For an intake team in West Virginia, a Cigna card means three layers: Evernorth’s national ABA policy EN0499 with the Cigna autism resource guide, West Virginia’s autism mandate for fully insured group plans, and the plan’s funding type. 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, 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. EN0499 does not mention West Virginia, so the national criteria apply. Evernorth’s Administrative Guidelines carry a West Virginia Regulatory Addendum for contracted providers, which binds Cigna to West Virginia claims law "including but not limited to, W. Va. Code § 33-45-2" and requires 20 business days’ notice of contract amendments.[1][2][3]
West Virginia’s autism mandate is written into each insurance article separately, with matching text: W. Va. Code § 33-16-3v (group accident and sickness insurers), § 33-24-7k (hospital, medical and health service corporations) and § 33-25A-8j (HMOs), all from HB 2693 (2011) as amended by HB 4260 (2012), plus a parallel paragraph for PEIA in § 5-16-7. Each applies to a "policy of group accident and sickness insurance" issued or renewed on or after January 1, 2012, and requires "coverage for diagnosis, evaluation and treatment of autism spectrum disorder in individuals ages eighteen months to eighteen years." Three gates follow. The child "must be diagnosed with autism spectrum disorder at age eight or younger." Treatment must be "medically necessary and ordered or prescribed by a licensed physician or licensed psychologist and in accordance with a treatment plan developed from a comprehensive evaluation by a certified behavior analyst." And ABA "shall be provided or supervised by a certified behavior analyst," defined as someone "certified by the Behavior Analyst Certification Board or certified by a similar nationally recognized organization." The insurer statutes let ABA be capped: "not to exceed $30,000 per individual, for three consecutive years from the date treatment commences," then "not to exceed $2,000 per month, until the individual reaches eighteen years of age." The PEIA paragraph carries the same age, diagnosis and supervision terms but no dollar cap. To keep treatment going, the analyst must "file progress reports … semiannually," and the plan must receive objective evidence or "a clinically supportable statement of expectation" that the child is improving, has not reached maximum improvement, and can reach the anticipated improvement in a reasonable time. Exemptions: "small employers" (25 or fewer eligible employees), cost-containment once the mandate raises total costs by 1% for a plan year, and any part that exceeds the ACA essential health benefits. The mandate does not reach self-funded ERISA plans, and nothing in it requires payment for services by public school personnel or replaces IDEA obligations. The WVCHIP autism section (§ 5-16B-6e) was repealed in 2022; WVCHIP now covers ABA on Medicaid’s terms.[4][5][6][7][18][19]
West Virginia does not license behavior analysts. The BACB’s state licensure table (2026) lists no West Virginia law or board, and the articles of Chapter 30 of the West Virginia Code (Professions and Occupations) include none for behavior analysts; the psychologists’ article (30-21) does not mention them. The working credential is therefore BACB certification, which both the commercial mandate ("certified behavior analyst") and Medicaid Policy 519.23 ("certification by the Behavior Analyst Certification Board is current and in good standing") require. For an out-of-state BCBA, that means there is no West Virginia license to obtain, but each payer still credentials and enrolls you: Medicaid requires enrollment through the BMS fiscal agent (Chapter 300), and BMS’s telehealth policy expects interstate practitioners to register "with the appropriate board in West Virginia" and enroll "as an Interstate Provider," a step that has no obvious board for a BCBA, so get BMS’s answer in writing. On commercial telehealth, § 33-57-1 defines the covered "health care practitioner" as someone licensed under Chapter 30, which an unlicensed BCBA is not, so the carrier’s own telehealth policy decides. On rates: commercial ABA rates are negotiated and unpublished. The public benchmark is the West Virginia Medicaid ABA fee schedule, which is very low (97153 $9.90 and 97155 $29.14 per 15-minute unit).[11][12][20][21][10][14]
West Virginia’s prompt-pay law, W. Va. Code § 33-45-2, requires an insurer to "either pay or deny a clean claim within 40 days of receipt of the claim if submitted manually and within 30 days of receipt of the claim if submitted electronically," to ask for any missing information within 30 days of receipt, and to pay interest at 10 percent a year on claims paid after the 40-day period. Evernorth’s ABA billing rules: electronic claims use payer ID 62308; 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; your fee schedule and the list of reimbursable autism services are in "Exhibit A in your Provider Agreement." Virtual services carry modifier 95, which "will not change the reimbursement." For a public benchmark, West Virginia Medicaid pays 97153 at $9.90 per 15 minutes.[9][2][3][14]
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 West Virginia Regulatory Addendum adds no filing deadline; it binds both parties to W. Va. Code § 33-45-2 on claims administration. State addenda do not apply to self-funded plans. The guidelines publish no check-run or weekly cut-off schedule.[9][2][3][14]
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 West Virginia, 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 don’t count, and the clocks run on data: standardized instrument and baseline data within 60 days before treatment. The West Virginia mandate separately requires diagnosis at age 8 or younger.[1][4]
A healthcare professional licensed to practice independently whose board considers diagnosis within scope, applying DSM-5-TR criteria.[1]
No single instrument is mandated, but it must be reliable, valid and standardized, and the current edition (EN0499’s example: Vineland-3, not Vineland-II).[1]
EN0499 requires no referral; assessments need no PA with an autism diagnosis, and treatment needs the ABA PA form. Evernorth publishes no ABA order form or validity period. On the claim, Evernorth’s administrative guidelines (September 2026) define a complete CMS-1500 claim without a referring provider (they require the rendering provider’s name, NPI and license type and the billing provider’s name, address and NPI); any "Referring Provider" reported on an 837 claim "must include the name and NPI." For a fully insured West Virginia group plan, the mandate requires treatment "ordered or prescribed by a licensed physician or licensed psychologist" and "in accordance with a treatment plan developed from a comprehensive evaluation by a certified behavior analyst," with semiannual progress reports from the analyst. Self-funded ERISA plans sit outside the statute.[2][4][3]
"All ABA CPT codes are covered telehealth services" per the autism resource guide, billed with modifier 95. For a West Virginia-regulated policy, W. Va. Code § 33-57-1 requires coverage of "health care services provided through telehealth services if those same services are covered through face-to-face consultation," bars excluding a service "solely because the service is provided through telehealth services," and counts the patient’s home as an originating site. The statute defines the practitioner as someone licensed under Chapter 30, and West Virginia does not license behavior analysts, so it is unclear whether it reaches BCBA-delivered ABA. Self-funded employer plans are outside it.[2][3][10]
EN0499 says access to focused intervention "should not be restricted by age." For fully insured West Virginia group plans, the mandate covers ages 18 months to 18 years, requires an ASD diagnosis "at age eight or younger," and lets the insurer cap ABA at $30,000 a year for three consecutive years from the start of treatment and $2,000 a month after that until age 18 (W. Va. Code §§ 33-16-3v, 33-24-7k, 33-25A-8j). Employers with 25 or fewer eligible employees are exempt, and self-funded ERISA plans are outside the statute, so plan funding and size decide whether that binds.[1][4][5][6]
Ask the plan: Live benefits verification, or the Evernorth Autism Care Coordinator team at 877.279.7603: establish funding type, employer size and age terms.
Depends on how the plan is funded. West Virginia-regulated plans fall under W. Va. Code § 33-24-7s and its twins (§ 33-16-3dd for insurers, § 33-25A-8s for HMOs), for plans beginning on or after January 1, 2024. Requests go through the carrier’s electronic portal, and once "all of the information as required is provided," the carrier "shall respond … within five business days," or "within two business days" for urgent care. If a request is incomplete, the carrier must identify every deficiency and return it within two business days; you then have three business days to supply the information, and the carrier decides within two business days after that (miss the three days and the request is denied and must be resubmitted). A peer-to-peer must finish within five business days of being requested, and a PA appeal within ten business days. An approved PA "is carried over to all other managed care organizations, health insurers, and the Public Employees Insurance Agency for three months if the services are provided within the state," and a practitioner with a 90% approval rate over six months (and at least 30 procedures a year) earns a six-month gold-card exemption. 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," one 15-day extension, urgent care within 72 hours. Cigna/Evernorth publishes no West Virginia-specific ABA turnaround.[8][22][23][13]
Ask the plan: At benefits verification ask whether the plan is fully insured (West Virginia-regulated) or self-funded (ERISA).
West Virginia regulates coordination of benefits by insurance rule (114 CSR 28), which we could not open this run, so we do not restate its birthday rule here; get the member’s order of benefits from both plans. When the child also has West Virginia Medicaid, the commercial plan pays first: Medicaid is "always the payer of last resort," and "All requirements of the third-party insurance plan must be met before Medicaid will reimburse including use of in-network providers" (BMS Chapter 100), consistent with 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).[15][24][16][17]
Ask the plan: Ask Cigna/Evernorth and any other carrier for the member’s order of benefits.
Coverage decides whether Cigna / Evernorth in West Virginia 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.
Direct plus indirect case supervision runs 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. Supervision is by a BCBA, a Licensed Behavior Analyst, or an independently licensed clinician with documented ABA training. West Virginia’s mandate requires ABA "provided or supervised by a certified behavior analyst."[1][4]
"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. EN0499 also 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)."[2][1]
No per-day cap is published. All ABA codes bill in 15-minute units and only as 97151–97158, 0362T and 0373T. On mandated West Virginia plans, the dollar cap ($30,000 a year for three years, then $2,000 a month) is the binding limit.[2][4]
Each service needs its own record with start and end date and time, location, a description of the intervention, who was present, and the name, credential and signature of the rendering provider.[1]
Services "primarily educational or vocational in nature" are not covered; goals and data are reported per setting. The West Virginia mandate does not require payment for services by public school personnel.[1][4]
Evernorth bills non-credentialed staff under the supervising provider; only a BCBA or other licensed provider goes in box 33, and 97152, 97153 and 97154 may be provided by a BCaBA or technician but billed only by a BCBA-D, BCBA or licensed mental health provider. 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 West Virginia’s autism mandate layered on for fully insured 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. PA starts at treatment.
Only for 97153, 97154 and 97155 during direct supervision, with both present with the patient at the same time.
Cigna publishes no rates; Evernorth says your fee schedule is Exhibit A of your Provider Agreement (Provider Services 800.926.2273). West Virginia Medicaid’s 97153 rate ($9.90 per 15 minutes) is the only 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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