For an intake team in Utah, a Cigna card means three layers at once: the carrier's national clinical policy, Utah's autism insurance mandate (Utah Code § 31A-22-642), and the plan's market segment and funding type deciding which of the two actually binds. This guide stacks them in order — and in Utah, the market-segment question comes first, because the mandate covers individual and large-group plans but not small group.
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 EN0499 carves out — Utah fully-insured business is squarely subject to the policy, so the no-assessment-PA fast path holds here, with the Utah mandate controlling wherever it is more generous. Plan market segment and funding type are still the first facts to establish on every benefits check. The full national policy breakdown lives in our Cigna / Evernorth guide; this page covers what changes in Utah.[1][2]
Utah Code § 31A-22-642 requires coverage for the diagnosis and treatment of autism spectrum disorder in the individual and large-group markets — small group plans are not named by the statute, making market segment the load-bearing question in Utah, even ahead of funding type. For plans entered or renewed on or after January 1, 2020 there is no age limit and no cap on covered ABA hours; the older 600-hours-a-year floor and the ages-2-to-under-10 window govern only legacy pre-2020 plans. The statute has operational teeth, too: the treatment plan is due to the insurer within 14 business days of starting treatment, the insurer may review it at most once every 3 months, and plan networks must include both board certified behavior analysts and qualified licensed mental health providers. Its diagnosis definition is strict — a board-certified neurologist, psychiatrist, or pediatrician with ASD experience, or an experienced licensed psychologist. Self-funded ERISA plans are exempt by federal preemption, and MHPAEA supplies the parity floor for group plans. New from the 2026 amendment: beginning before July 1, 2027, every health benefit plan must report autism-assessment wait times, whether it imposes PA on assessment or treatment, and ABA utilization to the Utah Insurance Department annually — with public website disclosure of which plans reimburse non-physician therapists from September 1, 2027. Insurer PA behavior in Utah is about to become public record.[3][5]
We checked: Cigna / Evernorth publishes no Utah-specific ABA policy, form, or supplement — EN0499 mentions Utah nowhere, and its only state exclusion is Virginia. The national policy plus the state mandate is the whole picture. That's worth knowing in itself: it means benefits verification (market segment, plan funding type, mandate applicability) is where Utah-specific answers come from, not a carrier document. Cigna also holds no Utah Medicaid ACO contract, so there is no Medicaid line of business to confuse a Cigna card with here.[1]
Utah requires a license to practice behavior analysis: the Licensed Behavior Analyst (LBA) and Licensed Assistant Behavior Analyst (LABA) credentials under the Behavior Analyst Licensing Act (Utah Code Title 58, Chapter 61, Part 7), administered by the Division of Professional Licensing (DOPL). Behavior technicians work as certified paraprofessionals under QHP supervision rather than as licensees. On rates: Cigna does not publish commercial ABA fee schedules for Utah (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement. Utah does give you a public benchmark, though: the Medicaid PRISM rates effective 7/1/2026 pay $19.67 per 15-minute unit on 97153 and $37.51 on 97151/97155/97156.[4]
Cigna publishes no ABA fee schedule. In-network ABA is paid at the rates in your Evernorth behavioral-health agreement; the autism resource guide sends "questions about credentialing, contracts, or rates" to your Provider Relations representative, and billing questions to Provider Services at 800.926.2273. Bill only 97151-97158, 0362T and 0373T, in 15-minute units.[2]
Network: Evernorth says it "is committed to expanding our network of autism providers." Individual analysts apply on the Evernorth Behavioral Provider Information Form and autism clinics or large groups on the Evernorth Screening Application for Autism Clinics; processing can take up to 90 days, and after a clinic contract each certified or licensed provider must be credentialed (another 60 to 90 days) before rendering in-network services. Evernorth requires the clinician to hold a national certification or state license (BCBA, BCBA-D, BCaBA, licensed behavior analyst or other behavioral-health licensure). It "does not credential nonlicensed/noncertified staff" such as technicians, whose services "must be billed under the supervising provider."[2]
Utah Code § 31A-26-301.6 requires an insurer, including an HMO, to pay a claim or deny it with a written explanation "within 30 days of the day on which the insurer receives a written claim," extendable by 15 days for matters beyond its control with written notice.[6][7]
Evernorth "will only consider claims submitted within 90 days of the date of service or as otherwise defined in your Provider Agreement," and a longer state-law limit applies where one exists. Appeals are initiated in writing within 180 calendar days of the initial payment or denial decision, and most are resolved within 60 calendar days.[6][7]
No. Evernorth’s administrative guidelines (September 2026) define a complete CMS-1500 claim as the patient’s ID number, name, address and date of birth; the subscriber’s name and address; release of information and assignment of benefits; diagnosis codes and pointer; date and place of service; CPT/HCPCS code and modifier; billed charge, units, TIN and total charge; the “Rendering provider’s name, NPI, and license type”; and the “Billing provider’s name, address, and NPI.” No referring or ordering provider is on that list. If you do report one on an 837, “Any additional provider identification on the claim, such as the “Rendering Provider” or “Referring Provider,” must include the name and NPI when submitted.”[7][2]
The ABA-specific paper-claim rules sit in the autism resource guide: use Form CMS-1500, “Print your name in box 31,” and “List only a BCBA or other licensed provider in box 33.” Evernorth does not credential non-licensed or non-certified staff, so their services are billed under the supervising provider.[7][2]
Cigna’s ABA claims run through Evernorth Behavioral Health, whose administrative guidelines (September 2026) set the filing rules. Initial claims: Evernorth "will only consider claims submitted within 90 days of the date of service or as otherwise defined in your Provider Agreement," and a longer state-law limit applies where one exists. Secondary claims: 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]," and the primary payer’s EOP goes in with the claim unless the COB data is sent electronically; Medicaid gets three years. A claim returned for more information gets a fresh 90 days from the date of the request. Corrected or replacement claims carry frequency code 7 (replace) or 8 (void) in box 22, not a "Corrected Claim" stamp; no separate corrected-claim deadline is published. Appeals are due in writing within 180 calendar days of the initial payment or denial decision. Evernorth publishes no weekly payment cycle or submission cutoff; it offers ERA and EFT "to help reduce your payment cycle."[2][7]
Which codes: Evernorth’s autism resource guide (March 2025) says "All ABA services must be billed with CPT codes 97151–97158, 0362T, and 0373T ONLY," so state HCPCS ABA codes such as H0031, H0032, H2014 or H2019 are not billable to Cigna for ABA. The same guide says "All ABA CPT codes are covered telehealth services."[2][7]
Evernorth’s EN0499 (effective May 15, 2026) sets what a continued-treatment request must show: an updated treatment plan covering current deficits and progress in every targeted area; "Quantitative baseline, interim and current data ... with dates reported from when the data were collected" for every behavior and skill, across all settings; current data collected "within no more than 60 days prior to the start date of the continued treatment request" and within 60 days before the request is received; data showing "ongoing and sustained progress"; and a reliable, valid, standardized assessment completed no more than one year before the continued-treatment start date. Where progress is not shown, the request must name the barriers and the protocol changes made. EN0499 asks for dated quantitative data, not for graphs as such; graphs are a common way to present it, but the policy does not require them.[1]
The questions that decide whether a family can start with Cigna / Evernorth in Utah, and what they have to bring. Each maps onto something intake should ask on the first call.
EN0499 sets no age limit — its gate is a confirmed ASD diagnosis. Utah fully-insured business is squarely subject to EN0499 (Virginia is the policy's only state carve-out). In Utah the legal floor is Utah Code § 31A-22-642: no age limit and no cap on covered ABA hours for individual and large-group plans entered or renewed on or after 1/1/2020 (the 600-hours-a-year floor and the ages-2-to-under-10 window govern only legacy pre-2020 plans), the treatment plan due to the insurer within 14 business days of starting treatment, and insurer review at most once every 3 months. Small-group plans are not named by the statute and self-funded ERISA plans are exempt, so market segment is the load-bearing question.[1][3]
EN0499 sets no recency window on the ASD diagnosis itself, but requires the date on which the diagnosis was most recently made to be supplied, and requires the standardized ABA assessment instrument to have been administered within the 60 days before treatment starts.[1]
A confirmed ASD diagnosis (ICD-10-CM F84.0-F84.9, excluding F84.2 Rett syndrome) made against DSM-5-TR criteria by a health care professional licensed to practise independently and whose licensure board considers diagnostics within their scope of practice, with the name, credentials and type of licensure of the diagnosing clinician provided. The Utah mandate's own diagnosis definition is strict and applies to plans it reaches: a board-certified neurologist, psychiatrist or pediatrician with ASD experience, or an experienced licensed psychologist.[1][3]
A reliable, valid and standardized assessment instrument measuring the DSM-5-TR ASD domains. EN0499 names no fixed list but sets conditions: completed in its entirety and as designed, reliability and validity established for the population tested, administered and interpreted by someone trained to do so, the most current version (Vineland-3, not Vineland-II), and reported with the date of administration, the respondent, and the form type.[1]
EN0499 imposes no referral or physician order — the gate is the confirmed independent-licensure diagnosis plus a full ABA assessment by a BCBA, LBA, or independently licensed mental health clinician with documented ABA training, and where that assessment came from someone other than the requesting provider, documented collaboration plus confirmation that the results reflect current functioning. Under Utah's mandate, which reaches fully insured individual and large-group plans, covered "Treatment for autism spectrum disorder" means care "prescribed or ordered for an individual diagnosed with an autism spectrum disorder by a physician or a licensed psychologist described in Subsection (1)(d) who determines the care to be medically necessary." Subsection (1)(d) means a licensed physician board certified in neurology, psychiatry or pediatrics, or a licensed psychologist, either with experience diagnosing ASD. In practice the diagnosing evaluator's written recommendation or prescription for ABA is the order to collect. The statute sets no expiry on it. It does require the provider to "submit a treatment plan for autism spectrum disorder to the insurer within 14 business days of starting treatment," and lets the insurer review treatment "not more than once every three months." Self-funded ERISA plans are outside the mandate.[1][8]
"All ABA CPT codes are covered telehealth services," per Evernorth's autism resource guide (March 2025). EN0499 treats ABA as deliverable in person, by telehealth, or as a hybrid, with the modality chosen on individual characteristics, the treatment plan, caregiver participation, environment, evidence of efficacy and safety, and technological requirements; the line-of-sight and close-proximity requirement on direct treatment expressly does not apply to telehealth services. The assessment and supervision codes are included: the resource guide's "All ABA CPT codes" covers 97151 (initial assessment and reassessment) and 97155 (protocol modification / direct supervision) as much as 97153, and neither document caps the share of supervision that may be remote. Neither of those two documents names a telehealth modifier or POS; Evernorth’s administrative guidelines (September 2026) do: use “Modifier 95 in Field 24-D to specify telehealth” and “02 for Place of Service in Field 24-B.”[7][1][2]
Cigna (Evernorth Behavioral Health) makes "coverage determinations in accordance with the time frames required under applicable law," and warns: "You must supply all information requested within the time frames specified … Failure to provide information within the time frames requested may result in nonpayment." ABA requests go to the Autism Utilization Management team. Lead time is published: "For ABA, we encourage providers to request authorizations 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" — so file each reauthorization up to 30 days before the current one ends. Utah requires fully insured plans' procedures to "comply with this rule, 29 CFR 2560.503-1, and 45 CFR 147.136" (R590-261-4), and self-funded plans follow 29 CFR 2560.503-1 directly, so through 2026 the ceiling is the same either way: a pre-service decision "not later than 15 days after receipt of the claim" (one 15-day extension) and 72 hours for urgent care. From January 1, 2027 Utah Code 31A-22-650 tightens insurers (fully insured only) to "no later than seven calendar days after the day on which the insurer receives all necessary information," and 72 hours for urgent care.[7][2][9][10][11]
Evernorth follows the NAIC order "subject to applicable law and the terms of the benefit plan": "The plan of the parent whose birthday falls earlier in the calendar year is primary … Only the month and day of birth are relevant" (same birthday: the longer-running plan); a court decree controls for divorced or separated parents, and with no decree the order is custodial parent, custodial parent's spouse, noncustodial parent, noncustodial parent's spouse. Utah's COB rule (R590-131-6) governs fully insured plans: for a child whose parents are married or living together, "the plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (same birthday: the plan that has covered the parent longest); a court order stating otherwise controls. When Cigna is secondary, bill the primary first, then send the claim "along with a copy of the primary payer's EOP" (not needed if HIPAA-compliant COB data goes electronically to payer ID 62308). If the child also has Medicaid, this plan pays first: Medicaid is payer of last resort (42 CFR 433.139) — bill here, then send the EOB or denial to Medicaid, and get Medicaid's own prior auth too if the state requires it. TRICARE is secondary to this plan ("TRICARE shall be last pay," 32 CFR 199.8), and "CHAMPVA is the last payer to OHI" (38 CFR 17.276(d)).[7][12][13][14][15]
Coverage decides whether Cigna / Evernorth in Utah 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 performed by a BCBA, LBA, or a mental health professional licensed to practise independently with documented ABA training. Direct case supervision (the BCBA face-to-face with the individual and the RBT or BCaBA delivering treatment) plus indirect case supervision runs at the accepted standard of one to two hours per ten hours of direct treatment; where direct treatment is 10 hours a week or less, a minimum of one to two hours a week of direct case supervision is provided, and the name and credentials of the supervisor must be documented. In Utah the LBA must additionally hold a DOPL licence under Utah Code 58-61 Part 7.[1][4]
EN0499 defines concurrent billing as multiple providers billing for the same patient at the same time regardless of funding source, and flatly excludes ABA delivered to the same individual at the same time as any other treatment modality (ABA and speech therapy, or ABA and occupational therapy). ABA delivered by multiple provider organizations in the same authorization period is not medically necessary unless additional documented conditions are met. It does not separately bless or bar a 97153-plus-97155 pairing.[1]
No per-day or per-week unit ceiling is published. EN0499 defines treatment intensity as direct ABA treatment hours per week, excluding case supervision and caregiver training, individually determined from assessment data and set on medical necessity independent of the individual's outside schedule or prior utilization. Under the Utah mandate there is no hour cap for individual and large-group plans entered or renewed since 1/1/2020.[1][3]
Each session record must carry the start date and time, end date and time, location of service delivery, focus of service, a detailed description of the intervention, the individuals present, the specific service delivered (direct service, supervision, stakeholder training), and the name, credential where applicable, and signature of the ABA provider who rendered the service.[1]
Goals must be defined across every setting where treatment will occur, and EN0499 names residential facilities, childcare facilities, homes, schools, transportation, community settings, clinics, vocational or educational classes, and recreational and social environments as payable sites when medically necessary. The boundary is purpose: services primarily educational or vocational in nature, or related to academic or work performance, are not covered, and ABA may not replace or replicate activities that are the responsibility of the setting — classroom aide, 1:1 teacher, tutor, vocational coach, respite.[1]
EN0499 governs who may render and supervise but publishes no rendering-versus-supervising NPI rule; claim-level attribution is a reimbursement-policy and contract question. In Utah, whoever supervises must hold the DOPL behavior-analyst licence.[1][4]
Ask the plan: Cigna/Evernorth provider services and the participating-provider agreement — EN0499 is a coverage policy and carries no claim-attribution rule.
Not graphs as such. EN0499 requires dated quantitative baseline, interim and current data (current data no more than 60 days old), an updated plan and a standardized assessment no more than a year old; graphs are a common way to show the data, but the policy does not require them.
CPT 97151–97158, 0362T and 0373T only; HCPCS H-codes such as H0031/H0032 are not billable for ABA (Evernorth autism resource guide).
Ninety days from the date of service under Evernorth’s administrative guidelines (or your agreement or a longer state-law limit); secondary claims get 90 days from the primary payer’s EOB/EOP date. Corrected claims use frequency code 7 or 8; no weekly payment cutoff is published.
Yes — under national policy EN0499 (which fully applies in Utah, unlike Virginia), layered on Utah's mandate (Utah Code § 31A-22-642) for individual and large-group fully-insured plans. Small-group and self-funded employer plans sit outside the mandate, so always verify market segment and funding type first.
No — EN0499 requires no PA on assessment codes 97151, 97152, and 0362T, and Utah is fully subject to that policy. Treatment then requires the completed assessment plus a treatment plan with Cigna's ABA PA form.
For individual and large-group plans entered or renewed since 1/1/2020: coverage for ASD diagnosis and treatment with no age limit and no cap on ABA hours, a treatment plan due within 14 business days of starting treatment, insurer reviews at most every 3 months, and networks that include BCBAs. Small group is not covered by the statute.
Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against Utah Medicaid's published PRISM rates ($19.67/unit on 97153, $37.51 on 97151/97155/97156, effective 7/1/2026) and treat rate-setting as part of contracting.
Yes. Evernorth's autism resource guide says all ABA CPT codes are covered telehealth services, and EN0499 allows in-person, telehealth or hybrid delivery. No POS code or modifier is published; confirm claim coding with Provider Services (800.926.2273).
Evernorth says it is committed to expanding its autism network. Apply with the Behavioral Provider Information Form (individuals) or the Screening Application for Autism Clinics (groups); allow up to 90 days, plus 60 to 90 days of individual credentialing for a clinic.
EN0499 treats school as a possible treatment setting but excludes educational services. It lists school among the settings where treatment goals may be set ("home, clinic, school, community setting"), requires the record to show that ABA in an academic setting still meets the direct-treatment definition, and excludes services "primarily educational or vocational in nature, or related to academic or work performance." Whether school hours are payable on a given plan is a benefit-document question.
Within 30 days of receiving the claim, extendable once by 15 days with notice (Utah Code § 31A-26-301.6).
Ninety days from the date of service under Evernorth’s administrative guidelines, unless your provider agreement or a longer state-law limit says otherwise.
No. Evernorth’s complete-claim definition for the CMS-1500 lists the rendering and billing providers but no referring provider. If you report a referring provider on an electronic claim, include both the name and the NPI.
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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