--- title: "Cigna / Evernorth ABA coverage in Arizona: the intake guide." url: "https://carelu.com/payers/cigna-arizona" markdown_url: "https://carelu.com/payers/cigna-arizona.md" state: AZ (Arizona) payer: Cigna / Evernorth in Arizona kind: Commercial insurance description: "How Cigna / Evernorth covers ABA for Arizona families — national policy EN0499, prior authorization, Steven's Law with its dollar caps repealed by SB 1590 (2025), A.R.S. § 32-2091 licensure, and what intake should verify." last_reviewed: September 2026 vob_data_updated: 2026-07-23 --- # Cigna / Evernorth ABA coverage in Arizona: the intake guide. _Payer Guide · Cigna · Arizona · Last updated September 2026 · 7 primary sources_ > EN0499 (no AZ carve-out) + Steven's Law with its caps repealed by SB 1590 (2025). For an intake team in Arizona, a Cigna card means three layers at once: the carrier's national clinical policy, Arizona's autism insurance mandate (Steven's Law, its dollar caps freshly repealed by SB 1590), and the plan's funding type deciding which of the two actually binds. This guide stacks them in order. ## Prior authorization and diagnosis at a glance - **Prior auth for the assessment**: Not required for assessment codes 97151, 97152, 0362T (per Cigna's autism resource guide — EN0499 itself states no prior-authorization rule) [2][1] - **Prior auth for treatment**: Required — assessment + treatment plan with the ABA PA form (see Cigna's autism resource guide; EN0499 sets the clinical criteria, not the PA rule) [1][2] - **Autism diagnosis required?**: Yes — ASD only; Rett syndrome (F84.2) excluded under EN0499 [1] ## At a glance - **Covers ABA?:** Yes — for ASD, per the national Cigna policy - **State mandate:** Steven's Law (A.R.S. § 20-826.04 and three parallel sections) - **Mandate caps:** NONE — the $50K/$25K annual caps were repealed by SB 1590 (2025) - **Mandate age:** No explicit age limit remains — the age tiers lived in the repealed cap subsection - **Exempt from mandate:** Individual & small-employer policies; self-funded ERISA - **Licensure:** AZ Licensed Behavior Analyst (A.R.S. § 32-2091, Board of Psychologist Examiners) ## The national policy, applied in Arizona 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 — EN0499 expects a confirmed ASD diagnosis (F84.0–F84.9, Rett excluded) by an independently licensed professional, a current-version standardized assessment instrument (e.g., Vineland-3) administered within 60 days before treatment start, and an individualized plan with baseline data. That clinical policy is national — what changes in Arizona is the legal floor underneath it: the state mandate below governs what fully-insured group plans must cover, while self-funded employer plans answer to ERISA and federal parity instead. Plan funding type is therefore the first fact to establish on every benefits check. The full national policy breakdown lives in our Cigna / Evernorth guide; this page covers what changes in Arizona. [1][2] ## The Arizona mandate: Steven's Law, caps repealed Steven's Law (HB 2847, 2008) lives in four parallel sections of the insurance code — A.R.S. §§ 20-826.04, 20-1057.11, 20-1402.03, and 20-1404.03 — covering state-regulated group coverage: large-group contracts, HMO plans, and group and blanket disability policies. Plans may not deny or limit treatment based solely on an autism spectrum disorder diagnosis, and may not exclude medically necessary behavioral therapy, which the statute defines to include ABA (discrete trial training, pivotal response training, intensive behavioral intervention), delivered or supervised by a licensed or certified provider. The headline change: SB 1590 (signed May 7, 2025) struck the dollar-cap subsection from all four sections — the old $50,000/year (under age 9) and $25,000/year (ages 9–16) behavioral-therapy maximums are repealed, taking the statute's only age tiers with them, and the ASD definition now tracks the current DSM. No annual dollar ceiling remains on any state-regulated group plan (federal parity had already made the caps largely unenforceable; SB 1590 cleaned the statute to match — do not treat the old $50K/$25K numbers as current). Exemptions: policies issued to an individual or small employer (those reach ABA via the ACA EHB benchmark instead), limited-benefit coverage, and self-funded ERISA plans. Ordinary cost sharing is still permitted. [3][4][5] ## No Arizona carve-out in EN0499 We checked: the current EN0499's state-mandate paragraph names only New York and Virginia — there is no Arizona carve-out, so Arizona fully-insured business runs on the standard EN0499 criteria, including the no-assessment-PA fast path and the 60-day assessment-instrument recency rule. Cigna publishes no Arizona-specific ABA policy or supplement, and it runs no AHCCCS Medicaid plan in Arizona. SB 1590's cap repeal still binds Cigna's Arizona-regulated group plans at the benefit level regardless of the clinical policy — so benefits verification (plan funding type, benefit terms) is where the Arizona-specific answers come from. [1] ## Licensure & rates in Arizona Arizona requires a state license to practice behavior analysis — A.R.S. § 32-2091, administered by the Arizona Board of Psychologist Examiners (behavior analysts sit under the psychology board, not a standalone board) — and BCBA certification alone is not sufficient; AHCCCS itself defines "Behavior Analyst" as a person licensed under § 32-2091. On rates: Cigna does not publish commercial ABA fee schedules for Arizona (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement. Benchmark against the AHCCCS fee schedule (97153 at $17.91–$23.69 per 15-minute unit by credential tier), remembering the ABA codes live on the AHCCCS physician fee schedule, not the behavioral-health one. [6][7] ## Intake gates The questions that decide whether a family can start with Cigna / Evernorth in Arizona, and what they have to bring. - **Diagnosis recency**: 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] - **Who may diagnose**: "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] - **Diagnostic tools required**: 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] - **Referral required?**: 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] - **Telehealth**: "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] - **Age limit** _(plan-dependent)_: 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. - **Prior-auth decision time** _(plan-dependent)_: 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. - **Other insurance (who pays first)** _(plan-dependent)_: 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. ## Delivery and billing rules Coverage decides whether Cigna / Evernorth in Arizona pays. These decide whether the claim survives: staffing and supervision, concurrent billing, per-day ceilings, who signs the note, where the service is payable, and whose NPI the claim goes out under. - **Supervision**: 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] - **Concurrent billing (97153 + 97155)**: 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] - **Bill as provider**: 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] - **Place of service** _(plan-dependent)_: 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. - **Daily limits / MUEs** _(ask the plan)_: 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. ## What intake should collect for Cigna / Evernorth in Arizona - **Plan funding type:** Fully insured group (mandate applies) vs. self-funded ERISA (exempt) vs. individual/small-group (EHB benchmark) — it decides which rulebook governs. - **Member ID + card photo:** Enough to run a live benefits verification — the only reliable answer on limits and cost-sharing. - **Diagnosis report + assessment recency:** DSM-5 ASD diagnosis by an independently licensed professional, and a standardized instrument within 60 days of treatment start (EN0499). - **Age:** Arizona's mandate now carries no explicit age limit — flag edge cases for the benefit analysis rather than turning families away. Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf ## Verification of benefits (VOB) data How Cigna / Evernorth in Arizona ABA benefits route and read on an eligibility check. Data last updated 2026-07-23. ### EDI routing - **Payer ID (pVerify):** 00004 — pVerify 00004 = "Cigna"; 00510 = "Cigna Behavioral". No "Evernorth" row in pVerify. - **Payer ID (Change Healthcare / Optum):** 62308 - **Supports 270/271 eligibility:** Yes - **Behavioral health administrator:** Evernorth Behavioral Health - **BH administrator payer ID:** 62308 - **ABA rides on:** behavioral health benefit - **Two-hop verification required:** No ### How the 271 reports ABA benefits - **ABA benefit bucket (service type code):** MH - **Deductible applies to ABA:** yes — Base deductible for MH-flavored codes is returned per the companion guide's own worked example, but REMAINING deductible/benefit amounts are explicitly withheld for Mental Health, Pharmacy, and Vision plans (§7.2.2-7.2.3) — a real 271 for an ABA member may show the base figure but not how much has been used. - **Cost-share type:** plan-dependent — Both copay (EB*C) and coinsurance (EB*A) segments are structurally supported per plan; which applies to a given member is plan-document-specific. - **271 response quality for ABA:** high ### Code-level coverage | Code | Covered | Prior auth | Unit cap | Place of service | Telehealth | Modifiers | | --- | --- | --- | --- | --- | --- | --- | | 97151 | Yes | Not required (per EN0499) | — | — | — | — | | 97152 | Yes | Not required (per EN0499) | — | — | — | — | | 97153 | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — | | 97154 | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — | | 97155 | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — | | 97156 | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — | | 97157 | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — | | 97158 | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — | | 0362T | Yes | Not required (per EN0499) | — | — | — | — | | 0373T | Yes | Required — assessment + treatment plan with the ABA PA form (EN0499) | — | — | — | — | Code notes: - **97151, 97152, 97153, 97154, 97155, 97156, 97157, 97158, 0362T, 0373T:** Verify via: Cigna/Evernorth provider services — EN0499 is a medical-necessity policy only (no AZ carve-out); ABA claims route to Evernorth payer ID 62308. Steven's Law caps repealed by SB 1590 (2025). ### Contacts - **Provider services phone:** 800.926.2273 (Provider Services — billing/benefits/eligibility) - **Phone menu path:** For ABA-specific eligibility, benefits, and prior-auth questions, ask for the Autism Care Coordinator team directly at 877.279.7603 (nonclinical) rather than general Provider Services. - **Hours:** Monday–Friday, 7:00 a.m.–7:00 p.m. CT (Provider Services); Autism Care Coordinator team Mon–Fri 8:30 a.m.–5:00 p.m. CT - **Portal:** [Evernorth Provider Portal](https://provider.evernorth.com) Questions to ask on a verification call: - What POS codes does Evernorth accept for ABA (home, clinic, school, telehealth)? - Is telehealth allowed for ABA codes, and does it require a specific modifier? - Is there a unit or hour cap per day or week, and what capPeriod applies? - What credential-tier modifiers does Evernorth require on ABA claims? ### VOB data sources - https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.pdf (accessed 2026-07-23) - https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/autism-resource-guide.pdf (accessed 2026-07-23) - https://essentials.availity.com/availity/documents/payer_list_wShortNames.pdf (accessed 2026-07-23; source document older than 18 months) - https://www.caqh.org/sites/default/files/CAQH%20CORE%20Eligibility%20Benefits%20(270_271)%20Data%20Content%20Rule%20vEB2.0.pdf (accessed 2026-07-23) - https://www.cigna.com/static/www-cigna-com/docs/5010-270-271-companion-guide.pdf (accessed 2026-07-23) ## Common questions ### Does Cigna cover ABA therapy in Arizona? Yes — under national policy EN0499 for ASD (no Arizona carve-out exists), layered on Steven's Law for state-regulated group plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first. ### Does Arizona still cap ABA benefits at $50,000 a year? No — SB 1590 (signed May 7, 2025) repealed the $50,000/$25,000 annual behavioral-therapy caps from all four Steven's Law sections. No annual dollar ceiling remains on any state-regulated group plan. ### What does Cigna pay for ABA in Arizona? Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against the AHCCCS physician fee schedule and treat rate-setting as part of contracting. ## Primary sources 1. [Evernorth EN0499 — Intensive Behavioral Interventions](https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/en_mm_0499_coveragepositioncriteria_intensive_behavioral_interventions.pdf) 2. [Cigna autism resource guide](https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/autism-resource-guide.pdf) 3. [SB 1590 — chaptered law (Laws 2025, ch. 142)](https://www.azleg.gov/legtext/57leg/1R/laws/0142.pdf) 4. [A.R.S. § 20-826.04 — current text](https://www.azleg.gov/ars/20/00826-04.htm) 5. [Autism Speaks — Arizona state-regulated insurance coverage](https://www.autismspeaks.org/arizona-state-regulated-insurance-coverage) 6. [A.R.S. § 32-2091 — behavior analyst licensure](https://www.azleg.gov/ars/32/02091.htm) 7. [AHCCCS — Final Public Notice, FFS rate changes 11/1/2023 (ABA codes)](https://www.azahcccs.gov/AHCCCS/Downloads/PublicNotices/rates/FinalPublicNotice_RateChanges_20231101_ABA.pdf) 8. [Evernorth Behavioral Health — Administrative Guidelines (March 2026)](https://static.evernorth.com/assets/evernorth/provider/pdf/resourceLibrary/behavioral/ebh-provider-admin-guide.pdf) 9. [A.R.S. § 20-3404 — prior authorization request deadlines (deemed granted if missed)](https://www.azleg.gov/ars/20/03404.htm) 10. [29 CFR 2560.503-1(f) — ERISA claims procedure: group health plan decision timeframes](https://www.ecfr.gov/current/title-29/section-2560.503-1) 11. [Ariz. Admin. Code R20-6-214 — coordination of benefits, order of benefit determination (Cornell LII mirror)](https://www.law.cornell.edu/regulations/arizona/Ariz-Admin-Code-SS-R20-6-214) 12. [32 CFR 199.8 — TRICARE double coverage (secondary to other plans, primary to Medicaid)](https://www.ecfr.gov/current/title-32/subtitle-A/chapter-VII/subchapter-M/part-199/section-199.8) 13. [38 CFR 17.276 — CHAMPVA is the last payer to other health insurance](https://www.ecfr.gov/current/title-38/section-17.276) 14. [42 CFR 433.139 — payment of claims involving third-party liability](https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-C/part-433/subpart-D/section-433.139) Payer policies change frequently and vary by plan, state, and funding type. This guide was compiled from the sources above and last reviewed September 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. Source: Carelu ABA Payer Directory — https://carelu.com/payers. Free to cite with attribution.