than other conditions
- **Exempt from mandate:** Small-employer and individual plans (ch. 27-50, ch. 27-18.5), Medicaid, self-funded ERISA plans
- **Licensure:** Yes: LBA/LABA licensed by the RI Department of Health (ch. 5-86); the mandate requires a licensed provider
- **Fee schedule:** Not public — Exhibit A of your Evernorth Provider Agreement; Provider Services 800.926.2273

## The national policy, applied in Rhode Island

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 when the provider is independently licensed or a BCBA; treatment needs the completed assessment and treatment plan on the ABA Prior Authorization Form. "All ABA CPT codes are covered telehealth services." EN0499 and the resource guide say nothing specific to Rhode Island; Evernorth’s Administrative Guidelines carry a Rhode Island regulatory addendum on contract terms, not on ABA criteria. [1][2][3]

## The Rhode Island mandate: what it guarantees

Rhode Island’s autism mandate is R.I. Gen. Laws chapter 27-20.11, in force for group contracts delivered, issued or renewed on or after January 1, 2012. It requires coverage for "pharmaceuticals, applied behavior analysis, physical therapy, speech therapy, psychology, psychiatric and occupational therapy services for the treatment of autism spectrum disorders," and benefits "shall continue until the covered individual reaches age fifteen (15)." The current text carries no dollar cap on ABA. Three limits matter at intake. First, reach: the chapter applies to group health insurance but "shall not apply to contracts, plans or group policies subject to the Small Employer Health Insurance Availability Act," Medical Assistance, or the Individual Health Insurance Coverage Act, and self-funded employer plans answer to ERISA, not the state. Second, place: benefits "apply only to services delivered within the state of Rhode Island," unless preauthorization shows the services are not available in Rhode Island from an in-network provider. Third, staffing: anyone "providing or supervising" ABA must be a Department of Health licensed applied behavior analyst, a licensed assistant analyst under supervision, or a licensed psychologist (§ 27-20.11-7). An insurer may require a treatment plan with frequency and duration signed by a child psychiatrist, a behavioral developmental pediatrician, a child neurologist, or a licensed psychologist trained in child psychology, updated "no more frequently than on a quarterly basis" (§ 27-20.11-4(d)). Cost sharing may be no more restrictive than for other conditions, and the mandate does not change a school district’s IEP or IFSP duties. [4][5][6][7]

## Licensure, prescriptions and out-of-state BCBAs

Rhode Island licenses behavior analysts under R.I. Gen. Laws chapter 5-86, through a board within the Department of Health. The titles are licensed applied behavior analyst (LBA) and licensed assistant applied behavior analyst (LABA). An LBA applicant needs a graduate degree, supervised fieldwork aligned with BACB requirements, a passing BCBA exam, and active BACB status (§ 5-86-9). Two provisions reach every payer. The statute’s definition of practice says ABA services "are provided by a person licensed under this chapter only when applied behavior analysis services are prescribed by a child psychiatrist, a behavioral developmental pediatrician, a child neurologist, or a licensed psychologist with training in child psychology" (§ 5-86-2(8)), so get that prescription on file before treatment starts. And the supervision section lets an LBA supervise assistant analysts and "applied behavior analyst aides," with "close supervision" of aides and no delegation of evaluation or program changes (§ 5-86-26). Rhode Island licenses behavior analysts, so a BCBA licensed elsewhere cannot simply treat a Rhode Island child. Under R.I. Gen. Laws § 5-86-21(g), an analyst "licensed or certified in another state" may practice in Rhode Island without a Rhode Island license "for up to ten (10) calendar days per calendar year with no more than five (5) days of this activity occurring consecutively." Beyond that, the clinician needs a Rhode Island license (LBA) from the Department of Health board, which requires passing the BCBA exam and keeping active BACB status (§ 5-86-9). Chapter 5-86 has no telehealth exception and no reciprocity section. For Medicaid telehealth, EOHHS is explicit: an out-of-state provider may serve Medicaid members by telehealth only with "an active and unrestricted license in the state of Rhode Island" and Rhode Island Medicaid enrollment; "Out-of-state licensure alone does not confer eligibility." [8][9][19][10][20][21]

## Claims operations: prompt pay, prior authorization clocks, appeals

Rhode Island’s prompt-pay statute, R.I. Gen. Laws § 27-18-61, requires a health plan to pay a complete claim "within forty (40) calendar days following the date of receipt of a complete written claim or within thirty (30) calendar days following the date of receipt of a complete electronic claim," to tell the provider within 30 days why a claim is denied or pended, and to pay 12% annual interest on late complete claims. The plan is not in violation for a claim "initially submitted more than ninety (90) days after the service is rendered," so bill promptly even where the contract allows longer; the actual filing limit is set by each carrier’s contract. For prior authorization of a fully insured plan, OHIC’s utilization review rule (230-RICR-20-30-14) and § 27-18.9-6 set the clocks: pre-service decisions within 15 calendar days (extendable once by 15), urgent within 72 hours, concurrent reviews within 24 hours. Appeals: the plan must give at least 180 calendar days to appeal an adverse determination, decide a pre-service appeal within 30 calendar days, decide an expedited appeal within 72 hours, and keep paying an ongoing course of treatment while the appeal is pending (§ 27-18.9-7). [11][12][13][14][3]

Evernorth’s Behavioral Health Administrative Guidelines (September 2026) set the filing limit: "We will only consider claims submitted within 90 days of the date of service or as otherwise defined in your Provider Agreement," unless "Applicable state law provides for a longer timely filing limit." For a secondary claim the 90 days run from "the primary payer’s processing date as stated on an explanation of benefits [EOB] or explanation of payment [EOP]," Medicaid-primary claims get three years, and a timely claim returned for more information gets a new 90 days from the date of the request. The Rhode Island Regulatory Addendum adds no claim rule. State addenda do not apply to self-funded plans. The guidelines publish no check-run or weekly cut-off schedule. [11][12][13][14][3]

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

Cigna publishes no ABA rate table. Evernorth’s Administrative Guidelines (September 2026) say the Provider Agreement terms "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." Contract and fee questions go to Provider Services at 800.926.2273. Telehealth claims carry modifier 95 and place of service 02. For a public benchmark, Rhode Island Medicaid pays HBTS direct service (T1024) at $33.30 per 15 minutes per OHIC’s 2025 report, on different codes. [3][18]

## What a reauthorization must show

Evernorth’s EN0499 sets what a continued-treatment request must show: "current data" 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," with collection dates, for every behavior and skill targeted; data showing "ongoing and sustained progress toward mastering the treatment goals"; measurable improvement on "a reliable, valid, and standardized assessment instrument completed no more than one year prior to the start date of the continued treatment request"; an account of barriers and plan changes where progress is not shown; and dated stakeholder (caregiver) training data. EN0499 does not require the data to be graphed. [1]

## Intake gates

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

- **Diagnosis recency**: No expiry on the diagnosis, but the request needs the date it was most recently made, and provisional or rule-out diagnoses do not count. Assessment instrument within 60 days before treatment starts, baseline data within 60 days, and current data within 60 days of a continued-treatment request. [1]
- **Who may diagnose**: A healthcare professional "licensed to practice independently and whose licensure board considers diagnostics" within scope, applying DSM-5-TR criteria. [1]
- **Diagnostic tools required**: No single instrument is mandated, but it must be standardized, valid and the current edition (the policy’s example: Vineland-3, not Vineland-II), with dates and standardized scores reported. [1]
- **Referral required?**: EN0499 requires no referral; assessments 97151, 97152 and 0362T need no PA with an autism diagnosis, and treatment needs the assessment and plan on the ABA PA form. Rhode Island adds a licensing-law prescription rule that applies whatever the plan says: a licensed behavior analyst provides ABA "only when applied behavior analysis services are prescribed by a child psychiatrist, a behavioral developmental pediatrician, a child neurologist, or a licensed psychologist with training in child psychology" (R.I. Gen. Laws § 5-86-2(8)). For a mandate plan, the insurer may also require a treatment plan signed by one of those specialists, updated no more than quarterly (§ 27-20.11-4(d)). [2][1][9][6]
- **Telehealth**: "All ABA CPT codes are covered telehealth services," per the autism resource guide; bill modifier 95 with place of service 02 (Evernorth Administrative Guidelines). For a Rhode Island plan, the Telemedicine Coverage Act (R.I. Gen. Laws § 27-81-4) bars excluding a service "solely because the healthcare service is provided through telemedicine," requires in-network behavioral health telemedicine to be reimbursed "at rates not lower than services delivered by the same provider through in-person methods," and bars stricter prior authorization for telemedicine; the originating site "can include a patient’s home" (§ 27-81-3). Self-funded employer plans are outside the state act. A clinician serving a child in Rhode Island by telehealth needs a Rhode Island license beyond the 10-day out-of-state allowance (§ 5-86-21(g)). [2][3][16][10]
- **Age limit** _(plan-dependent)_: EN0499 sets no age cap and says access "should not be restricted by age." For fully insured large-group Rhode Island plans, R.I. Gen. Laws § 27-20.11-3(b) carries the mandate only "until the covered individual reaches age fifteen (15)"; the statute has no dollar cap. Small-group and individual plans are outside chapter 27-20.11, and self-funded ERISA plans set their own terms. [1][5]
  - Ask the plan: Live benefits verification: establish fully insured large group vs. small group, individual or self-funded first.
- **Prior-auth decision time** _(plan-dependent)_: Depends on how the plan is funded. Fully insured Rhode Island plans follow R.I. Gen. Laws § 27-18.9-6 and OHIC rule 230-RICR-20-30-14: pre-service decisions "within a reasonable period of time appropriate to the medical circumstances," before the service, and "no later than fifteen (15) calendar days after the receipt of the claim," extendable once by 15 days for special circumstances; urgent requests within 72 hours; concurrent requests within 24 hours, and before the authorized period runs out if the request comes at least 24 hours ahead. If information is missing on an urgent request, the plan must say so within 24 hours and give at least 48 hours to respond. A reviewer may not retrospectively deny an authorized service unless the approval rested on inaccurate information or the care did not follow the submitted plan. Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1: 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 Rhode Island-specific ABA turnaround or reauthorization lead time. [13][12][14][17]
  - Ask the plan: At benefits verification ask whether the plan is fully insured (Rhode Island-regulated) or self-funded (ERISA), and what reauthorization lead time Evernorth expects.
- **Other insurance (who pays first)** _(plan-dependent)_: For a child on two group plans, Rhode Island follows the birthday rule: for parents who are married or living together, "The plan of the parent whose birthday falls earlier in the calendar year is the primary plan," and if both share a birthday, the plan that has covered a parent longest (230-RICR-20-30-2.6). For separated parents a court decree controls; without one, the custodial parent’s plan pays first, then the custodial parent’s spouse’s, then the non-custodial parent’s. That rule binds state-regulated plans; a self-funded plan sets its own order. If the child also has Rhode Island Medicaid, Cigna/Evernorth pays first: Medicaid is payer of last resort (42 CFR 433.139), and the Medicaid health plans require the primary carrier’s EOB with the claim. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270). [15][22][23][24][25]
  - 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.

## Delivery and billing rules

Coverage decides whether Cigna / Evernorth in Rhode Island 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**: Case supervision is by a BCBA, a Licensed Behavior Analyst, or an independently licensed mental health professional with ABA training, 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. In Rhode Island the supervisor must also hold a Rhode Island license (§ 27-20.11-7). [1][7]
- **Concurrent billing (97153 + 97155)**: "Only one provider can bill for a unit of time, with the exception of CPT codes 97153, 97154, and 97155" during direct supervision, when the BCBA or QHP and the technician are both with the patient at the same time. Other therapies are a separate rule: EN0499 (eff. 5/15/2026) says “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]
- **Daily limits / MUEs**: No per-day cap is published. ABA bills in 15-minute units with "CPT codes 97151–97158, 0362T, and 0373T ONLY"; intensity must reflect severity, goals and response. [2][1]
- **Session-note signature**: Each service record must include, among other items, the "Name, credential (if applicable), and signature of ABA provider who rendered the service." [1]
- **Place of service**: Goals are tracked per setting (home, clinic, school, community). Services "primarily educational or vocational in nature" are not covered. Rhode Island’s mandate covers services delivered in the state unless unavailable in-network (§ 27-20.11-3(c)). [1][5]
- **Bill as provider**: Evernorth credentials licensed or certified providers only; non-credentialed staff bill under the supervising provider. On a CMS-1500 "List only a BCBA or other licensed provider in box 33"; electronic claims use payer ID 62308. 97152–97154 may be delivered by a BCaBA or technician but billed by a BCBA or licensed provider. [2]

## What intake should collect for Cigna / Evernorth in Rhode Island

- **Plan funding and size:** Fully insured large group (ch. 27-20.11 applies) vs. small group, individual or self-funded ERISA.
- **Child’s age:** The state mandate runs until age 15; older children depend on the plan.
- **Diagnosis report:** Diagnosing clinician’s name, credentials and licensure type, and the date of the most recent diagnosis. Provisional or rule-out diagnoses don’t count.
- **Standardized assessment timing:** Instrument administered within 60 days before treatment starts.
- **Specialist prescription:** Rhode Island law has licensed analysts provide ABA only on a prescription from a child psychiatrist, behavioral developmental pediatrician, child neurologist or child-trained psychologist.

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

## Common questions

### Does Cigna require graphs for ABA reassessments?

No. Evernorth’s EN0499 requires dated data collected within 60 days before both the requested start date and the request’s receipt, sustained progress, and a standardized assessment from the past year, but it does not require graphs.

### What are Cigna (Evernorth)’s claim filing deadlines for Rhode Island ABA claims?

90 days from the date of service unless your provider agreement or a longer state limit applies; secondary claims get 90 days from the primary payer’s EOB/EOP date, and a claim returned for more information gets a new 90 days. No check-run schedule is published.

### Does Cigna cover ABA therapy in Rhode Island?

Yes, under national policy EN0499 for ASD, with Rhode Island’s ch. 27-20.11 mandate layered on for fully insured large-group plans until age 15.

### Does the Cigna ABA assessment need prior authorization?

No, for 97151, 97152 and 0362T with an autism diagnosis when the provider is independently licensed or a BCBA. PA starts at treatment.

### Can ABA be delivered by telehealth with Cigna?

Yes: Cigna lists all ABA CPT codes as covered telehealth services, billed with modifier 95 and POS 02. The clinician still needs a Rhode Island license to treat a Rhode Island child beyond 10 days a year.

### What does Cigna pay for ABA in Rhode Island?

Cigna publishes no ABA rates; your fee schedule is Exhibit A of your Evernorth Provider Agreement (Provider Services 800.926.2273).

## Primary sources

1. [Evernorth EN0499 — Intensive Behavioral Interventions (eff. 5/15/2026)](https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/en_mm_0499_coveragepositioncriteria_intensive_behavioral_interventions.pdf)
2. [Cigna / Evernorth autism resource guide (PCOMM-2025-225, March 2025)](https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/autism-resource-guide.pdf)
3. [Evernorth Behavioral Health Administrative Guidelines (PCOMM-2026-191, September 2026; includes a Rhode Island regulatory addendum)](https://static.evernorth.com/assets/evernorth/provider/pdf/resourceLibrary/behavioral/ebh-provider-admin-guide.pdf)
4. [R.I. Gen. Laws ch. 27-20.11 — Autism Spectrum Disorders (§§ 27-20.11-1 to -8)](https://webserver.rilegislature.gov/Statutes/TITLE27/27-20.11/INDEX.htm)
5. [R.I. Gen. Laws § 27-20.11-3 — Scope of coverage (benefits continue until age 15; in-state services)](https://webserver.rilegislature.gov/Statutes/TITLE27/27-20.11/27-20.11-3.htm)
6. [R.I. Gen. Laws § 27-20.11-4 — Medical necessity; treatment plan signed by listed specialists, updates no more than quarterly](https://webserver.rilegislature.gov/Statutes/TITLE27/27-20.11/27-20.11-4.htm)
7. [R.I. Gen. Laws § 27-20.11-7 — Credentials (licensed applied behavior analyst, supervised assistant, or psychologist)](https://webserver.rilegislature.gov/Statutes/TITLE27/27-20.11/27-20.11-7.htm)
8. [R.I. Gen. Laws ch. 5-86 — Licensing of Applied Behavior Analysts (index)](https://webserver.rilegislature.gov/Statutes/TITLE5/5-86/INDEX.htm)
9. [R.I. Gen. Laws § 5-86-2 — Definitions (practice of ABA; services provided only when prescribed by listed specialists), as amended effective June 30, 2025](https://webserver.rilegislature.gov/Statutes/TITLE5/5-86/5-86-2.htm)
10. [R.I. Gen. Laws § 5-86-21 — Persons and practices exempt (out-of-state analysts: 10 calendar days a year)](https://webserver.rilegislature.gov/Statutes/TITLE5/5-86/5-86-21.htm)
11. [R.I. Gen. Laws § 27-18-61 — Prompt processing of claims (40 days written / 30 days electronic, 12% interest)](https://webserver.rilegislature.gov/Statutes/TITLE27/27-18/27-18-61.htm)
12. [230-RICR-20-30-14 — Benefit Determination and Utilization Review (OHIC; effective 01/04/2022)](https://rules.sos.ri.gov/Regulations/part/230-20-30-14)
13. [R.I. Gen. Laws § 27-18.9-6 — Non-administrative benefit determination notifications (decision timeframes)](https://webserver.rilegislature.gov/Statutes/TITLE27/27-18.9/27-18.9-6.htm)
14. [R.I. Gen. Laws § 27-18.9-7 — Internal appeal procedural requirements](https://webserver.rilegislature.gov/Statutes/TITLE27/27-18.9/27-18.9-7.htm)
15. [230-RICR-20-30-2 — Coordination of Benefits (formerly Insurance Regulation 48)](https://rules.sos.ri.gov/regulations/part/230-20-30-2)
16. [R.I. Gen. Laws § 27-81-4 — Telemedicine Coverage Act: coverage of telemedicine services](https://webserver.rilegislature.gov/Statutes/TITLE27/27-81/27-81-4.htm)
17. [29 CFR 2560.503-1 — ERISA claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
18. [OHIC — 2025 Social and Human Service Programs Review, Final Report (August 29, 2025)](https://ohic.ri.gov/sites/g/files/xkgbur736/files/2025-08/2025%20Social%20and%20Human%20Service%20Programs%20Review%20Final%20Report%20August%2029%202025.pdf)
19. [R.I. Gen. Laws § 5-86-9 — Qualifications and examinations for licensing (BCBA exam, active BACB status)](https://webserver.rilegislature.gov/Statutes/TITLE5/5-86/5-86-9.htm)
20. [R.I. Gen. Laws § 5-86-26 — Supervision (assistant analysts, aides)](https://webserver.rilegislature.gov/Statutes/TITLE5/5-86/5-86-26.htm)
21. [RI EOHHS — Telemedicine Billing Guidance (July 2025, effective September 1, 2025)](https://eohhs.ri.gov/sites/g/files/xkgbur226/files/2025-07/Telemedicine%20Billing%20Guidance.pdf)
22. [42 CFR 433.139 — Medicaid third-party liability (eCFR)](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139)
23. [Neighborhood Health Plan of RI — Provider Manual (effective 1/1/2026)](https://www.nhpri.org/wp-content/uploads/2023/08/Provider-Manual.pdf)
24. [10 U.S.C. 1079(i)(1) — TRICARE pays after other coverage except Medicaid](https://www.govinfo.gov/content/pkg/USCODE-2023-title10/html/USCODE-2023-title10-subtitleA-partII-chap55-sec1079.htm)
25. [38 CFR 17.270 — CHAMPVA is the last payer](https://www.ecfr.gov/current/title-38/section-17.270)

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.