For an intake team in South Dakota, a Cigna card means three layers: Evernorth’s national ABA policy EN0499 with the Cigna autism resource guide, South Dakota’s autism mandate, and the plan type, which decides whether the mandate applies. Many Cigna members are on self-funded employer plans, which sit outside both the mandate and Evernorth’s South Dakota regulatory addendum, so check funding first.
Cigna, through Evernorth Behavioral Health, covers ABA under EN0499 (effective May 15, 2026). Per the autism resource guide, prior authorization is no longer required for 97151, 97152 and 0362T with an autism diagnosis, as long as the provider is independently licensed or a BCBA and the policy covers ABA. Treatment needs the completed assessment and treatment plan on the ABA Prior Authorization Form. EN0499 does not mention South Dakota, so the national criteria apply. Evernorth’s Administrative Guidelines (September 2026) add a South Dakota Regulatory Addendum for insured business. It does not apply to self-funded plans. It lets a patient continue an ongoing course of treatment for 90 days with a provider who leaves the network or is terminated without cause, on request and if the provider agrees, and it limits recoupment of a paid claim to 18 months with written notice. Patients with Cigna Healthcare coverage have access to the Evernorth network in South Dakota.[1][2][3]
South Dakota’s autism mandate is SDCL 58-17-154 to 58-17-162 (SL 2015, ch 250), in force for plan years beginning on or after January 1, 2016. Every policy it reaches "shall provide coverage for applied behavior analysis for the treatment of autism spectrum disorders" (58-17-157). "Treatment" means evidence-based care "prescribed or ordered for a person diagnosed with an autism spectrum disorder by a licensed physician or psychologist" (58-17-154(4)). The carrier may use "pre-authorization, prior approval, and other care management requirements," visit limits, deductibles, copayments and coinsurance that apply to other medical services, and it may cap the benefit, but the annual maximum "may not be less than" $36,000 through age 6, $25,000 from age 7 through 13, and $12,500 from age 14 through 18 (58-17-158). The statute sets no benefit floor for anyone 19 or older. Anyone who performs or supervises ABA must be a physician or psychologist licensed in South Dakota with documented ABA training, or a licensed behavior analyst (58-17-159). The carrier may review the treatment "not more than once every three months" unless the insurer and the treating physician or psychologist agree to more frequent review, and the carrier pays for that review (58-17-160). School IEP and family-service-plan obligations are untouched (58-17-161). The reach is narrower than in most states. The mandate covers individual and group policies from health carriers and self-funded non-federal governmental plans, but it does not apply to the State of South Dakota employee plan (58-17-156), to self-funded ERISA plans, or to "nongrandfathered plans in the individual and small group markets that are required to include essential health benefits" under the ACA (58-17-155). In practice it binds fully insured large-group and grandfathered plans and local-government self-funded plans. For an ACA individual or small-group plan, check the plan’s own benefit documents.[4]
South Dakota licenses behavior analysts. Under SDCL 36-38 (SL 2016, ch 199) the license is issued by the Board of Social Work Examiners (36-38-1(3)), advised by a three-member Applied Behavior Analyst Advisory Committee. An applicant needs a master’s or doctoral degree and current BCBA certification (36-38-7). No one may "engage in the practice of, or attempt to practice applied behavior analysis" without the license or an exemption (36-38-6), and practicing without one is a Class 2 misdemeanor (36-38-19). BCaBAs and technicians are exempt if they work "under the extended authority and direction of a behavior analyst" and are supervised under BACB requirements, but each must pass a fingerprint background check, which the supervising analyst pays for (36-38-5(6), 36-38-25). Credentialing is on a state clock. A carrier must send an application within 10 business days of a request (58-17-151). It must flag an incomplete application within 30 days and decide a complete one within 90 days, longer only for a "special review." It must then pay clean claims for covered services delivered during the credentialing period, and its timely-filing clock starts only when you are notified that you are credentialed (58-17-150). Do not submit claims during that period (58-17-150(3)). The rule does not apply to Medicaid (58-17-152). Commercial ABA rates are negotiated and unpublished. The public benchmark is the South Dakota Medicaid ABA fee schedule (97153 $21.73 and 97155 $39.00 per 15-minute unit, effective July 1, 2026).[5][13][7][15][2]
Evernorth adds its own timeline: after a clinic contract is signed, "each certified or licensed autism provider must become credentialed with Evernorth," which "can take an additional 60 to 90 days," and providers "must be fully credentialed to render in-network services."[5][13][7][15][2]
Can a BCBA licensed in another state treat a South Dakota child? Generally not without a South Dakota license. SDCL 36-38-6 requires the state license to practice ABA here. The only exemption for out-of-state analysts is narrow: a provider "who is not a resident of this state, and who has established an office in this state," authorized in their home state, may practice for no more than an aggregate of 20 days a year, and must report to the board once past 20 consecutive days (36-38-5(2)). Telehealth does not get around this. SDCL 34-52-2 says any health care professional "treating a patient in the state through telehealth" must be "fully licensed to practice in the state" or employed by one of the listed facility types (a licensed health care facility, accredited prevention or treatment facility, community support provider, nonprofit mental health center, or licensed child welfare agency). The carriers say the same thing: Aetna tells providers to "ensure that they have the proper licensure based on state requirements," and Aetna’s ABA guide requires billing by "licensed behavior analysts (in states with behavior analyst licensure laws)." For a remote BCBA, plan on a South Dakota license before the first session.[5][6][17][18]
Cigna publishes no ABA rate table. Evernorth’s Administrative Guidelines (September 2026) 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. Evernorth considers claims "submitted within 90 days of the date of service or as otherwise defined in your Provider Agreement," and a longer state limit applies where one exists. Telehealth claims carry modifier 95 with POS 02. Payment appeals must be started in writing within 180 calendar days of the payment or denial. Electronic claims use payer ID 62308. For insured South Dakota plans, the prompt-pay law requires a clean claim to be paid within 30 days electronic or 45 days paper (SDCL 58-12-20). For a public benchmark, South Dakota Medicaid pays 97153 at $21.73 per 15 minutes.[3][2][9][15]
Evernorth’s guidelines also set the secondary and resubmission clocks: 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. No check-run or weekly cut-off schedule is published.[3][2][9][15]
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 Dakota, and what they have to bring. Each maps onto something intake should ask on the first call.
No expiry on the diagnosis, but provisional or rule-out diagnoses do not count, and the clocks run on data: the standardized instrument and baseline data within 60 days before treatment starts, and current data within 60 days of a continued-treatment request.[1]
A healthcare professional licensed to practice independently whose licensure board considers diagnosis within scope, applying DSM-5-TR criteria. The ABA assessment is by a BCBA, a Licensed Behavior Analyst, or an independently licensed clinician with documented ABA training.[1]
No single instrument is mandated, but it must be standardized, valid and the current edition (the policy’s example: Vineland-3, not Vineland-II), administered within 60 days before treatment starts.[1]
EN0499 requires no referral. Assessments 97151, 97152 and 0362T need no PA with an autism diagnosis when the provider is independently licensed or a BCBA; treatment needs the assessment and plan on the ABA PA form. For a plan subject to the South Dakota mandate, treatment is care "prescribed or ordered" for a child diagnosed with autism "by a licensed physician or psychologist" (SDCL 58-17-154(4)), so keep that order on file. Self-funded ERISA and ACA individual or small-group plans sit outside the statute.[2][1][4]
"All ABA CPT codes are covered telehealth services" per the autism resource guide, and EN0499 allows in-person, telehealth or hybrid delivery. Evernorth bills telehealth with modifier 95 and POS 02. For an insured South Dakota plan, SDCL 58-17-168 says no health insurer "may exclude a service for coverage solely because the service is provided through telehealth," and 58-17-169 bars discrimination between in-person and telehealth coverage for services "appropriate to be provided through telehealth" (policies issued or renewed from January 1, 2020). South Dakota’s insurance definition of telehealth is "HIPAA-compliant interactive audio-video" and excludes audio-only (58-17-167(4)). The insurer may still set criteria for a service it does not already pay others to deliver by telehealth, as long as they are not "unduly burdensome or unreasonable." Separately, the clinician must hold a South Dakota license (SDCL 34-52-2).[2][1][3][8][6]
EN0499 sets no age cap; it says access to focused intervention "should not be restricted by age." Age terms come from the benefit plan and any controlling mandate. For plans subject to the South Dakota mandate, the coverage duty in SDCL 58-17-157 names no age limit, but the minimum annual benefits in 58-17-158 run only through age 18: $36,000 through age 6, $25,000 from 7 to 13, and $12,500 from 14 to 18. Self-funded ERISA plans, the State employee plan and ACA individual or small-group plans are outside the statute, so the plan type decides whether those floors apply.[1][4]
Ask the plan: Live benefits verification: establish plan type first, then the plan’s own ABA terms.
Depends on how the plan is funded. Insured South Dakota plans fall under SDCL 58-17H. A prospective (pre-service) decision is due "within a reasonable period of time appropriate to the covered person’s medical condition, but in no event later than fifteen days after the date the health carrier receives the request," with one 15-day extension for matters beyond the carrier’s control. If the extension is for missing information, the family gets "at least forty-five days" to supply it, and the clock stops in the meantime (58-17H-28, -31). An urgent request is decided within 24 hours of receipt (58-17H-43). A request to extend an ongoing course, made at least 24 hours before it ends, is also decided within 24 hours (58-17H-46). Cutting or ending an authorized course early counts as an adverse determination, and the service continues until the internal review is decided (58-17H-29). An appeal (first-level grievance) may be filed within 180 days of the denial notice (58-17I-7) and is decided within 30 days for a pre-service request (58-17I-9). Self-funded employer (ERISA) plans follow 29 CFR 2560.503-1 instead: pre-service decisions "not later than 15 days after receipt of the claim," with one 15-day extension. Cigna/Evernorth publishes no South Dakota-specific ABA turnaround.[10][11][14]
Ask the plan: At benefits verification ask whether the plan is insured (South Dakota-regulated) or self-funded (ERISA), and what reauthorization lead time Evernorth expects.
For a child on two group plans, South Dakota uses the birthday rule. When the parents are married or living together, "the plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (SDCL 58-18A-70); a court decree controls for separated parents. That binds plans regulated by the state; a self-funded plan sets its own order. If the child also has South Dakota Medicaid, the commercial plan pays first, because Medicaid is generally the payer of last resort (42 CFR 433.139). South Dakota Medicaid also processes the claim "even if the commercial payer denies the claim (i.e., out of network)." A claim filed with the primary insurer’s EOB is timely if it reaches Medicaid within 6 months of the primary’s payment or denial. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)), and CHAMPVA is the last payer (38 CFR 17.270).[12][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 Dakota pays. These decide whether the claim survives: how sessions must be staffed and supervised, what may be billed concurrently, the per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under.
Case supervision is by a BCBA, a Licensed Behavior Analyst, or an independently licensed mental health professional with ABA training, at one to two hours per ten hours of direct treatment, and at least one to two hours a week when direct treatment is 10 hours a week or less. In South Dakota the supervising analyst must hold the state license (SDCL 36-38-6), and supervised technicians must pass a fingerprint background check (36-38-25).[1][5]
Only one provider may bill for a unit of time, except 97153, 97154 and 97155 during direct supervision, when the BCBA or QHP directs the technician and both are face-to-face with the patient at the same time.[2]
No per-day cap is published. All ABA codes bill in 15-minute units and only with 97151–97158, 0362T and 0373T; intensity must reflect severity, goals and response to treatment.[2][1]
Each service needs its own record including the name, credential (if applicable) and signature of the ABA provider who rendered it, along with the date and time, who was present, and what was done.[1]
EN0499 expects goals and data reported by setting and excludes primarily educational or vocational services; SDCL 58-17-161 leaves IEP and IFSP obligations untouched.[1][4]
Evernorth "does not credential nonlicensed/noncertified staff"; their services "must be billed 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.[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 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.
Yes, under national policy EN0499 for ASD, with South Dakota’s mandate layered on for the plans it reaches. Self-funded employer plans and ACA individual and small-group plans follow their own documents.
No, for 97151, 97152 and 0362T with an autism diagnosis when the provider is independently licensed or a BCBA. PA starts at treatment.
Yes. South Dakota requires a behavior-analyst license to practice ABA in the state (SDCL 36-38-6), including by telehealth (SDCL 34-52-2).
Evernorth considers claims submitted within 90 days of the date of service, unless your Provider Agreement or a longer state limit says otherwise. Payment appeals are due within 180 days.
Cigna publishes no ABA rates; the fee schedule is Exhibit A of your Evernorth Provider Agreement (Provider Services 800.926.2273). South Dakota Medicaid’s 97153 rate ($21.73 per 15 minutes) is the public benchmark.
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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