Cigna / Evernorth ABA coverage in Arizona: the intake guide.

EN0499 puts no expiry on the ASD diagnosis — it requires only that the submission carry "the name, credentials, and type of licensure of the individual who made the diagnosis" and "the date on which the diagnosis was most recently made." The 60-day clocks run on the assessment instead: administration of the standardized assessment instrument must be completed within 60 days prior to the start of treatment, and quantitative baseline data must be collected within 60 days prior to the start of treatment.^[1]

"A confirmed diagnosis of autism spectrum disorder (ASD); (ICD-10-CM Diagnosis Codes F84.0 – F84.9, with the exception of F84.2, Rett syndrome) based on the criteria in the DSM-5-TR by a healthcare professional who is licensed to practice independently and whose licensure board considers diagnostics to be within their scope of practice." The ABA assessment itself is then performed by a BCBA, LBA, or an independently licensed mental health clinician with documented ABA training.^[1]

EN0499 names no instrument but sets six tests the instrument must pass: it must be reliable, valid and standardized, measure functioning in the DSM-5-TR ASD domains (social communication/interaction; restricted, repetitive behavior), be completed in its entirety and as designed, have established reliability and validity for the population tested, be administered by someone trained to administer and interpret it, and be the most current version — "must be the Vineland-3 vs. Vineland-II." Date of administration, respondent and form type must be recorded.^[1]

No referral or physician order is required. Prior authorization is not required on assessment codes 97151, 97152 or 0362T with an autism diagnosis "as long as the provider is independently licensed or a Board Certified Behavior Analyst (BCBA) and the patient's policy covers ABA services"; the authorization gate arrives at the treatment step, with the completed assessment and treatment plan.^[2][1]

"All ABA CPT codes are covered telehealth services," subject to EN0499. The policy adds a documentation duty rather than a code restriction: where services are delivered "via telehealth modalities," the record must show the service still meets the definition of direct treatment/direct engagement "regardless of treatment location or modality" and is conducted per the treatment-plan goals.^[2][1]

Steven's Law now carries no explicit age limit: SB 1590 (signed May 7, 2025) struck the dollar-cap subsection from all four sections of the mandate, and the age tiers — under 9, and 9 through 16 — lived inside that subsection. Optum's own state-mandate entry describes the change as repealing "the maximum benefit limitations for behavioral therapy coverage for eligible persons who are 16 years old and younger." The carrier's national ABA policy adds no age bound of its own, so age comes from the benefit document, not the statute.^[3][4][1]

Ask the plan: Benefits verification on the specific plan — funding type first, then the ABA benefit terms.

Evernorth (Cigna behavioral health) makes coverage determinations "in accordance with the time frames required under applicable law" and publishes no day counts; for ABA it asks 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." Assessment codes 97151, 97152 and 0362T no longer need PA with an autism diagnosis. So the governing clock depends on funding. For a fully insured plan issued in Arizona, A.R.S. § 20-3404 governs: urgent requests "not later than five days after the receipt of all necessary information", non-urgent "not later than fourteen days after receipt of all necessary information", with the same five/fourteen days again after the provider completes an incomplete request — and "A prior authorization request is deemed granted if a health care services plan or its utilization review agent fails to comply with the deadlines." A granted authorization cannot be rescinded after services are rendered in good faith, absent fraud. A self-funded employer plan sits outside state law and follows ERISA: a non-urgent pre-service decision "not later than 15 days after receipt of the claim by the plan", extendable once by up to 15 days; an urgent one within 72 hours; the clock starts when the request is filed, whether or not it is complete; and an urgent request to extend an approved course is decided within 24 hours if made "at least 24 hours prior to the expiration" of the current authorization.^{[8][2][9][10]}

Ask the plan: At benefits verification, ask whether the plan is fully insured (a policy issued in the state) or a self-funded employer (ERISA) plan — that decides which clock applies — then ask the carrier’s behavioral health precert line its expected ABA turnaround and how early it wants the reauth.

Arizona’s COB rule for group plans (A.A.C. R20-6-214) sets the order: the plan covering the person other than as a dependent pays first; for a dependent child, "The plan of a parent whose birthday occurs earlier in a calendar year shall cover a dependent child before" the other parent’s plan (month and day only); for separated or divorced parents, the custodial parent’s plan, then the custodial parent’s spouse’s, then the non-custodial parent’s, unless a court decree the plan knows of says otherwise. Self-funded plans follow their own plan document. Evernorth spells the same order out: the employee/subscriber plan is "always considered the primary payer" over a dependent plan; married parents follow "the 'birthday rule'"; divorced, separated or not-living-together parents follow the custodial rule (custodial parent, their spouse, non-custodial parent, their spouse) unless a court decree assigns it, and joint custody without a named parent falls back to the birthday rule. Paper COB claims need "a copy of the primary payer's explanation of payment (EOP)." Government coverage sorts itself by federal rule: a commercial plan pays before TRICARE, which is secondary to every other health plan but "In any double coverage situation involving Medicaid, CHAMPUS is always the primary payer"; CHAMPVA "is the last payer to OHI"; and Medicaid pays after all of them (42 CFR 433.139), so a child with commercial plus Medicaid needs this plan’s authorization and EOB before Medicaid will pay.^{[11][8][12][13][14]}

Ask the plan: Collect both parents’ plans, dates of birth, and any custody decree at intake; confirm primary/secondary with each carrier’s COB unit (and whether the plan is self-funded) before the first claim.

One to two hours per ten hours of direct treatment. "Direct case supervision (occurs concurrently with the delivery of direct treatment to the individual and consists of BCBA face-to-face with the individual and either the Registered Behavior Technician or the Board Certified Assistant Behavior Analyst) and indirect case supervision is consistent with the general accepted standard of care of one to two hours per ten hours of direct treatment." When direct treatment is 10 hours per week or less, a minimum of one to two hours per week of direct case supervision is provided, and the supervisor's name and credentials must be documented.^[1]

Yes — and Evernorth writes it as an explicit carve-out from its general rule: "Only one provider can bill for a unit of time, with the exception of CPT codes 97153, 97154, and 97155 (direct supervision when the BCBA/qualified health care provider directs the technician and both are face-to-face with the patient at the same time)." Both must be with the patient; analyst time away from the patient is not inside the exception.^[2]

Under the supervising provider, because the technician cannot be credentialed: "Evernorth does not credential nonlicensed/noncertified staff. Services for these staff members must be billed under the supervising provider." Practically, the BCBA's credential is what the claim rides on for technician-delivered 97153.^[2]

No POS list is published. EN0499 requires the treatment plan to identify the "settings and environments where treatment will occur (e.g., home, clinic, school, community setting)" and to collect data corresponding to each location of service; for settings with competing behavioral expectations — "academic setting, vocational placement, services delivered via telehealth modalities" — the record must show the service still meets the direct-treatment definition. Which of those settings is payable is a benefit-document question.^[1][2]

Ask the plan: Evernorth Provider Services at 800.926.2273 for school and community settings, plus the member's benefit document.

Not published. The resource guide sets the code set (97151–97158, 0362T and 0373T only, all in 15-minute increments) but no per-day unit ceiling and no statement of which MUE table Evernorth applies.^[2]

Ask the plan: Evernorth Provider Services at 800.926.2273.

Not published in the autism resource guide — no rule on who signs a session note or when. EN0499 does require the name and credentials of the supervising and stakeholder-training providers to be documented, and dates of administration on every assessment instrument.^[1]

Blocked on: The Evernorth Behavioral Health provider administrative guide and your participation agreement.