---
title: "Cigna / Evernorth ABA coverage in Colorado: the intake guide."
url: "https://carelu.com/payers/cigna-colorado"
markdown_url: "https://carelu.com/payers/cigna-colorado.md"
state: CO (Colorado)
payer: Cigna / Evernorth in Colorado
kind: Commercial insurance
description: "How Cigna / Evernorth covers ABA for Colorado families — the national clinical policy, prior authorization, the C.R.S. § 10-16-104(1.4) mandate (no age limits, no caps, exemptions), Colorado's coming behavior-analyst licensure, and what intake should verify."
last_reviewed: September 2026
vob_data_updated: 2026-07-23
---

# Cigna / Evernorth ABA coverage in Colorado: the intake guide.

_Payer Guide · Cigna · Colorado · Last updated September 2026 · 4 primary sources_

> EN0499 + autism resource guide + the C.R.S. § 10-16-104(1.4) mandate layer.

For an intake team in Colorado, a Cigna card means three layers at once: the carrier's national clinical policy, Colorado's autism insurance mandate (C.R.S. § 10-16-104(1.4)), and the plan's funding type deciding which of the two actually binds. This guide stacks them in order. Note the contrast with Colorado Medicaid: Cigna's commercial policy requires an ASD diagnosis, while Health First Colorado does not — so a family that qualifies for Medicaid ABA without a diagnosis will still need one here.

## 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:** C.R.S. § 10-16-104(1.4) (originally SB 09-244)
- **Mandate age:** No age limits in the current statute
- **Mandate caps:** None — the historical $34K/$12K annual ABA caps were removed
- **Exempt from mandate:** Short-term limited-duration; individual grandfathered; self-funded ERISA
- **Licensure:** None yet (BCBA governs) — state license required 7/1/2028 per HB26-1425

## The national policy, applied in Colorado

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. That clinical policy is national — what changes in Colorado is the legal floor underneath it: the state mandate below governs what fully-insured 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 Colorado. [1][2]

## The Colorado mandate: what it guarantees (and doesn't)

Colorado's mandate — C.R.S. § 10-16-104(1.4), originally 2009's SB 09-244 — is one of the stronger ones in our directory: it applies to all health benefit plans issued or renewed in Colorado except short-term limited-duration policies and individual grandfathered plans, carries no age limits, and carries no dollar caps — the historical $34,000/year (birth-8) and $12,000/year (9-18) ABA caps no longer appear in the current statute text, and carriers may not deny or restrict coverage because of an ASD diagnosis or utilization of mandated benefits. The statute also defines "autism services provider" with six qualification pathways reaching down to BACB Registered Behavior Technician. Self-funded ERISA plans are exempt by federal preemption, and MHPAEA parity applies on top for plans covering mental-health benefits — the caps' removal from the statute aligns the mandate with parity rather than fighting it. [3]

## No Colorado carve-out found in EN0499

Unlike Virginia — where EN0499 explicitly does not apply to fully-insured business — we found no Colorado carve-out in the policy, so the national rules (including the no-assessment-PA fast path) should apply to Colorado members. One honesty note: the current EN0499 PDF could not be fully text-parsed to confirm the state-exceptions list with certainty, so treat "no Colorado carve-out" as high-confidence rather than absolute and confirm the assessment-PA answer on the benefits call before promising families a fast start. [1]

## Licensure & rates in Colorado

Colorado currently requires no state license to practice behavior analysis — BCBA/BACB certification is the operative credential. That is changing: HB26-1425 (signed June 2, 2026) creates a Colorado Behavior Analyst Licensing Board under DORA's Division of Professions and Occupations, and on and after July 1, 2028 practicing ABA without a behavior analyst or assistant behavior analyst license becomes a class 2 misdemeanor; the law also mandates state licensure of ABA clinics. Practices should put the 2028 licensure conversion on their credentialing roadmap now. On rates: Cigna does not publish commercial ABA fee schedules for Colorado (none of the national carriers do) — rates are contract-negotiated and live in your participating-provider agreement; the Health First Colorado fee schedule (97153 at $17.20/unit for DOS 10/1/2025+) is the published in-state benchmark. [4]

## Intake gates

The questions that decide whether a family can start with Cigna / Evernorth in Colorado, 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)_: Colorado's mandate carries no age limit: C.R.S. § 10-16-104(1.4) applies to all health benefit plans issued or renewed in the state except short-term limited-duration policies and individual grandfathered plans, with no age terms and no dollar caps (the cap language was struck effective 1/1/2017). The carrier's national ABA policy adds no age bound of its own, so age comes from the benefit document — and self-funded ERISA plans sit outside the mandate entirely. [3][1]
  - Ask the plan: Benefits verification on the specific plan — funding type first, then the ABA benefit terms.
- **Prior-auth decision time** _(plan-dependent)_: Depends on how the plan is funded. Fully insured Colorado plans follow C.R.S. § 10-16-112.5: within five business days after receipt the carrier must say the request is "approved, denied, or incomplete" (naming the missing information), then decide within five business days after receiving it; urgent requests within "two business days but not longer than seventy-two hours." If the carrier misses those deadlines the request "is deemed granted" — but the provider must send any requested information within two business days of the notice or loses that protection. An approval "is valid for at least one hundred eighty days after the date of approval and continues for the duration of the authorized course of treatment." Self-funded (ERISA) plans follow the federal claims rule instead: pre-service decisions within 15 days of receipt (one 15-day extension), urgent within 72 hours. Cigna's ABA policy (EN0499) sets no decision clock; continued-treatment requests need current data "collected within no more than 60 days prior to the start date of the continued treatment request." [5][6][1]
  - Ask the plan: Benefits verification: fully insured Colorado policy (5-business-day clock, 180-day approvals, deemed-granted rule) vs. self-funded ERISA plan (15 days / 72 hours).
- **Other insurance (who pays first)** _(plan-dependent)_: For a child on two parents' plans, Colorado's group coordination-of-benefits regulation (fully insured plans): parents married or living together — "The plan of the parent whose birthday falls earlier in the calendar year is the primary plan" (same birthday → the plan that covered the parent longer); otherwise a court decree controls, and without one the order is custodial parent, custodial parent's spouse, non-custodial parent, then the non-custodial parent's spouse. Self-funded plans set their own order in the plan document. Cigna's ABA documents publish no coordination-of-benefits rule of their own. If the child also has TRICARE, this plan pays first — TRICARE is the secondary payer to other health insurance under its double-coverage rule (Medicaid is the only coverage it pays ahead of). CHAMPVA likewise pays last: "In double coverage situations, CHAMPVA would be the last payer." If the child also has Medicaid, this plan is primary and Medicaid pays last. [7][8][9][10]
  - Ask the plan: Benefits verification with both plans: funding type, which is primary for the child, and whether the secondary plan requires its own authorization.

## Delivery and billing rules

Coverage decides whether Cigna / Evernorth in Colorado 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 Colorado

- **Plan funding type:** Fully insured (mandate applies) vs. self-funded ERISA (exempt) — it decides which rulebook governs. Ask for the employer and check the card.
- **Member ID + card photo:** Enough to run a live benefits verification — the only reliable answer on limits and cost-sharing.
- **Diagnosis report:** DSM-5 ASD diagnosis, diagnosing provider and credentials, evaluation date — required here even though Colorado Medicaid doesn't require one.
- **Age:** The Colorado mandate has no age limits — don't screen out older clients on age alone.

Free verification-call checklist (PDF): https://carelu.com/downloads/aba-verification-call-checklist.pdf

## Verification of benefits (VOB) data

How Cigna / Evernorth in Colorado ABA benefits route and read on an eligibility check. Data last updated 2026-07-23.

### EDI routing

- **Payer ID (pVerify):** 00004
- **Payer ID (Availity):** 62308
- **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:** medical 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 coding/reimbursement mechanics are published in it. We found no Colorado carve-out in EN0499 (only Virginia is carved out), so the no-assessment-PA fast path should apply to Colorado members.

### Contacts

- **Provider services phone:** 800.926.2273 — Evernorth Provider Services (billing, benefits, eligibility questions), Mon–Fri 7:00 a.m.–7:00 p.m. CT
- **Phone menu path:** For ABA-specific benefits, eligibility, and authorization questions, ask for the Autism Care Coordinator team (877.279.7603) instead of general Provider Services — it's Evernorth's dedicated non-clinical ABA line.
- **Hours:** Provider Services: Mon–Fri 7:00 a.m.–7:00 p.m. CT. Autism Care Coordinator team (877.279.7603): 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 are the daily/session unit caps for 97153, 97154, 97155, 97156, 97157, 97158, and 0373T under this plan?
- Which places of service are approved for ABA — home, clinic, school, telehealth?
- Is telehealth allowed for any ABA codes, and if so which modifier should we bill?
- Are credential-tier billing modifiers required (e.g., BCBA vs. RBT) for any of these codes?

### VOB data sources

- https://pverify.com/wp-content/uploads/2026/03/pVerifyPayers_All-Payers-List-3-2026.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://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/autism-resource-guide.pdf (accessed 2026-07-23)
- 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)
- https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/en_mm_0499_coveragepositioncriteria_intensive_behavioral_interventions.pdf (accessed 2026-07-23)

## Common questions

### Does Cigna cover ABA therapy in Colorado?

Yes — under the carrier's national policy for ASD, layered on Colorado's mandate (C.R.S. § 10-16-104(1.4)) for fully-insured plans. Self-funded employer plans are exempt from the mandate, so always verify plan funding type first.

### Does the ABA assessment need prior authorization with Cigna in Colorado?

Per the national EN0499 policy, no — assessment codes 97151, 97152, and 0362T need no PA, and we found no Colorado carve-out from that policy. Confirm on the benefits call, since the current policy PDF could not be fully parsed for the state-exceptions list.

### What does the Colorado autism mandate require?

It applies to all Colorado-issued or renewed health benefit plans (short-term limited-duration and individual grandfathered plans excepted), with no age limits and no dollar caps — the historical $34K/$12K annual ABA caps were removed from the statute. Self-funded ERISA plans are exempt by preemption.

### What does Cigna pay for ABA in Colorado?

Commercial ABA rates are not published — they are negotiated in your participating-provider agreement. Benchmark against the Health First Colorado 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 (Mar 2025)](https://static.cigna.com/assets/chcp/pdf/coveragePolicies/medical/autism-resource-guide.pdf)
3. [C.R.S. § 10-16-104 (FindLaw, current through 1/1/2025)](https://codes.findlaw.com/co/title-10-insurance/co-rev-st-sect-10-16-104/)
4. [HB26-1425 — Applied Behavior Analysis Services (Colorado General Assembly)](https://leg.colorado.gov/bills/HB26-1425)
5. [C.R.S. § 10-16-112.5 — Prior authorization for health-care services](https://colorado.public.law/statutes/crs_10-16-112.5)
6. [29 CFR 2560.503-1 — ERISA claims procedure (eCFR)](https://www.ecfr.gov/current/title-29/section-2560.503-1)
7. [3 CCR 702-4-6-2-6 — Rules for Coordination of Benefits (LII)](https://www.law.cornell.edu/regulations/colorado/3-CCR-702-4-6-2-6)
8. [32 CFR 199.8 — TRICARE double coverage (eCFR)](https://www.ecfr.gov/current/title-32/section-199.8)
9. [38 CFR 17.270 — CHAMPVA definitions, double coverage (eCFR)](https://www.ecfr.gov/current/title-38/section-17.270)
10. [HCPF — General Provider Information Manual (Third-Party Liability / Coordination of Benefits)](https://hcpf.colorado.gov/gen-info-manual)

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.