For an intake team in South Carolina, a Cigna card means three layers: Evernorth’s national ABA policy EN0499 with the Cigna autism resource guide, South Carolina’s autism mandate in S.C. Code § 38-71-280, and the plan’s funding and size. Many Cigna members are on self-funded employer plans, which the state mandate does not reach, so check funding first.
Cigna, through Evernorth Behavioral Health, covers ABA under EN0499 (effective May 15, 2026). The autism resource guide says prior authorization "is no longer required for assessment … codes 97151, 97152, or 0362T with a diagnosis of autism, as long as the provider is independently licensed or a Board Certified Behavior Analyst" and the policy covers ABA; treatment needs the completed assessment and plan on the ABA Prior Authorization form. EN0499 and the resource guide contain no South Carolina provisions. Evernorth’s Administrative Guidelines carry a South Carolina Regulatory Addendum for insured business: it limits overpayment recovery to 18 months and requires 90 days of continued care after a contract ends when the treating physician attests to serious jeopardy (S.C. Code § 38-71-243); it does not apply to self-funded plans. Cigna is not a South Carolina Medicaid plan.[1][2][3][14]
South Carolina’s autism mandate, S.C. Code § 38-71-280 (2007 Act No. 65, known as Ryan’s Law), requires a "health insurance plan" to "provide coverage for the treatment of autism spectrum disorder." The definition is narrow in three ways. It reaches group policies and group benefit plans plus the State Health Plan, and it expressly excludes the individual market, individually underwritten plans and plans sold to small employers; self-funded employer plans answer to ERISA instead. It defines autism spectrum disorder by three older DSM labels (autistic disorder, Asperger’s syndrome, PDD-NOS). And the child must be "diagnosed with autistic spectrum disorder at age eight or younger," with benefits provided to "any eligible person under sixteen years of age." Coverage "is limited to treatment that is prescribed by the insured’s treating medical doctor in accordance with a treatment plan," which must state the diagnosis, treatment by type, frequency and duration, goals, the update schedule and the doctor’s signature; the plan "may only request an updated treatment plan once every six months." Dollar limits, deductibles and coinsurance may not be less favorable than for physical illness, but "Coverage for behavioral therapy is subject to a fifty thousand dollar maximum benefit per year," adjusted each January 1 by CPI. The Department of Insurance set that cap at $73,400 for calendar year 2026 (Bulletin 2025-09). The statute lets plans keep coordination of benefits, participating-provider rules, utilization review and "restrictions on services provided by family or household members."[4][5]
South Carolina does not license behavior analysts. Title 40, Chapter 75 of the Code (the LLR board for counselors, marriage and family therapists, addiction counselors and psycho-educational specialists) has no behavior-analyst article, the 2021 licensure bill (H. 3731) never left committee, and the BACB’s licensure table does not list the state. Practically, BACB certification is the credential every payer checks. Two payer-level location rules matter more than any license. SC Medicaid requires ASD providers, including those working by telehealth, to be located within the South Carolina Medical Service Area (SCMSA; SCDHHS describes it as within 25 miles of the state border). BlueCross BlueShield of South Carolina’s ABA policy says the BCBA completing the assessment "must be located in the same state as the member or in a contiguous county." On claims, the state prompt-pay law (S.C. Code § 38-59-230) makes insurers pay a clean claim within 20 business days if filed electronically and 40 business days on paper, with interest after that; a "clean claim" must be received "within one hundred twenty business days" of the service. Overpayment recovery may not start more than 18 months after payment, except for fraud, self-insured plans or government programs. Commercial ABA rates are negotiated and unpublished; the public benchmark is the SC Medicaid ASD fee schedule (97153 $14.88 per 15-minute unit).[9][15][10][16][17][18][6][13]
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." Fee questions go to Provider Services at 800.926.2273. Non-credentialed technicians are paid only through the supervising provider’s claim. For a public benchmark, SC Medicaid pays 97153 at $14.88 per 15 minutes; commercial contracts are negotiated separately.[3][2][13]
Evernorth’s Behavioral Health Administrative Guidelines (September 2026): "We will only consider claims submitted within 90 days of the date of service or as otherwise defined in your Provider Agreement," unless state law allows longer. For coordination of benefits the 90 days run from "the primary payer’s 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 fresh 90 days from the date of the request. The South Carolina Regulatory Addendum adds no filing or payment-time rule (it covers overpayment recovery and continuity of care) and does not apply to self-funded plans. For insured South Carolina plans, S.C. Code § 38-59-230 sets the clean-claim payment clock: 20 business days electronic, 40 on paper. No check-run schedule is published.[3][6]
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]
The questions that decide whether a family can start with Cigna / Evernorth in South Carolina, 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 on which the diagnosis was most recently made," and the standardized assessment must be administered within 60 days before treatment starts. For a mandated plan, the child must have been diagnosed at age eight or younger.[1][4]
A "healthcare professional who is licensed to practice independently and whose licensure board considers diagnostics to be within their scope of practice," applying DSM-5-TR, with name, credentials and licensure type documented.[1]
No single instrument is mandated; the assessment must use reliable, valid, standardized, current-edition instruments completed in full and administered within 60 days before treatment.[1]
EN0499 requires no referral; assessments need no PA with an autism diagnosis when the provider is independently licensed or a BCBA, and treatment needs the ABA PA form. For a group plan subject to S.C. Code § 38-71-280, covered treatment must be "prescribed by the insured’s treating medical doctor in accordance with a treatment plan" signed by that doctor; the plan may ask for an updated plan only once every six months. Individual, small-employer and self-funded plans are outside the statute.[2][1][4]
"All ABA CPT codes are covered telehealth services" (autism resource guide), and EN0499 says the line-of-sight requirement "does not apply to telehealth services." Evernorth bills telehealth with modifier 95.[2][1][3]
EN0499 sets no age cap; access to focused intervention "should not be restricted by age." For a South Carolina group plan subject to S.C. Code § 38-71-280, coverage runs to "any eligible person under sixteen years of age" who was diagnosed at age eight or younger, with behavioral therapy capped at $73,400 for 2026 (DOI Bulletin 2025-09). Individual, small-employer and self-funded plans are outside the statute.[1][4][5]
Ask the plan: Live benefits verification, or Evernorth Provider Services 800.926.2273: establish group size and funding first.
No South Carolina statute read sets a prior-authorization decision deadline for commercial plans. Title 38, Chapter 70 (utilization review) sets minimum standards for review programs, including notice of an adverse decision "within five business days" and a reconsideration or appeal procedure, but no clock for deciding a request. Federal claims rules therefore set the outer limit: ERISA plans must decide a pre-service claim "not later than 15 days after receipt of the claim" (one 15-day extension; urgent care within 72 hours), and insured group coverage must follow the same rule under 45 CFR 147.136. Cigna asks providers to request ABA authorization up to 30 days before, or within two weeks after, the start of service; later requests may go to retrospective review, which can take up to 30 days.[7][11][12][2]
Ask the plan: At benefits verification ask whether the plan is insured or self-funded and what decision timeframe Evernorth applies.
For a child on two group plans, South Carolina Regulation 69-43 sets the birthday rule: when parents are not separated or divorced, "the benefits of the plan of the parent whose birthday falls earlier in a year are determined before those of the plan of the parent whose birthday falls later" (month and day only); for separated or divorced parents the custodial parent’s plan pays first unless a court decree assigns health costs to the other parent. The regulation binds insured group plans; a self-funded plan sets its own order. If the child also has SC Medicaid, the commercial plan pays first: Medicaid is payer of last resort (42 CFR 433.139), and SCDHHS asks for its own ASD authorization only "if Medicare or the primary carrier denied the service or the service is considered not covered." TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[8][19][16][20][21]
Ask the plan: Ask Cigna/Evernorth at benefits verification for the member’s coordination-of-benefits order, and record every other coverage the child has.
Coverage decides whether Cigna / Evernorth in South Carolina 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 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. The supervisor’s name and credentials must be documented.[1]
"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)." ABA alongside speech or occupational therapy: EN0499 (effective 5/15/2026) states that "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)." Same-day sessions at different times are not barred; overlapping clock time is.[2][1]
No per-day cap is published; "All ABA services must be billed with CPT codes 97151–97158, 0362T, and 0373T ONLY," and intensity must reflect severity and response. A mandated South Carolina group plan may still apply the $73,400 annual behavioral-therapy cap for 2026.[2][1][4][5]
Each service record needs the "Name, credential (if applicable), and signature of ABA provider who rendered the service," with date, times, location and who was present.[1]
Services delivered in academic, vocational or telehealth settings must still meet the direct-treatment definition, and services "primarily educational or vocational in nature" are not covered.[1]
"Evernorth does not credential nonlicensed/noncertified staff. Services for these staff members must be billed under the supervising provider." On paper claims list "only a BCBA or other licensed provider in box 33"; electronic claims use payer ID 62308.[2]
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.
90 days from the date of service unless your provider agreement or state law allows longer; secondary claims get 90 days from the primary payer’s EOB or EOP date. Insured plans must pay clean claims within 20 business days electronically (40 on paper) under S.C. Code § 38-59-230.
Yes, under national policy EN0499 for ASD, with Ryan’s Law added for insured large-group 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. Prior authorization starts at treatment.
Yes. Cigna’s autism resource guide says all ABA CPT codes are covered telehealth services; bill with modifier 95.
South Carolina 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 October 2026; it is general information, not billing, legal, or clinical advice. Always verify current requirements against the payer's live policy and a benefits check for the specific member.
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