For an intake team in Wisconsin, a Cigna card means three layers: Evernorth’s national ABA policy EN0499 with the Cigna autism resource guide, Wisconsin’s autism mandate in § 632.895(12m) and Ins 3.36, and the plan’s funding type. Many Cigna members are on self-funded employer plans, which sit outside the mandate, so check funding first. In western Wisconsin there is a network wrinkle: Evernorth’s guidelines say providers there "must be contracted through HealthPartners" to be in network for Cigna members.
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, as long as the provider is independently licensed or a BCBA and the policy covers ABA. Treatment needs the assessment and plan on the ABA Prior Authorization Form. A full-text check of EN0499 and the resource guide found no mention of Wisconsin, so the national criteria apply, alongside the state mandate on plans it reaches.[1][2][3]
Two Wisconsin-specific contract facts sit in Evernorth’s Administrative Guidelines (September 2026). First, HealthPartners serves "Minnesota, North Dakota, and Western Wisconsin," and providers there "must be contracted through HealthPartners to be considered in network for patients with Cigna Healthcare coverage or a HealthPartners ID card." Second, the Wisconsin Regulatory Addendum (which does not apply to self-funded plans) requires a terminating provider to keep treating a member in a course of treatment for the rest of the course or 90 days, whichever is shorter, paid at the contract rate for those 90 days.[1][2][3]
Wisconsin’s autism mandate is Wis. Stat. § 632.895(12m). Every disability insurance policy, and every self-insured health plan of the state or a county, city, town, village or school district, "shall provide coverage for an insured of treatment for the mental health condition of autism spectrum disorder if the treatment is prescribed by a physician" and delivered by a listed provider: a psychiatrist, a person who practices psychology, a social worker licensed or certified to practice psychotherapy, "a behavior analyst who is licensed under s. 440.312," a paraprofessional working under one of those, a professional supervised by a certified outpatient mental health clinic, or a speech-language pathologist or occupational therapist. The statute splits treatment into "intensive-level services" (evidence-based behavioral therapy) and "nonintensive-level services," and sets dollar floors, not ceilings: "at least $50,000 for intensive-level services per insured per year, with a minimum of 30 to 35 hours of care per week for a minimum duration of 4 years, and at least $25,000 for nonintensive-level services," adjusted each year by the medical CPI. For 2026 the Office of the Commissioner of Insurance (OCI) puts those floors at $74,240 and $37,119. The coverage may carry the plan’s usual deductibles, coinsurance and copays but "may not be subject to limitations or exclusions, including limitations on the number of treatment visits." The OCI rule, Ins 3.36, sets the age gate: intensive-level therapy must be "commenced after an insured is two years of age and before the insured is nine years of age," runs up to 48 cumulative months (prior intensive therapy from any payer counts), needs a treatment plan of at least 20 hours a week over six months, and requires direct observation by the qualified provider at least once every two months. Nonintensive-level services have no age limit. OCI adds that once a child moves to nonintensive-level services they cannot go back to intensive. Exempt: specified-disease policies, limited service health organizations and preferred provider plans that are not defined network plans, long-term care and Medicare supplement or replacement policies, and, per OCI, self-funded private employer plans under federal jurisdiction and out-of-state group plans unless at least 25% of covered employees live in Wisconsin.[4][5][6]
OCI says prior authorization is "generally" not required for mandated autism services, "but it may be beneficial," and that "if your plan requires prior authorization for similar outpatient services, then you may be required to have autism services prior authorized, too."[4][5][6]
Wisconsin licenses behavior analysts, and has since 2010 (BACB licensure table; the regulator is the Department of Safety and Professional Services). The law, Wis. Stat. §§ 440.310–440.317, defines a behavior analyst as someone "certified by the Behavior Analyst Certification Board, Inc., as a board-certified behavior analyst" who "has been granted a license under this subchapter." Licensure is issued on BACB certification plus an application and fee (§ 440.312), and each renewal needs proof of current BACB certification (§ 440.313). It is mainly a title law: § 440.311 bars anyone without the license from using the title "behavior analyst," but does not restrict other licensed professionals practicing behavior analysis within their own scope. For insurance, though, the license matters. The mandate names "a behavior analyst who is licensed under s. 440.312," and Ins 3.36 defines a qualified intensive-level provider as someone "acting within the scope of a currently valid state-issued license." So a BCBA licensed in another state is not a qualified provider under the mandate until they hold a Wisconsin license, and that holds for telehealth too. Ins 3.36 also requires insurers to verify the license, certification and training of supervising and intensive-level providers, and requires agencies to verify paraprofessionals’ credentials and check for felony and child-maltreatment convictions. A qualified paraprofessional is 18 or older, has a high school diploma, has passed a criminal background check, has at least 20 hours of autism training plus 10 hours of hands-on behavioral training, and is regularly overseen by a qualified supervising provider. Claims: an insurer must pay a clean claim within 30 days of written notice of the loss, and overdue payments carry 7.5% simple annual interest (Wis. Stat. § 628.46). Rates: commercial ABA rates are negotiated and not published. The public benchmark is the Wisconsin Medicaid (ForwardHealth) fee schedule, which pays 97153 at $11.91 per 15 minutes for comprehensive treatment.[8][7][4][5][9][13][3]
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 Wisconsin Regulatory Addendum adds no claim rule. State addenda do not apply to self-funded plans. The guidelines publish no check-run or weekly cut-off schedule.[8][7][4][5][9][13][3]
Cigna publishes no ABA rate table. Evernorth tells 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 and contract questions go to Provider Services at 800.926.2273. Bill telehealth with modifier 95 and POS 02. Non-credentialed staff are paid only through the supervising provider’s claim. For a public benchmark, Wisconsin Medicaid pays 97153 at $11.91 per 15 minutes for comprehensive treatment; commercial contracts are negotiated separately.[3][2][13]
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 Wisconsin, 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, and a provisional or rule-out diagnosis doesn’t count. The clocks run on data: the standardized instrument within 60 days before treatment, baseline data within 60 days, and current data within 60 days of the request.[1]
A healthcare professional licensed to practice independently whose board considers diagnosis within scope, applying DSM-5-TR criteria (EN0499). For mandated Wisconsin policies, Ins 3.36(3) requires "a diagnostician skilled in testing and in the use of empirically-validated tools specific for autism spectrum disorders."[1][5]
No single instrument is mandated by EN0499, but it must be standardized, measure both DSM-5-TR domains, and be the current edition (Vineland-3, not Vineland-II). Ins 3.36(3)(b) lets the insurer require validated tools in intelligence, parent report, language, adaptive behavior and direct observation.[1][5]
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 policy subject to Wis. Stat. § 632.895(12m), the treatment must be "prescribed by a physician," so get a physician’s prescription on file. Self-funded private employer plans are 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 chosen on clinical factors. Evernorth bills telehealth with modifier 95 and POS 02. The clinician still needs the credential the plan requires, which under the Wisconsin mandate means a Wisconsin behavior analyst license.[2][1][3]
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 Wisconsin mandate, Ins 3.36(4)(a)5. requires intensive-level therapy to begin after age 2 and before age 9 (up to 48 cumulative months), while nonintensive-level services have no age limit (OCI). Self-funded private employer plans are outside the statute, so plan funding type decides whether that binds.[1][5][6]
Ask the plan: Live benefits verification, or the Evernorth Autism Care Coordinator team: establish fully insured vs. self-funded first.
Wisconsin’s autism rule sets no decision clock for authorizations, and we found no Wisconsin-specific ABA turnaround from Cigna/Evernorth. For private employer group health plans, insured or self-funded, the federal ERISA claims rule applies: the plan must decide a pre-service claim "not later than 15 days after receipt of the claim," with one extension of up to 15 days, and an urgent-care claim within 72 hours. If a mandated autism claim is denied, Ins 3.36(9) treats the insurer’s decision on diagnosis and level of service as an adverse determination, so the family can file a grievance and then ask for independent review under Wis. Stat. § 632.835. Evernorth notes a late request "may result in a retrospective review and could delay the determination for up to 30 days."[12][5][10][2]
Ask the plan: At benefits verification ask whether the plan is a Wisconsin fully insured policy or self-funded, and what reauthorization lead time Evernorth expects.
For a child on two group plans, Wisconsin’s coordination-of-benefits rule is the birthday rule: "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 in that year" (Ins 3.40(11)(b)3.; "birthday" means month and day, not year). That rule binds group policies regulated by the state; a self-funded plan sets its own order. If the child also has Wisconsin Medicaid, Cigna/Evernorth pays first: Medicaid is payer of last resort (42 CFR 433.139). ForwardHealth pays a balance only after a correct claim to the commercial plan, and "will not reimburse claims denied by commercial health insurance due to billing errors or when the provider was out of the commercial insurer’s network." Bill the commercial plan with its own codes and modifiers, and get ForwardHealth prior authorization too, because ForwardHealth needs an approved PA for the dates of service. TRICARE pays after this plan (10 U.S.C. 1079(i)(1)); CHAMPVA is the last payer (38 CFR 17.270).[11][15][14][16][17]
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 Wisconsin 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. 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. The supervisor’s name and credentials must be documented. For mandated Wisconsin policies, Ins 3.36 also requires "regular, scheduled oversight" of paraprofessionals and direct observation by the qualified intensive-level provider at least every two months.[1][5]
"Only one provider can bill for a unit of time, with the exception of CPT codes 97153, 97154, and 97155," when the BCBA or QHP directs the technician and both are face-to-face with the patient at the same time. ABA delivered at the same time as another treatment (such as speech or occupational therapy) is not reimbursable.[2][1]
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. Wisconsin’s mandate bars "limitations on the number of treatment visits."[2][1][4]
Each service needs its own record with start and end date and time, location, focus, a description of the intervention, who was present, the service type, and the name, credential and signature of the provider who rendered it.[1]
Goals and data are reported separately for each setting (home, clinic, school, community). Primarily educational or vocational services are not covered. For mandated Wisconsin policies, Ins 3.36(11) requires coverage in the office, clinic or "a setting conducive to the acquisition of the target skill," and in schools when tied to treatment-plan goals and not duplicating school services.[1][5]
Evernorth does not credential non-licensed or non-certified staff; their services are billed under the supervising provider. On a CMS-1500 only a BCBA or other licensed provider goes in box 33; electronic claims use payer ID 62308. For Wisconsin mandate coverage, the BCBA must hold the Wisconsin license (§ 440.312).[2][4]
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 Wisconsin’s § 632.895(12m) mandate layered on for policies the state regulates. 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 if it is contracted through HealthPartners. Evernorth says providers in western Wisconsin must contract through HealthPartners to be in network for Cigna members.
Cigna publishes no ABA rates. Your fee schedule is Exhibit A of your Evernorth Provider Agreement (Provider Services 800.926.2273). Wisconsin Medicaid’s 97153 rate ($11.91 per 15 minutes, comprehensive) 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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