For an intake team in Washington, a Cigna card means three layers: Evernorth’s national ABA policy EN0499 with the Cigna autism resource guide, Washington’s mental health parity law, and the plan’s funding type, which decides whether state law applies. Many Cigna members are on self-funded employer plans, so check funding first.
Cigna, through Evernorth Behavioral Health, covers ABA under EN0499 (effective May 15, 2026). Per the autism resource guide (March 2025), prior authorization is no longer required for assessment codes 97151, 97152 and 0362T with an autism diagnosis, as long as the provider is independently licensed or a BCBA and the plan covers ABA; treatment needs the completed assessment and treatment plan on the ABA Prior Authorization Form. "All ABA CPT codes are covered telehealth services." Electronic claims use Evernorth payer ID 62308. A full-text check of EN0499 and the resource guide found no Washington-specific provision, so the national criteria apply. Cigna is not an Apple Health managed care plan.[1][3][23]
Washington has no stand-alone autism insurance statute. ABA reaches state-regulated plans through the mental health parity laws instead. Until January 1, 2027, RCW 48.44.341 (health care service contractors), RCW 48.46.291 (HMOs) and RCW 48.21.241 (group disability insurers) require a plan that covers medical and surgical services to cover "mental health services," defined for plans issued or renewed on or after January 1, 2021 as "medically necessary outpatient and inpatient services provided to treat mental health and substance use disorders covered by the diagnostic categories listed in" the DSM. Autism spectrum disorder is a DSM diagnosis. Cost sharing for mental health services may be no more than for medical and surgical services, and "Treatment limitations or any other financial requirements on coverage for mental health services are only allowed if the same limitations or requirements are imposed on coverage for medical and surgical services." The statutes name no ABA-specific age, hour or dollar limit. For individual and small-group plans, the Insurance Commissioner’s essential health benefit rule (WAC 284-43-5642, effective January 19, 2026) lists "Behavioral treatment for a DSM category diagnosis" among the mental health services every plan must include, and says that when habilitative services treat a DSM diagnosis, "the mental health parity requirements apply." The law changes on January 1, 2027: Chapter 227, Laws of 2025 (E2SHB 1432) repeals those parity sections and replaces them with RCW 48.43.766, which covers DSM diagnoses plus the mental, behavioral and neurodevelopmental chapters of ICD and DC:0-5, and bars utilization review and clinical review criteria that "deviate from generally accepted standards of mental health and substance use disorder care." Regence’s own ABA policy names "Washington’s Mental Health Parity Act (RCW 48.44)" as the Washington basis for its coverage. None of this reaches self-funded employer plans, which answer to ERISA and federal parity law.[5][6][7][8][9][10][24]
Washington licenses ABA practitioners at three levels under chapter 18.380 RCW, administered by the Department of Health: licensed behavior analyst (LBA), licensed assistant behavior analyst (LABA) and certified behavior technician (CBT). The BACB’s licensure table lists Washington (2015, WA State Department of Health). "No person may engage in the practice of applied behavior analysis unless he or she holds a license or a temporary license under this chapter," and no one may practice as a technician without DOH certification (RCW 18.380.020). The exemptions in RCW 18.380.030 cover holders of another Washington credential practicing within their own scope (psychologists, for example), federal employees, school employees working only for their school, supervised students and trainees, and supervised family members; none of them exempts a BCBA licensed in another state. DOH may accept national certification in lieu of the education and exam requirements (RCW 18.380.050(3); WAC 246-805-100 accepts current certification from an approved credentialing entity). An out-of-state LBA has two quicker routes: reciprocity where the other state’s standards are "substantially equivalent" (WAC 246-805-510), and a 180-day temporary license for applicants who do not live in Washington and hold an active, unrestricted behavior analyst license elsewhere, which "will not be renewed, reissued, or extended" (WAC 246-805-520). Telehealth does not get around this. Washington’s Uniform Telehealth Act lets an out-of-state practitioner treat a patient located in Washington only with a Washington license, or for a consultation with the treating practitioner, a specialty assessment or recommendation "This does not include the provision of treatment," or follow-up for an established patient temporarily in the state (RCW 18.134.050). Supervision rules come from DOH: a CBT works "under close, ongoing supervision," with at least two face-to-face contacts a month (in person or by video) and direct supervision and observation of at least five percent of the CBT’s hours each month, including seeing the CBT with each client at least once every three months (WAC 246-805-330).[11][12][13][14]
Washington sets the claim-side floor for state-regulated plans. Prompt pay: participating-provider contracts must require the carrier to pay 95 percent of the monthly volume of clean claims within 30 days of receipt and to pay or deny 95 percent of all claims within 60 days; clean claims more than 61 days old earn interest at one percent a month (WAC 284-170-431). A denial must give "the specific reason," and a medical necessity denial must, on request, disclose how the claim failed the guidelines. Prior authorization: for health plans issued or renewed on or after January 1, 2024, a carrier must decide an electronic standard request within three calendar days (excluding holidays) and an electronic expedited request within one calendar day; non-electronic requests get five and two calendar days. A request for missing information must come within one calendar day of an electronic submission (five days for a non-electronic standard one), only a licensed physician or licensed health professional may deny on medical necessity, and since 2026 artificial intelligence "shall not be the sole means used to deny, delay, or modify health care services" (RCW 48.43.830). Members can take an adverse decision to a certified independent review organization (RCW 48.43.535). Timely filing limits and appeal windows for providers are set by each carrier’s contract; get them from your agreement.[3][4][15][16][17]
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."[3][4][15][16][17]
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."[3][4][15][16][17]
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 point ABA providers to "Exhibit A in your Provider Agreement" for the fee schedule and the list of reimbursable autism services. Fee questions go to Provider Services at 800.926.2273. Virtual services are billed with modifier 95, which "will not change the reimbursement." For a public benchmark, Washington Apple Health’s fee-for-service ABA schedule (effective July 1, 2026) pays 97153 at $12.40 and 97155 at $14.09 per 15-minute unit; commercial contracts are negotiated separately.[4][20]
Cigna (Evernorth) publishes no referring-provider requirement for ABA. Its autism resource guide gives the ABA paper-claim instructions field by field and names only box 31 (your name), the claims mailing address and box 33 ("List only a BCBA or other licensed provider in box 33"); box 17 is not mentioned. The Evernorth administrative guidelines state for SureFit, Connect and HMO/POS plans alike that "Referrals are not required for behavioral health services."[3][4]
Leave box 17 blank unless a referral actually exists for the service. Bill technician time under the supervising provider: "Evernorth does not credential nonlicensed/noncertified staff. Services for these staff members must be billed under the supervising provider."[3][4]
No. EN0499 (effective 5/15/2026): "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)." The policy defines that overlap as concurrent billing: "multiple providers bill for services rendered to the same patient when those services occur at the same time."[1][3]
Schedule ABA hours around speech, OT and PT, and keep session start and stop times that show no overlap. The only same-time billing EN0499 and Cigna's autism resource guide allow is within ABA: 97153 or 97154 alongside 97155 when the BCBA directs the technician face-to-face.[1][3]
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 Washington, 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 it was most recently made. The data clocks: standardized instrument within 60 days before treatment starts, baseline data within 60 days, and current data within 60 days of a continued-treatment request (EN0499).[1]
A healthcare professional licensed to practice independently whose board considers diagnosis within scope, applying DSM-5-TR criteria (EN0499).[1]
No single instrument is mandated, but it must be reliable, valid and standardized, completed in full, and the current edition (EN0499’s example: Vineland-3, not Vineland-II).[1]
EN0499 requires no referral or prescription. 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. Washington’s parity statutes add no referral requirement of their own; they allow a plan to require medical necessity and to manage mental health services only where it applies "a comparable requirement" to medical and surgical services (RCW 48.44.341(3)–(4)). Self-funded ERISA plans sit outside the statute.[3][1][5]
"All ABA CPT codes are covered telehealth services" (autism resource guide), billed with modifier 95, which "will not change the reimbursement" (Evernorth Administrative Guidelines). For fully insured Washington plans, RCW 48.43.735 also requires same-amount reimbursement for covered telemedicine services, with the home as an originating site. The clinician still needs Washington licensure to treat a child located in Washington (RCW 18.134.050).[3][4][25][13]
EN0499 sets no age cap; it says focused intervention "should not be restricted by age." Age terms come from the benefit plan. For fully insured Washington plans, the parity statutes allow treatment limitations on mental health services "only if the same limitations or requirements are imposed on coverage for medical and surgical services," and they name no ABA-specific age or dollar limit. Self-funded ERISA plans are outside the statute, so plan funding type decides whether that binds.[1][5]
Ask the plan: Live benefits verification: establish fully insured vs. self-funded ERISA first.
Depends on how the plan is funded. Fully insured Washington plans issued or renewed on or after January 1, 2024 fall under RCW 48.43.830: an electronic standard prior-authorization request must be decided "within three calendar days, excluding holidays," an electronic expedited request within one calendar day, a non-electronic standard request within five calendar days and a non-electronic expedited one within two. If information is missing, the carrier must ask within one calendar day of an electronic request (five days for a non-electronic standard request). 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 Washington-specific ABA turnaround.[16][19]
Ask the plan: At benefits verification ask whether the plan is fully insured in Washington or self-funded (ERISA), whether you are submitting through Cigna/Evernorth’s electronic prior-authorization process, and what reauthorization lead time it expects.
For a child on two plans, Washington’s coordination-of-benefits rule is the birthday rule: unless a court decree says otherwise, "The plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (if both parents share a birthday, the plan that has covered a parent longer); a court decree assigning health coverage controls, and with no decree the custodial parent’s plan pays first (WAC 284-51-205). That binds state-regulated plans; a self-funded plan sets its own order. If the child also has Apple Health, Cigna/Evernorth pays first: Apple Health requires providers to bill known third parties and does not pay when third-party benefits are available (WAC 182-501-0200; 42 CFR 433.139). TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[18][26][27][28][29]
Ask the plan: Ask Cigna/Evernorth 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.
Coverage decides whether Cigna / Evernorth in Washington 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 of direct plus indirect supervision per ten hours of direct treatment; at 10 hours a week or less, at least one to two hours a week (EN0499). Washington’s DOH rule adds two face-to-face contacts a month with each CBT and direct supervision of at least 5 percent of the CBT’s monthly hours (WAC 246-805-330).[1][12]
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.[3]
No per-day cap is published. ABA codes bill in 15-minute units, and intensity must reflect severity, goals and response to treatment.[3][1]
Each service needs its own record with start and end date and time, location, focus, the intervention, who was present, the service type, and the name, credential and signature of the provider who rendered it (EN0499).[1]
Goals and data are reported separately for each setting (home, clinic, school, community). Primarily educational or vocational services are not covered (EN0499).[1]
Evernorth does not credential non-licensed or non-certified staff; their services are billed under the supervising provider. On a CMS-1500 the rendering provider prints their name in box 31 and only a BCBA or other licensed provider goes in box 33; electronic claims use payer ID 62308 (autism resource guide). In Washington the supervising behavior analyst must hold a DOH license.[3][11]
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 for ASD. Fully insured Washington plans are also bound by the state’s mental health parity law; 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. PA starts at treatment.
Yes, to practice in Washington. Chapter 18.380 RCW requires a DOH license (or temporary license) to practice ABA in the state, whatever the payer.
Cigna publishes no ABA rates; your fee schedule is Exhibit A of your Evernorth Provider Agreement (questions: 800.926.2273). Apple Health’s 97153 rate ($12.40 per 15 minutes) is the public benchmark.
No. Cigna's ABA billing instructions cover boxes 31 and 33 only, and Evernorth states that referrals are not required for behavioral health services.
No. EN0499 says ABA "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)." Schedule the therapies back to back, not overlapping.
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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