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

EN0499 sets no maximum age on the diagnosis, but it requires the date to be on the record and puts the currency burden on the instruments. Required with the diagnosis: “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.” For the assessment instrument, “the instrument used represents the most current version, and does not represent obsolete editions of the assessment (e.g., must be the Vineland-3 vs. Vineland-II)” and it must assess “the individual’s specific and current abilities and skills,” with the date of administration and the respondent named. A diagnosis termed “provisional,” “proposed,” “potential,” “at risk of” or “rule out” is not a confirmed diagnosis.^[1]

Scope-of-practice based, and strict about what does not count. The individual must have “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.” Two disqualifiers intake should screen for: “educational identification or meeting educational eligibility for services related to autism through the [Individuals] with Disabilities Education Act may not meet criteria as a formal diagnosis of ASD,” and a provisional or rule-out diagnosis is not confirmed. The ABA assessment itself must be performed by a BCBA, a Licensed Behavior Analyst, or an independently licensed mental health clinician with documented training in ABA — and in Georgia that analyst must also hold a Georgia Behavior Analyst Licensing Board licence under HB 412.^[1]

EN0499 names no required instrument list — it sets instrument criteria instead, which is a harder bar to meet by accident. The assessment must include “administration of a reliable, valid, and standardized assessment instrument that measures the individual’s functioning in the domains included in the diagnostic criteria for ASD in the DSM-5-TR… social communication and social interaction; and restricted, repetitive patterns of behavior, interests, or activities,” and the instrument “must be completed in its entirety and as designed,” have established reliability and validity “for use with members of the population tested (e.g., age, language preference),” be administered and interpreted by someone trained to do so, be the most current version, assess current abilities, and carry the date of administration, the respondent’s name and the form type.^[1]

Open, and stated at both the policy and the guide level. EN0499: “ABA treatment may be rendered via traditional in-person service delivery, telehealth, or a hybrid of in-person and telehealth service modalities,” with the modality chosen on individual characteristics, the treatment plan, caregiver participation, environment, evidence of efficacy and safety, and technological requirements — and the line-of-sight/close-proximity documentation rule expressly “does not apply to telehealth services, when applicable.” The Evernorth autism resource guide is blunter: “all ABA CPT codes are covered telehealth services,” subject to EN0499. Services delivered via telehealth must still meet the direct treatment / direct engagement definition and be documented as such.^[1][2]

EN0499 publishes no age limit — coverage turns on a confirmed DSM-5-TR ASD diagnosis and medical necessity, not on age. The age term in Georgia comes from Ava’s Law, which reaches individuals 20 years of age or under on state-regulated plans, with employers of 10 or fewer employees exempt and self-funded ERISA plans preempted; federal parity generally makes that cap hard to enforce against covered large-group plans.^[1][3]

Ask the plan: Plan funding type and employer size, then a live benefits verification — EN0499 itself will not answer an age question.

No referral requirement is published, and Cigna’s front door is unusually open: assessment codes 97151, 97152 and 0362T need no prior authorization under EN0499, so the assessment can start on the diagnosis alone. The rigour arrives at the treatment step, which requires the completed assessment plus a treatment plan submitted with Cigna’s ABA prior-authorization form. Whether a specific plan layers a PCP referral on top is a benefit-design question.^[1][2]

Ask the plan: A live benefits verification and Evernorth Provider Services at 800.926.2273 — confirm whether the plan requires a referral in addition to the treatment PA.

It depends on how the plan is funded. A fully insured Cigna plan sold in Georgia follows the Ensuring Transparency in Prior Authorization Act. A standard request gets notice "within 7 calendar days of obtaining all necessary information to make such authorization or adverse determination" (O.C.G.A. 33-46-26). Urgent requests get notice "no later than 72 hours after receiving all information needed" (33-46-27). A missed deadline means "automatic authorization" of the service (33-46-29), with a narrow de minimis exception. Both clocks start only once the plan has everything it needs, so send a complete packet. The Act also binds DCH contracts under the State Health Benefit Plan. A self-funded employer plan is governed by ERISA instead: "not later than 15 days after receipt of the claim," with one 15-day extension, and 72 hours for urgent care. No reauthorization lead time is published for Cigna ABA in Georgia.^[6][7][8]

Ask the plan: Benefits verification with Cigna: ask whether the plan is fully insured (Georgia prior-authorization law), self-funded (ERISA), or the State Health Benefit Plan, and the plan's reauthorization lead time.

Between two parents' group plans, Georgia's coordination-of-benefits rule uses 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." "Birthday" means month and day only. If the birthdays match, the plan that has covered the parent longer pays first. For separated or divorced parents, the order is the custodial parent's plan, then the step-parent's, then the non-custodial parent's, unless a court decree assigns health costs to one parent. That rule governs fully insured group plans. A self-funded employer plan sets its own order in its plan document. The Cigna plan pays before Georgia Medicaid, which is payer of last resort and still wants its own ABS PA when secondary. It also pays before TRICARE, which pays only after other coverage. When the child also has CHAMPVA, the Cigna plan pays first: "If you have any other type of other health insurance, CHAMPVA will pay secondary."^{[9][10][11][12]}

Ask the plan: Cigna member services / benefits verification: confirm funding type and the COB order in the plan document, and collect the other parent's plan, each parent's date of birth and any custody decree at intake.

Evernorth DOES publish a supervision standard, in EN0499 — direct case supervision (the BCBA face-to-face with the individual alongside the RBT or BCaBA) plus indirect case supervision “is consistent with the general accepted standard of care of one to two hours per ten hours of direct treatment”, and “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.” It is stated as a standard of care rather than a hard caseload cap, and supervisory services must match the CPT code descriptions.^[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]

Not published. The resource guide sets the code set (97151–97158, 0362T, 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.

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

Only the telehealth half is published: “all ABA CPT codes are covered telehealth services,” subject to the Intensive Behavioral Interventions coverage policy (EN0499). The guide states no school, community or group-home rule.^[2]

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